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1.
J Thorac Dis ; 13(10): 5582-5591, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34795909

RESUMO

Background: This study evaluated operative mortalities following adult cardiac surgical operations to determine if this metric remains appropriate for the modern era. Methods: This was a retrospective review of Society of Thoracic Surgeons (STS) indexed adult cardiac operations that included coronary artery bypass grafting (CABG), aortic valve replacement (AVR), CABG + AVR, mitral valve repair (MVr), CABG + MVr, mitral valve replacement (MVR) and CABG + MVR, performed at a single institution between 2011 and 2017. The primary outcome was the timing and relatedness of operation mortality, as defined by the STS as mortality within 30-day or during the index hospitalization, compared to the index operation. The secondary outcomes evaluated cause of death and the rates of postoperative complications. Results: A total of 11,190 index cardiac operations were performed during the study period and operative mortality occurred in 246 (2.2%) of patients. The distribution of operative mortalities included 83.7% (n=206) who expired within 30-day while an inpatient, 6.9% (n=17) died within 30-day as an outpatient, 11.2% (n=23) expired after 30-day. The most common causes of operative mortality were cardiac (38.7%, n=92), renal failure (15.6%, n=37), and strokes (13.9%, n=33). Furthermore, 98.4% (n=242) of deaths were attributable to the index operation. Postoperative complications occurred frequently in those with operative mortality, with blood transfusions (80.1%), reoperations (65.0%) and prolonged ventilation (62.2%) being most common. Conclusions: Most of the operative mortalities seemed to be attributable to the index cardiac operation. We believe that the current definition of mortality remains appropriate in the modern era.

2.
J Thorac Dis ; 13(9): 5458-5466, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34659812

RESUMO

Background: Left ventricular dimension has the potential to impact clinical outcomes following implantation of left ventricular assist devices (LVAD). We investigated the effect of pre-implant left ventricular end-diastolic diameter (LVEDD) on outcomes following LVAD implantation. Methods: Patients implanted with a continuous-flow LVAD between 2004 and 2018 at a single institution were included. The primary outcome was death while on LVAD support. Secondary outcomes included adverse event rates such as renal failure requiring dialysis, device thrombosis, and right ventricular failure. The LVEDD measurements were dichotomized using restricted cubic splines and threshold regression. Survival was determined using Kaplan-Meier estimates. Multivariable logistic regression was used to determine risk-adjusted mortality based on LVEDD. Results: A total of 344 patients underwent implantation of a continuous flow LVAD during the study period. The optimal cut point for LVEDD was 65 mm, with 126 (36.6%) subjects in the <65 mm group and 165 (48.0%) in the >65 mm group. The LVEDD <65 mm group was older, had more females, higher incidence of diabetes, more pre-implant mechanical ventilation, and more admissions for acute myocardial infarctions (all, P<0.05). Importantly, post-implant adverse events were similar between the groups (all, P>0.05). Risk-adjusted survival at 1-year (OR 1.3, 95% CI: 0.6-2.5, P=0.53) was also comparable between the groups. Furthermore, incremental increases in LVEDD when modeled as a continuous variable did not impact overall mortality (OR 0.98, 95% CI: 0.9-1.0, P=0.09). Conclusions: Preoperative LVEDD was not associated with rates of major morbidities or mortality following LVAD implantation.

3.
J Card Surg ; 36(11): 4015-4023, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34368992

RESUMO

BACKGROUND: This study investigated the impact of transplanting center donor acceptance patterns on usage of extended-criteria donors (ECDs) and posttransplant outcomes following orthotopic heart transplantation (OHT). METHODS: The Scientific Registry of Transplant Recipients was queried to identify heart donor offers and adult, isolated OHT recipients in the United States from January 1, 2013 to October 17, 2018. Centers were stratified into three equal-size terciles based on donor heart acceptance rates (<13.7%, 13.7%-20.2%, >20.2%). Overall survival was compared between recipients of ECDs (≥40 years, left ventricular ejection fraction [LVEF] <60%, distance ≥500 miles, hepatitis B virus [HBV], hepatitis C virus [HCV], or human immunodeficiency virus [HIV], or ≥50 refusals) and recipients of traditional-criteria donors, and among transplanting terciles. RESULTS: A total of 85,505 donor heart offers were made to 133 centers with 15,264 (17.9%) accepted for OHT. High-acceptance programs (>20.2%) more frequently accepted donors with LVEF <60%, HIV, HCV, and/or HBV, ≥50 offers, or distance >500 miles from the transplanting center (each p < .001). Posttransplant survival was comparable across all three terciles (p = .11). One- and five-year survival were also similar across terciles when examining recipients of all five ECD factors. Acceptance tier and increasing acceptance rate were not found to have any impact on mortality in multivariable modeling. Of ECD factors, only age ≥40 years was found to have increased hazards for mortality (hazard ratio, 1.33; 95% confidence interval [CI], 1.22-1.46; p < .001). CONCLUSIONS: Of recipients of ECD hearts, outcomes are similar across center-acceptance terciles. Educating less aggressive programs to increase donor acceptance and ECD utilization may yield higher national rates of OHT without major impact on outcomes.


Assuntos
Transplante de Coração , Adulto , Humanos , Estudos Retrospectivos , Volume Sistólico , Doadores de Tecidos , Transplantados , Estados Unidos , Função Ventricular Esquerda
4.
Clin Transplant ; 35(11): e14459, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34398485

RESUMO

BACKGROUND: This study evaluated the impact of the 2018 heart allocation policy change on geographic disparities in United States orthotopic heart transplantation (OHT). METHODS: The United Network for Organ Sharing registry was queried to measure geographic disparity in OHT rates between pre-policy and post-policy change eras. We performed multilevel Poisson regression to measure region-level OHT rates. We derived an allocation priority-adjusted median incidence rate ratio (MIRR) for each policy era, a measure of median change in OHT rates between regions. RESULTS: 5958.78 waitlist person-years were analyzed, comprising 6596 OHT procedures (3890 pre-policy and 2706 post-policy). Median region-level OHT rate was .94 transplants/person-years before and 1.51 transplants/person-years after the policy change (P < .001). The unadjusted OHT MIRR across regions was 1.29 (95% CI 1.00-1.50) pre-policy change and 1.17 (95% CI 1.00-1.43) post-policy change, suggesting that the region-related variance in OHT rates decreased under the new allocation. After adjustment for allocation priority risk factors, the MIRR pre-policy change was 1.13 (95% CI 1.01-1.32) and post-policy change was 1.15 (95% CI 1.00-1.35). CONCLUSIONS: Geography accounts for ∼10% of the disparity among United States OHT rates. Despite broader heart sharing, the updated allocation policy did not substantially alter the existing geographic disparities among OHT recipients.

6.
Ann Thorac Surg ; 2021 Jul 06.
Artigo em Inglês | MEDLINE | ID: mdl-34237293

RESUMO

BACKGROUND: Aortic root translocation (Nikaidoh), Rastelli, and réparation à l'etage ventriculaire (REV) are repair options for transposition of the great arteries (TGA) with ventricular septal defects and left ventricular outflow tract obstruction (VSD-LVOTO) or double outlet right ventricle TGA type (DORV-TGA). METHODS: This retrospective study using The Society of Thoracic Surgeons Congenital Heart Surgery Database evaluates surgical procedure utilization and outcomes of patients undergoing repair of TGA-VSD-LVOTO and DORV-TGA with a Nikaidoh, Rastelli, or REV procedure. RESULTS: A total of 293 patients underwent repair at 82 centers (January 2010 to June 2019). Most patients underwent a Rastelli (n = 165, 56.3%) or a Nikaidoh (n = 119, 40.6%) operation; only 3.1% (n = 9) underwent a REV. High-volume centers performed the majority of the repairs. Fewer Nikaidoh than Rastelli patients had prior cardiac operations (n = 57 [48.7%] vs n = 102 [63.0%]; P = .004). Nikaidohs had longer median cardiopulmonary bypass time (227 [interquartile range (IQR), 167-299] minutes vs 175 [IQR, 133-225] minutes; P < .001) and median aortic cross-clamp times (131 [IQR, 91-175] minutes vs 105 [IQR, 82-141] minutes; P = .0015). Operative mortality was 3.1% (95% confidence interval [CI], 1.0%-7.0%; n = 5) for Rastelli, 4.4% (95% CI, 1.4%-9.9%; n = 5) for Nikaidoh, and 11.1% (95% CI, 0.3%-48.3%, n = 1) for REV. The rates of cardiac arrest, unplanned reoperation, mechanical circulatory support, prolonged ventilation, and permanent pacemaker placement were higher in the Nikaidoh population but with 95% CIs overlapping those of the other procedures. CONCLUSIONS: Rastelli and Nikaidoh procedures are the prevalent repair strategies for patients with DORV-TGA and TGA-VSD-LVOTO. Most are performed at high-volume institutions, and early outcomes are similar.

7.
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.

8.
Ann Thorac Surg ; 2021 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-33971175

RESUMO

Available aortic prosthesis replacement options are challenged to achieve low perioperative morbidity, low pressure gradients, and prolonged durability. Trileaflet aortic valve reconstruction using autologous pericardium offers an alternative treatment option with excellent postoperative gradients, large effective orifice areas, and the avoidance of long-term anticoagulation. The modified Bentall procedure with either tissue xenograft valved conduit or mechanical valved conduit is considered the gold standard for patients with aortic root pathology requiring surgical replacement. We report a novel adaptation of the modified Bentall procedure with a self-fabricated valved conduit with trileaflet aortic valve neocuspidization using autologous pericardium. Currently available aortic prosthesis replacement options are challenged to achieve low perioperative morbidity, low pressure gradients, and prolonged durability. Trileaflet aortic valve reconstruction using autologous pericardium with the AVNeoTM system offers an alternative treatment option with excellent postoperative gradients, large effective orifice areas, and the avoidance of long-term anticoagulation1. Professor Ozaki reported excellent durability with over 95% of patients free from reoperation at 10-years1. The modified Bentall procedure with prosthesis valved conduit is considered the gold standard for patients with aortic root pathology requiring surgical replacement2. We report a novel adaptation of the modified Bentall procedure with a self-fabricated valved conduit with trileaflet aortic valve neocuspidization using autologous pericardium with the AVNeoTM system. Since the AVNeoTM template is a U.S. Food and Drug Administration approved device for treatment of aortic valve diseases1, institutional review board approval for this procedure was not necessary.

9.
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.

10.
ASAIO J ; 2021 Mar 29.
Artigo em Inglês | MEDLINE | ID: mdl-33788800

RESUMO

This study evaluates the impact of the recent United Network for Organ Sharing (UNOS) allocation policy change on outcomes of patients bridged with durable left ventricular assist devices (LVADs) to orthotopic heart transplantation (OHT). Adults bridged to OHT with durable LVADs between 2010 and 2019 were included. Patients were stratified based on the temporal relationship of their OHT to the UNOS policy change on October 18, 2018. The primary outcome was early post-OHT survival. In total, 9,628 OHTs were bridged with durable LVADs, including 701 (7.3%) under the new policy. Of all OHTs performed during the study period, the proportion occurring following durable LVAD bridging decreased from 45% to 34% (p < 0.001). The more recent cohort was higher risk, including more extracorporeal membrane oxygenation bridging (2.6% vs. 0.3%, p < 0.001), more mechanical right ventricular support (9.7% vs. 1.4%, p < 0.001), greater pretransplant ICU admission (22.8% vs. 8.7%, p < 0.001) more need for total functional assistance (62.8% vs. 53.0%, p < 0.001), older donor age (33.3 vs. 31.7 years, p < 0.001), and longer ischemic times (3.38 vs. 3.13 hours, p < 0.001). Despite this, early post-OHT survival was comparable at 30 days (96.1% vs. 96.0%, p = 0.89), 90 days (93.7% vs. 94.0%, p = 0.76), and 6 months (91.0% vs. 93.0%, p = 0.96), findings that persisted after risk-adjustment. In this early analysis, OHT following bridging with durable LVADs is performed less frequently and in higher risk recipients under the new allocation policy. Despite this, short-term posttransplant outcomes appear to be unaffected in this patient cohort in the current era.

11.
J Card Surg ; 36(3): 981-989, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33491239

RESUMO

BACKGROUND: This study evaluates the impact of secondary functional tricuspid regurgitation (TR) and concomitant tricuspid valve repair (TVr) at the time of left-sided valve operations. METHODS: Adults undergoing left-sided valve operations between 2010 and 2019 at a multihospital academic institution were included. Patients were stratified into three groups: less-than-moderate TR without TVr (Group 1), moderate-or-greater TR without TVr (Group 2), and moderate-or-greater TR with TVr (Group 3). Primary outcomes included survival and hospital readmissions. Secondary outcomes included major postoperative morbidities. Multivariable logistic regression evaluated risk-adjusted mortality and readmission. RESULTS: About 3444 patients were included in the analysis and were stratified into Group 1 (n = 2612, 75.8%), Group 2 (n = 563, 16.3%), and Group 3 (n = 269, 7.8%). Patients with moderate or greater TR (Groups 2 and 3) had higher rates of mortality, hospital readmissions and major postoperative complications including reoperations, renal failure requiring dialysis, blood transfusions, and prolonged ventilation (all, p < .05). When assessed individually, the Group 3 had substantially higher rates of renal failure requiring dialysis, prolonged ventilation, and reoperations, although the Group 2 had higher rates of 30-day mortality (all, p < .05). These findings persisted in risk-adjusted analysis with the highest hazards for mortality (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.7-2.2) and readmission (HR 1.3, 95% CI 1.2-1.5) appreciated in the Group 2. CONCLUSIONS: In this analysis of 3444 patients, those with moderate-to-severe TR who did not undergo a TVr at the time of their left-sided valve operation had substantially higher risks of mortality and hospital readmissions compared with those who did undergo TV surgery.


Assuntos
Implante de Prótese de Valva Cardíaca , Insuficiência da Valva Tricúspide , Adulto , Humanos , Diálise Renal , Estudos Retrospectivos , Resultado do Tratamento , Valva Tricúspide/cirurgia , Insuficiência da Valva Tricúspide/cirurgia
12.
J Card Surg ; 36(3): 894-901, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33428223

RESUMO

BACKGROUND: The purpose of this study was to investigate the incidence, predictors, and long-term impact of gastrointestinal (GI) complications following adult cardiac surgery. METHODS: Index Society of Thoracic Surgeons (STS) adult cardiac operations performed between January 2010 and February 2018 at a single institution were included. Patients were stratified by the occurrence of postoperative GI complications. Outcomes included early and late survival as well as other associated major postoperative complications. A subanalysis of propensity score-matched patients was also performed. RESULTS: A total of 10,285 patients were included, and the overall rate of GI complications was 2.4% (n = 246). Predictors of GI complications included dialysis dependency, intra-aortic balloon pump, congestive heart failure, chronic obstructive pulmonary disease, and longer aortic cross-clamp times. Thirty-day (2.6% vs. 24.8%), 1- (6.3% vs. 41.9%), and 3-year (11.1% vs. 48.4%) mortality were substantially higher in patients who experienced GI complications (all p < .001). GI complication was associated with a threefold increased hazard for mortality (hazard ratio = 3.1, 95% confidence interval = 2.6-3.7) after risk adjustment, and there was an association between the occurrence of GI complications and increased rates of renal failure (39.4% vs. 2.5%), new dialysis dependency (31.3% vs. 1.5%), multisystem organ failure (21.5% vs .1.0%), and deep sternal wound infections (2.6% vs. 0.2%; all p < .001). These results persisted in propensity-matched analysis. CONCLUSION: GI complications are infrequent but have a profound impact on early and late survival, and often occur in association with other major complications. Risk factor modification, heightened awareness, and early detection and management of GI complications appear warranted.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Gastroenteropatias , Cirurgia Torácica , Adulto , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Gastroenteropatias/epidemiologia , Gastroenteropatias/etiologia , Humanos , Incidência , Complicações Pós-Operatórias/epidemiologia , Diálise Renal , Estudos Retrospectivos , Fatores de Risco
13.
J Card Surg ; 36(4): 1249-1257, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33484169

RESUMO

BACKGROUND: This study evaluated the impact of the heart allocation policy change in 2018 on the characteristics and outcomes of multiorgan transplants involving heart allografts. METHODS: Adults undergoing multiorgan heart transplantation from 2010 to 2020 were identified from the United Network for Organ Sharing (UNOS) registry. Transplants were stratified into occurring before versus after the October 2018 heart allocation change. The primary outcome was 1-year survival following transplantation. A Cox proportional hazards model was used to evaluate the risk-adjusted effect of the allocation policy change on outcomes between cohorts. RESULTS: A total of 1832 patients underwent multiorgan heart transplantation during the study period with 245 (13.37%) undergoing heart-lung transplantation, 244 (13.32%) undergoing heart-liver transplantation, and 1343 (73.31%) undergoing heart-kidney transplantation. There was a higher utilization of temporary MCSDs as well as longer ischemic times for all three types of transplantation following the policy change. Heart-lung and heart-liver recipients had a similar 1-year survival before and after the policy change (each p > .05). Renal failure requiring dialysis (29.5% vs. 39.4%, p = .001) as well as 1-year survival (88% vs. 82%; log-rank p = .01) were worse in the heart-kidney cohort after the organ allocation system modification. CONCLUSIONS: This study demonstrates similar trends in multiorgan transplants as has been observed in isolated heart transplants following the allocation change, including more frequent utilization of temporary mechanical support and longer ischemic times. Although outcomes have remained comparable in the new allocation era with heart-lung and heart-liver transplants, heart-kidney recipients have a worse 1-year survival following the change.


Assuntos
Transplante de Coração , Transplante de Coração-Pulmão , Transplante de Rim , Obtenção de Tecidos e Órgãos , Adulto , Sobrevivência de Enxerto , Humanos , Políticas , Sistema de Registros , Diálise Renal , Taxa de Sobrevida
14.
Ann Thorac Surg ; 111(6): 1983-1990, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33038339

RESUMO

BACKGROUND: Racial disparities exist between Black and White patients with coronary artery disease with regard to access to revascularization, preprocedural comorbidities, and postprocedural outcomes. This study investigated the differences in the treatment of multivessel coronary artery disease (MVCAD) and long-term outcomes between Black and White patients. METHODS: This was a propensity-matched retrospective analysis that utilized pooled institutional data from a large, multihospital health care system. It included Black and White patients who underwent coronary revascularization for MVCAD between 2011 and 2018. RESULTS: A total of 6005 patients were included (5689 White and 316 Black). In the unmatched cohort, Black patients had a higher incidence of preexisting comorbidities such as diabetes, dialysis dependence, peripheral arterial disease, heart failure, and underwent percutaneous coronary intervention (PCI) more frequently. Five-year overall survival was similar, but Black patients experienced higher rates of major adverse cardiac and cerebrovascular events and repeat revascularization. Propensity matching resulted in a sample of 926 (312 Black, 614 White) patients that were well matched. In the matched analysis, Black patients underwent PCI more frequently and a had higher rate of stoke. Five-year survival, major adverse cardiac and cerebrovascular events and repeat revascularization rates were comparable. CONCLUSIONS: Black patients with MVCAD have a higher comorbidity burden and undergo PCI at higher rates. After adjusting for baseline differences, Black patients still had higher rates of PCI utilization and long-term stroke. It is possible that a significant portion of racial disparities in MVCAD are driven by differences in baseline risk; however, there is evidence of possible racial bias with regard to revascularization strategies.


Assuntos
Afro-Americanos/estatística & dados numéricos , Doença da Artéria Coronariana/etnologia , Doença da Artéria Coronariana/cirurgia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Revascularização Miocárdica/estatística & dados numéricos , Idoso , Tomada de Decisão Clínica , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Intervenção Coronária Percutânea/estatística & dados numéricos , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Estados Unidos
15.
J Card Surg ; 36(1): 105-110, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33124124

RESUMO

BACKGROUND: The predictive value of preoperative pulmonary function testing (PFT) in left ventricular assist device (LVAD) patients remains unknown. This study evaluates the relationship between abnormal PFTs and postimplant outcomes in LVAD patients. METHODS: LVAD implants from January 2004 to December 2018 at a single institution were included. Patients were stratified based on the presence of abnormal preoperative PFTs, and the primary outcome was respiratory adverse events (AE). Secondary outcomes included 1-year overall postimplant survival, and complications including bleeding, renal failure, thromboembolism, and device malfunction. RESULTS: The total of 333 patients underwent LVAD implant, 46.5% (n = 155) with normal PFTs and 53.5% (n = 178) with abnormal PFTs. Patients with abnormal PFTs were noted to have higher rates of respiratory AEs (25.9% vs. 15.1%, p = .049). In multivariable analysis, the impact of PFTs was most significant when forced expiratory volume in 1 s/forced expiratory volume (FEV1/FVC) ratio was less than 0.5 (hazard ratio [HR] 16.32, 95% confidence interval [CI], 1.70-156.78). The rates of other AEs including bleeding, renal failure, right heart failure, and device malfunction were similar. One-year overall postimplant survival was comparable between the groups (56.8% vs. 68.8%, p = .3183), though patients in the lowest strata of FEV1 (<60% predicted) and FEV1/FVC (<0.5) had elevated risk-adjusted hazards for mortality (HR 2.63, 95% CI, 1.51-4.60 and HR 18.92, 95% CI, 2.10-170.40, respectively). CONCLUSIONS: The presence of abnormal preoperative PFTs is not prohibitory for LVAD implantation although it can be used for risk stratification for respiratory AEs and mortality, particularly in patients with severely reduced metrics. The importance of careful patient selection should be underscored in this higher risk patient subset.


Assuntos
Insuficiência Cardíaca , Coração Auxiliar , Insuficiência Renal , Insuficiência Cardíaca/terapia , Coração Auxiliar/efeitos adversos , Humanos , Testes de Função Respiratória , Estudos Retrospectivos , Resultado do Tratamento
16.
Ann Thorac Surg ; 111(3): 906-913, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-32745515

RESUMO

BACKGROUND: This study evaluated the impact of very early hospital discharge after coronary artery bypass grafting (CABG) on subsequent readmission and survival. METHODS: Adults undergoing isolated CABG from 2011 to 2018 at a single institution were included. Patients were stratified on the basis of their postoperative length of hospital stay: short stay (≤4 days) and nonshort stay (>4 days). The primary outcomes were longitudinal survival and freedom from hospital readmission. Secondary outcomes included rates of postoperative complications. Propensity score matching with a 1:1 ratio was performed to generate cohorts with comparable baseline characteristics. RESULTS: A total of 6327 patients underwent CABG during the study period, and a matched cohort of 2286 patients was identified. In matched analysis, the average Society of Thoracic Surgeons predicted risk of operative mortality was low in both groups (average, 0.7%). Rates of postoperative complications were low and several complication rates were even lower in the short-stay cohort: stroke (1.14% vs 0.26%; P = .01), renal failure (0.87% vs 0.09%; P = .007), reoperations (1.84% vs 0.26%; P < .001), and new-onset atrial fibrillation (34.21% vs 13.04%; P < .001). Survival was similar between the matched groups at 30 days (99.56% vs 99.21%), 1 year (97.73% vs 97.46%), and 5 years (91.15% vs 92.48%) (all P > .05). Readmission rates were also comparable at all time intervals, and there were no differences in cardiac-related or heart failure-specific readmissions (all P > .05). Risk-adjusted analyses confirmed these findings. CONCLUSIONS: This study demonstrates that very early discharge within 4 days of isolated CABG is safe and has no substantial impact on subsequent mortality or readmission risk.


Assuntos
Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Alta do Paciente/tendências , Readmissão do Paciente/tendências , Idoso , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Período Pós-Operatório , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Fatores de Tempo
17.
Ann Thorac Surg ; 111(6): 2066-2071, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-32866478

RESUMO

BACKGROUND: Burnout has been linked to poor job satisfaction and increased medical errors, and is prevalent among health care professionals. We sought to characterize burnout and distress among US cardiothoracic surgery (CTS) trainees. METHODS: A 19-question survey was sent to CTS trainees in collaboration with the Thoracic Surgery Residents Association. We queried sociodemographic variables, balance/quality of life, and indicators of depression and regret. We included questions along the emotional exhaustion, depersonalization, and personal accomplishment subscales of the Maslach Burnout Inventory. RESULTS: The survey was sent to 531 CTS trainees across 76 institutions and there were 108 responses (20.3%). More than 50% of respondents expressed dissatisfaction with balance in their professional life and more than 40% screened positively for signs of depression. More than 25% of respondents (n = 28) would not complete CTS training again, given a choice. More than half met criteria for burnout on emotional exhaustion and depersonalization subscales. The CTS residents with children were more likely to express regret toward pursuing CTS training. A greater proportion of women than men reported poor levels of balance/quality of life during training as measured by missed health appointments, negative impact on relationships, and self-perception. Similarly, those in the final 3 years of training were more likely to report poor levels of balance/quality of life. CONCLUSIONS: High rates of burnout, regret, and depression are present among US CTS trainees. Efforts to promote trainee well-being and implement interventions that support those at high risk for burnout are warranted, to benefit trainees as well as the patients they serve.


Assuntos
Esgotamento Profissional/epidemiologia , Internato e Residência , Cirurgia Torácica/educação , Adulto , Depressão/epidemiologia , Emoções , Feminino , Humanos , Satisfação no Emprego , Masculino , Qualidade de Vida , Inquéritos e Questionários , Carga de Trabalho , Adulto Jovem
18.
J Card Surg ; 36(1): 74-81, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33135295

RESUMO

BACKGROUND: This study compares the postoperative outcomes, 30-day readmission rates, and incidence of sternal wound infection-related readmissions between patients receiving bilateral internal mammary arteries (BIMA) and single internal mammary artery (SIMA) grafting during coronary artery bypass graft (CABG) surgery. METHODS: We utilized the weighted 2013-2014 National Readmission Database claims to identify all US adult patients who underwent CABG utilizing SIMA (n = 279,891) or BIMA (n = 11,651). Thirty-day overall and wound-related readmissions, in-hospital outcomes, costs, lengths of stay (LOS) at readmissions were compared between the two groups. Predictors of 30-day readmission were assessed using multivariable Cox proportional hazards analysis. RESULTS: After propensity matching (n = 10,339 pairs), there were no significant differences between the two groups during the index hospitalization, except for higher total hospital costs in the BIMA group (p = .02). The incidence of wound infections was also comparable between BIMA and SIMA (1.1% vs. 1.2%; p = .50). At 30-days, the overall readmission rate was elevated in SIMA patients (9.5% vs. 8.8%; p < .01), primarily impacted by cardiovascular causes. While the proportion of 30-day readmissions due to infections was significantly higher among BIMA versus SIMA patients (20.4% vs. 15.9%; p < .01), wound infections during the index hospitalization did not predict all-cause 30-day readmission among BIMA patients (p = .24) in the risk-adjusted analysis. Among the readmitted patients, LOS (6.4 vs. 6.2 days), costs ($14,440 vs. $16,461), and in-hospital mortality (2.4% vs. 1.7%) were comparable between the two groups (all p > .05). CONCLUSIONS: BIMA grafting is not an independent predictor of all-cause 30-day readmissions. Cardiovascular causes remain the primary driver of 30-day readmissions among SIMA and BIMA patients after CABG.


Assuntos
Doença da Artéria Coronariana , Artéria Torácica Interna , Adulto , Ponte de Artéria Coronária , Mortalidade Hospitalar , Humanos , Anastomose de Artéria Torácica Interna-Coronária , Readmissão do Paciente , Estudos Retrospectivos , Resultado do Tratamento
19.
Transplantation ; 105(3): 620-627, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-32301909

RESUMO

BACKGROUND: Donors with drowning or asphyxiation (DA) as a mechanism of death (MOD) are considered high risk in pediatric lung transplantation. We sought to evaluate whether recipients of DA donors had negatively impacted outcomes. METHODS: Pediatric recipients recorded in the United Network for Organ Sharing registry between 2000 and 2019 were included. Primary stratification was donor MOD. Propensity matching with a 1:1 ratio was performed to balance the DA and non-DA MOD donor cohorts. Cox multivariable regression was used to determine the risk-adjusted impact of donor MOD. A subanalysis of the effect of lung allocation score was also evaluated. RESULTS: A total of 1016 patients underwent bilateral lung transplantation during the study period, including 888 (85.6%) from non-DA donors and 128 (14.4%) from DA donors. Survival at 90 days, 1 year, and 2 years were similar in the matched and unmatched cohorts regardless of the donor MOD. Moreover, separate risk-adjusted analysis of drowning and asphyxiated donors was similar to other MOD donors at 30 days, 1 year, and 5 years. Similar survival findings persisted regardless of pretransplant lung allocation score. Although the rates of posttransplant stroke (1.0% versus 3.1%, P = 0.04) and the length of hospital stay (19 versus 22 d, P = 0.004) were elevated in the unmatched DA MOD recipients, these differences were mitigated after propensity matching. CONCLUSIONS: This study evaluated the impact of DA MOD donors in pediatric lung transplant recipients and found similar rates of complications and survival in a propensity-matched cohort. These data collectively support the consideration of DA MOD donors for use in pediatric lung transplantation.


Assuntos
Asfixia , Afogamento , Transplante de Pulmão , Sistema de Registros , Doadores de Tecidos , Obtenção de Tecidos e Órgãos/métodos , Transplantados , Fatores Etários , Criança , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
20.
Int J Artif Organs ; 44(1): 65-67, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32475219

RESUMO

A 50-year-old male with a history of nonischemic dilated cardiomyopathy presented in cardiogenic shock and ultimately underwent durable left ventricular assist device implantation. He recovered well initially but developed persistent bacteremia. His indwelling pacemaker leads were extracted due to evidence of vegetation. Shortly thereafter, around 3 months post-left ventricular assist device, he succumbed to a massive intracranial hemorrhage due to ruptured cerebral mycotic aneurysm. This case highlights the potential importance of brain imaging in left ventricular assist device patients with persistent bacteremia to avoid this likely catastrophic complication.


Assuntos
Aneurisma Infectado/diagnóstico por imagem , Bacteriemia/diagnóstico por imagem , Coração Auxiliar/efeitos adversos , Aneurisma Intracraniano/diagnóstico por imagem , Choque Cardiogênico/cirurgia , Infecções Estafilocócicas/diagnóstico por imagem , Antibacterianos/uso terapêutico , Bacteriemia/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Infecções Estafilocócicas/tratamento farmacológico
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