Depression predicts cognitive and functional decline one month after coronary artery bypass graft surgery (Neuropsychiatric Outcomes After Heart Surgery study).

BACKGROUND: Prior research on cognitive and functional outcomes after coronary artery bypass graft (CABG) surgery has largely explored these two domains in isolation. In this study, we assess baseline depression and cognition as risk factors for decline in the Clinical Dementia Rating Sum-of-Boxes (CDR-SB) 1 month post-CABG surgery, which a combined measure of cognition and function. DESIGN: The Neuropsychiatric Outcomes After Heart Surgery study is a prospective observational cohort study. SETTING: A tertiary care, academic center. PARTICIPANTS: Of a total study sample of 148 patients undergoing CABG surgery, 124 (83.8%) completed 1-month follow-up assessment. Mean age was 66.3, 32 (25.8%) female and 112 (90.3%) White. MEASUREMENTS: Cognition, function, and depression were assessed on semi-structured clinical interviews. Cognitive and functional status were defined using CDR-SB; mild or major depression was defined by the Hamilton Depression Rating Scale. Additionally, neuropsychological battery was performed at baseline. RESULTS: CDR-SB decline occurred in 18 (14.5%) subjects. Older age, depression, baseline CDR-SB, and postoperative delirium were associated with 1-month decline on univariate analysis. Older age (OR 1.1 [1.0-1.2]) and depression (OR 6.2 [1.1-35.0]) remained significant on multivariate regression. In separate models, baseline performance on visual Wechsler memory scale (delayed), Hopkins verbal learning test (immediate and delayed), controlled oral word fluency test, and Trails B predicted CDR-SB decline. CONCLUSION: Roughly one in seven patients experienced CDR-SB decline 1 month after CABG surgery. Also, preoperative depression deserves recognition for being a predictor of CDR-SB decline one month post-CABG.

Depression Predicts Delirium After Coronary Artery Bypass Graft Surgery Independent of Cognitive Impairment and Cerebrovascular Disease: An Analysis of the Neuropsychiatric Outcomes After Heart Surgery Study.

OBJECTIVE: Although depression is a known risk factor for delirium after coronary artery bypass graft (CABG) surgery, it is unclear whether this risk is independent of delirium risk attributable to cognitive impairment or cerebrovascular disease. This study examines depression, mild cognitive impairment (MCI), and cerebrovascular disease as post-CABG delirium risk factors. METHODS: This prospective observational cohort study was performed in a tertiary-care academic hospital. Subjects were without dementia and undergoing CABG surgery. Preoperative cognitive assessment included Clinical Dementia Rating and neuropsychological battery; depression was assessed using Depression Interview and Structured Hamilton. Baseline intracranial stenosis was evaluated by transcranial Doppler of bilateral middle cerebral arteries (MCAs). Study psychiatrists assessed delirium on postoperative days 2-5 using the Confusion Assessment Method. RESULTS: Our analytic sample comprised 131 subjects (average age: 65.8 ± 9.2years, 27% women). MCI prevalence was 24%, preoperative depression 10%, lifetime depression 35%, and MCA stenosis (≥50%) 28%. Sixteen percent developed delirium. Multivariate analysis revealed that age, MCI (odds ratio [OR]: 5.1; 95% confidence interval [CI]: 1.3-20.1), and preoperative depression (OR: 9.9; 95% CI: 1.3-77.9)-but not lifetime depression-predicted delirium. MCA stenosis and severity predicted delirium in univariate but not multivariate analysis. Right MCA stenosis severity predicted delirium severity, but left-sided stenosis severity did not. CONCLUSION: We established that the risk of delirium attributable to depression extends beyond the potential moderating influence of cognitive impairment and cerebrovascular disease alone. Even mild depression and cognitive impairment before CABG deserve recognition for their effect on post-CABG cognitive health.

Cognitive and functional status predictors of delirium and delirium severity after coronary artery bypass graft surgery: an interim analysis of the Neuropsychiatric Outcomes After Heart Surgery study.

BACKGROUND: Cognitive and functional impairment increase risk for post-coronary artery bypass graft (CABG) surgery delirium (PCD), but how much impairment is necessary to increase PCD risk remains unclear. METHODS: The Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study is a prospective, observational cohort study of participants undergoing elective CABG surgery. Pre-operative cognitive and functional status based on Clinical Dementia Rating (CDR) scale and neuropsychological battery are assessed. We defined mild cognitive impairment (MCI) based on either (1) CDR global score 0.5 (CDR-MCI) or (2) performance 1.5 SD below population means on any cognitive domain on neurocognitive battery (MCI-NC). Delirium was assessed daily post-operative day 2 through discharge using the confusion assessment method (CAM) and delirium index (DI). We investigate whether MCI - either definition - predicts delirium or delirium severity. RESULTS: So far we have assessed 102 participants (mean age 65.1 ± 9; male: 75%) for PCD. Twenty six participants (25%) have MCI-CDR; 38 (62% of those completing neurocognitive testing) met MCI-NC criteria. Fourteen participants (14%) developed PCD. After adjusting for age, sex, comorbidity, and education, MCI-CDR, MMSE, and Lawton IADL score predicted PCD on logistic regression (OR: 5.6, 0.6, and 1.5, respectively); MCI-NC did not (OR [95% CI]: 11.8 [0.9, 151.4]). Using similarly adjusted linear regression, MCI-CDR, MCI-NC, CDR sum of boxes, MMSE, and Lawton IADL score predicted delirium severity (adjusted R(2): 0.26, 0.13, 0.21, 0.18, and 0.32, respectively). CONCLUSIONS: MCI predicts post-operative delirium and delirium severity, but MCI definition alters these relationships. Cognitive and functional impairment independently predict post-operative delirium and delirium severity.

Simple score to assess the risk of rejection after orthotopic heart transplantation.

BACKGROUND: The aim of this study was to derive and validate a risk score for rejection after orthotopic heart transplantation. METHODS AND RESULTS: The United Network for Organ Sharing registry was used to identify patients undergoing orthotopic heart transplantation between 1998 and 2008. A total of 14 265 eligible patients were randomly divided into derivation (80%; n=11 412) and validation (20%; n=2853) cohorts. The primary outcome was drug-treated rejection within 1 year of orthotopic heart transplantation. Covariates found to be associated (exploratory univariate P<0.2) with rejection were entered into a multivariable logistic regression model. Inclusion of each variable in the model was assessed by improvement in the McFadden pseudo-R(2), likelihood ratio test, and c index. A risk score was then generated through the use of relative magnitudes of the odds ratios from the derivation cohort, and its ability to predict rejection was tested independently in the validation cohort. A 13-point risk score incorporating 4 variables (age, race, sex, HLA matching) was created. The mean scores in the derivation and validation cohorts were 8.3±2.2 and 8.4±2.1, respectively. Predicted 1-year rejection rates based on the derivation cohort ranged from 16.2% (score=0) to 50.7% (score=13; P<0.001). In weighted regression analysis, there was a strong correlation between these predicted rates of rejection and actual, observed rejection rates in the validation cohort (r(2)=0.96, P<0.001). Logistic regression analysis also demonstrated a significant association (odds ratio, 1.13; P<0.001). The c index of the composite score was equivalent in both the derivation and validation cohorts (c=0.67). CONCLUSIONS: This novel 13-point risk score is highly predictive of clinically significant rejection episodes within 1 year of orthotopic heart transplantation. It has potential utility in tailoring immunosuppressive regimens and in research stratification in orthotopic heart transplantation.

Ventricular assist device implantation in the elderly: nationwide outcomes in the United States.

BACKGROUND: The aim of this study was to evaluate nationwide outcomes of ventricular assist device (VAD) implantation in elderly patients in the United States. METHODS: Patients undergoing VAD implantation between 2003 and 2008 were identified in the Nationwide Inpatient Sample. The primary outcome was inpatient mortality following VAD implantation. Secondary outcomes included disposition following discharge and costs of care. After stratification based on primary versus postcardiotomy VAD support, outcomes were compared between controls aged 60-69 years and elderly patients aged ≥70 years. RESULTS: A total of 2787 patients aged 60-69 years and 1472 patients aged ≥70 years underwent VAD implantation during the study period. Unadjusted mortality rates were comparable between elderly and control patients in both primary support (35.7% vs. 32.1%, p = 0.61) and postcardiotomy support (58.1% vs. 56.1%, p = 0.70). Similarly, in risk-adjusted multivariable logistic regression analysis incorporating clinically relevant variables, age ≥70 did not exert an independent effect on inpatient mortality for either indication. Inpatient costs in the elderly were lower than controls in the primary support cohort, although costs per day were similar, with comparable overall costs between age groups in the postcardiotomy cohort. Elderly survivors were discharged to a facility more frequently than control survivors (primary: 49.9% vs. 29.6%, p = 0.007; postcardiotomy: 67.4% vs. 45.7%, p = 0.03). CONCLUSIONS: This large-cohort population-based analysis provides a useful framework for inpatient prognosis and resource utilization in elderly patients undergoing VAD implantation. Although mortality rates and costs were found to be comparable between elderly patients and those aged 60-69 years, these rates were nonetheless significant. This combined with more frequent discharge-to-facility in elderly survivors underscores the importance of careful patient selection in this population.

Institutional factors beyond procedural volume significantly impact center variability in outcomes after orthotopic heart transplantation.

OBJECTIVE: To evaluate the contribution of institutional volume and other unmeasured institutional factors beyond volume to the between-center variability in outcomes after orthotopic heart transplantation (OHT). BACKGROUND: It is unclear if institutional factors beyond volume have a significant impact on OHT outcomes. METHODS: The United Network for Organ Sharing registry was used to identify OHTs performed between 2000 and 2010. Separate mixed-effect logistic regression models were constructed, with the primary endpoint being post-OHT mortality. Model A included only individual centers, model B added validated recipient and donor risk indices as well as the year of transplantation, and model C added institutional volume as a continuous variable to model B. The reduction in between-center variability in mortality between models B and C was used to define the contribution of institutional volume. Kaplan-Meier survival curves were also compared after stratifying patients into equal-size tertiles based on center volume. RESULTS: A total of 119 centers performed OHT in 19,156 patients. After adjusting for transplantation year and differences in recipient and donor risk, decreasing center volume was associated with an increased risk of 1-year mortality (P < 0.001). However, procedural volume only accounted for 16.7% of the variability in mortality between centers, and significant between-center variability persisted after adjusting for institutional volume (P<0.001). In Kaplan-Meier analysis, there was significant variability in 1-year survival between centers within each volume category: low-volume (66.7%-96.6%), intermediate-volume (80.7%-97.3%), and high-volume (83.8%-93.9%). These trends were also observed with 5-year mortality. CONCLUSIONS: This large-cohort analysis demonstrates that although institutional volume is a significant predictor of post-OHT outcomes, there are other unmeasured institutional factors that contribute substantially to the between-center variability in outcomes. Institutional volume should therefore not be the sole indicator of "center quality" in OHT.

Review of methods for objective surgical skill evaluation.

BACKGROUND: Rising health and financial costs associated with iatrogenic errors have drawn increasing attention to the dexterity of surgeons. With the advent of new technologies, such as robotic surgical systems and medical simulators, researchers now have the tools to analyze surgical motion with the goal of differentiating the level of technical skill in surgeons. METHODS: The review for this paper is obtained from a Google Scholar and PubMed search of the key words "objective surgical skill evaluation." Only studies that included motion analysis were used. RESULTS: In this paper, we provide a clinical motivation for the importance of surgical skill evaluation. We review the current methods of tracking surgical motion and the available data-collection systems. We also survey current methods of surgical skill evaluation and show that most approaches fall into one of three methods: (1) structured human grading; (2) descriptive statistics; or (3) statistical language models of surgical motion. We discuss the need for an encompassing approach to model human skill through statistical models to allow for objective skill evaluation.

Safe and effective intravenous thrombolysis for acute ischemic stroke caused by left atrial myxoma.

Atrial myxoma may be associated with syncope or sudden death attributed to left-sided cardiac outflow obstruction or embolization caused by tumor dislodgement or thrombus formation. Definitive treatment for primary and secondary stroke prevention is surgical resection. The role of thrombolysis in acute brain ischemia in patients with atrial myxoma is not defined. There are few data available regarding safety and efficacy of thrombolytic therapy in acute ischemic strokes caused by atrial myxoma. Prior case reports described partial success using intra-arterial local thrombolysis; however, this is invasive and can be associated with significant complications. A previously reported case of systemic thrombolysis resulted in development of cerebral hemorrhage. We describe a young man who presented with syncope and a dense stroke developing as a complication of atrial myxoma, followed by a remarkable recovery after treatment with intravenous recombinant tissue plasminogen activator and urgent cardiac surgery. Contrary to some expert opinion, systemic thrombolytic therapy may be safely and effectively used to treat acute ischemic strokes from atrial myxoma.

Automatic recognition of surgical motions using statistical modeling for capturing variability.

The ability to accurately recognize elementary surgical gestures is a stepping stone to automated surgical assessment and surgical training. However, as the pool of subjects increases, variation in surgical techniques and unanticipated motion increases the challenge of creating robust statistical models of gestures. This paper examines the applicability of advanced modeling techniques from automated speech recognition to the problem of increasing variability in surgical motions. In particular, we demonstrate the effectiveness of automatically bootstrapped user-adaptive models on diverse data acquired from the da Vinci surgical robot.

Nontuberculous Mycobacterium Infections Associated With Heater-Cooler Devices.

BACKGROUND: Disseminated nontuberculous mycobacterium infections have occurred following surgical procedures involving extracorporeal circulation; contaminated water from heater-cooler devices (HCDs) has been implicated as the source. The purpose of this review was to evaluate the public health concern and to educate physicians who care for this patient population. METHODS: The Food and Drug Administration Medical Device Reporting (MDR) database was queried for reports received between January 2010 and August 2016 for patient infections and device contaminations associated with the use of HCDs. Reports were reviewed for type of infection, patient demographics or outcome, reporting country, HCD manufacturer, and the time to event occurrence. RESULTS: A total of 339 MDR reports involving 99 facilities and 5 HCD manufacturers were found. MDR reports originated within (n = 154) and outside the United States (n = 185), and included 107 MDR reports describing patient infections involving at least 86 patients and 232 MDR reports describing HCD contamination without known patient infections. The MDR reports identified the surgical procedure in 94 reports and infection location in 83 reports. The time from surgical procedure using an HCD to infection diagnosis was calculable in 67 reports and was reported up to 60 months following the initial surgery. Nontuberculous mycobacterium was the most frequent organism identified, with M. chimaera being the predominate isolate. CONCLUSIONS: Nontuberculous mycobacterium infections associated with HCDs used during cardiothoracic surgery may have a long latency period and may be lethal. Cardiothoracic surgeon awareness or involvement in this issue is critical in helping to mitigate this emerging public health concern.

Personalized mitral valve closure computation and uncertainty analysis from 3D echocardiography.

Intervention planning is essential for successful Mitral Valve (MV) repair procedures. Finite-element models (FEM) of the MV could be used to achieve this goal, but the translation to the clinical domain is challenging. Many input parameters for the FEM models, such as tissue properties, are not known. In addition, only simplified MV geometry models can be extracted from non-invasive modalities such as echocardiography imaging, lacking major anatomical details such as the complex chordae topology. A traditional approach for FEM computation is to use a simplified model (also known as parachute model) of the chordae topology, which connects the papillary muscle tips to the free-edges and select basal points. Building on the existing parachute model a new and comprehensive MV model was developed that utilizes a novel chordae representation capable of approximating regional connectivity. In addition, a fully automated personalization approach was developed for the chordae rest length, removing the need for tedious manual parameter selection. Based on the MV model extracted during mid-diastole (open MV) the MV geometric configuration at peak systole (closed MV) was computed according to the FEM model. In this work the focus was placed on validating MV closure computation. The method is evaluated on ten in vitro ovine cases, where in addition to echocardiography imaging, high-resolution µCT imaging is available for accurate validation.

Fatal outcome of a calcified amorphous tumor of the heart (cardiac CAT).

Calcified amorphous tumor of the heart (cardiac CAT) is an unusual non-neoplastic cardiac mass that can mimic a more malignant lesion. We describe a case of cardiac CAT in a 60-year-old female who presented with syncope. Workup revealed a 2.1-cm mass in the right ventricular wall involving the chordae tendineae of the tricuspid valve, impacting right ventricular function. Magnetic resonance imaging, echocardiography, angiography, and histologic descriptions of the lesion are described.

Effect of sensory substitution on suture-manipulation forces for robotic surgical systems.

OBJECTIVES: Direct haptic (force or tactile) feedback is not yet available in commercial robotic surgical systems. Previous work by our group and others suggests that haptic feedback might significantly enhance the execution of surgical tasks requiring fine suture manipulation, specifically those encountered in cardiothoracic surgery. We studied the effects of substituting direct haptic feedback with visual and auditory cues to provide the operating surgeon with a representation of the forces he or she is applying with robotic telemanipulators. METHODS: Using the robotic da Vinci surgical system (Intuitive Surgical, Inc, Sunnyvale, Calif), we compared applied forces during a standardized surgical knot-tying task under 4 different sensory-substitution scenarios: no feedback, auditory feedback, visual feedback, and combined auditory-visual feedback. RESULTS: The forces applied with these sensory-substitution modes more closely approximate suture tensions achieved under ideal haptic conditions (ie, hand ties) than forces applied without such sensory feedback. The consistency of applied forces during robot-assisted suture tying aided by visual feedback or combined auditory-visual feedback sensory substitution is superior to that achieved with hand ties. Robot-assisted ties aided with auditory feedback revealed levels of consistency that were generally equivalent or superior to those attained with hand ties. Visual feedback and auditory feedback improve the consistency of robotically applied forces. CONCLUSIONS: Sensory substitution, in the form of visual feedback, auditory feedback, or both, confers quantifiable advantages in applied force accuracy and consistency during the performance of a simple surgical task.