Long-term Mortality and Reintervention After Repair of Ruptured Abdominal Aortic Aneurysms Using VQI-matched Medicare Claims.

OBJECTIVE: The objective of this study was to compare endovascular aortic aneurysm repair (EVAR) versus open aortic repair (OAR) on mortality and reintervention after ruptured infrarenal abdominal aortic aneurysm (rAAA) repair in the Vascular Quality Initiative (VQI). BACKGROUND: The optimal treatment modality for rAAA remains debated, with little data on long-term comparisons. METHODS: VQI rAAA repairs (2004-2018) were matched with Medicare claims (VQI-VISION). Primary outcomes were in-hospital and long-term mortality. Secondary outcome was reintervention. Inverse probability weighting was used to adjust for treatment selection, and Cox Proportional Hazards models and negative binomial regressions were used for analysis. Landmark analysis was performed among patients surviving hospital discharge. RESULTS: Among 1885 VQI/Medicare rAAA patients, 790 underwent OAR, and 1095 underwent EVAR. Median age was 76 years; 73% were male. Inverse probability weighting produced comparable groups. In-hospital mortality was lower after EVAR versus OAR (21% vs 37%, odds ratio: 0.52, 95% CI, 0.4-0.7). One-year mortality rates were lower for EVAR versus OAR [hazard ratio (HR) 0.74, 95% CI, 0.6-0.9], but not statistically different after 1 year (HR: 0.95, 95% CI, 0.8-1.2). This implies additional benefits to EVAR in the short term. Reintervention rates were higher after EVAR than OAR at 2 and 5 years (rate ratio: 1.79 95% CI, 1.2-2.7 and rate ratio:2.03 95% CI, 1.4-3.0), but not within the first year. Reintervention was associated with higher mortality risk for both OAR (HR: 1.66 95% CI, 1.1-2.5) and EVAR (HR: 2.14 95% CI, 1.6-2.9). Long-term mortality was similar between repair types (HR: 0.99, 95% CI, 0.8-1.2). CONCLUSIONS: Within VQI/Medicare patients undergoing rAAA repair, the perioperative mortality rate favors EVAR but equalizes after 1 year. Reinterventions were more common after EVAR and were associated with higher mortality regardless of treatment.

Estimating risk of adverse cardiac event after vascular surgery using currently available online calculators.

BACKGROUND: The decision to proceed with vascular surgical interventions requires evaluation of cardiac risk. Recently, several online risk calculators were created to predict outcomes and to lead to a more informed conversation between surgeons and patients. The objective of this study was to compare and further validate these online calculators with actual adverse cardiac outcomes at a single institution. METHODS: All patients from January 2011 through December 2015 undergoing carotid endarterectomy (CEA), infrainguinal lower extremity bypass, open abdominal aortic aneurysm (AAA) repair, and endovascular aneurysm repair (EVAR) on the vascular surgical service were included using the Society for Vascular Surgery Vascular Quality Initiative database at our health system. Additional information was collected through retrospective chart review. Each patient was entered through three online risk calculators: (1) the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) estimates the risk of cardiac arrest and myocardial infarction (MI); (2) the Revised Cardiac Risk Index (RCRI) estimates risk of MI, pulmonary edema, ventricular fibrillation, primary cardiac arrest, and complete heart block; and (3) the Vascular Study Group of New England (VSGNE) Cardiac Risk Index estimates risk of postoperative MI only. Observed adverse cardiac events (ACEs) were compared with expected values for each calculator using a χ2 goodness-of-fit test. Institutional Review Board exemption was obtained. RESULTS: A total of 856 cases were included: 350 CEAs, 210 infrainguinal bypasses, 77 open AAA repairs, and 219 EVARs. For CEA, no risk calculator showed statistically significant variation from the observed values (NSQIP, P = .45; RCRI, P = .17; VSGNE, P = .24). For infrainguinal bypass, NSQIP slightly underpredicted adverse events (P = .054), RCRI strongly underpredicted (P = .002), and VSGNE showed no difference (P = .42). For open AAA repair, NSQIP (P = .51) and VSGNE (P = .98) were adequate predictors, but RCRI strongly underpredicted the adverse events (P ≤ .0001). Finally, EVAR cardiac outcomes showed greater adverse events than predicted by all three calculators (NSQIP, P = .02; RCRI, P = .0002; and VSGNE, P = .025). Pooled data for the entire group documented that the VSGNE proved an accurate tool for prediction (P = .34), whereas ACEs were underpredicted by NSQIP (P = .0055) and RCRI (P ≤ .001). CONCLUSIONS: Although online cardiac risk calculators of adverse surgical events are easy to use and to reference in broad surgical decision-making, there is significant variability in their predictability at the procedure and institutional level. Our data suggest that ACEs often occur at a higher rate than expected on the basis of calculated risks profiles, thus creating a platform for future discussion about preoperative evaluation and postoperative care decision-making models.

Open Surgical Incisions After Colorectal Surgery Improve Quality Metrics, But Do Patients Benefit?

BACKGROUND: Surgical site infection is a frequent cause of morbidity after colorectal resection and is a quality measure for hospitals and surgeons. In an effort to reduce the risk of postoperative infections, many wounds are left open at the time of surgery for secondary or delayed primary wound closure. OBJECTIVE: The purpose of this study was to evaluate the impact of delayed wound closure on the rate of surgical infections and resource use. DESIGN: This retrospective propensity-matched study compared colorectal surgery patients with wounds left open with a cohort of patients with primary skin closure. SETTINGS: The American College of Surgeons National Quality Improvement Program Participant Use file for 2014 was queried. PATIENTS: A total of 50,212 patients who underwent elective or emergent colectomy, proctectomy, and stoma creation were included. MAIN OUTCOME MEASURES: Rates of postoperative infections and discharge to medical facilities were measured. RESULTS: Surgical wounds were left open in 2.9% of colorectal cases (n = 1466). Patients with skin left open were broadly higher risk, as evidenced by a significantly higher median estimated probability of 30-day mortality (3.40% vs 0.45%; p < 0.0001). After propensity matching (n = 1382 per group), there were no significant differences between baseline characteristics. Within the matched cohort, there were no differences in the rates of 30-day mortality, deep or organ space infection, or sepsis (all p > 0.05). Resource use was higher for patients with incisions left open, including longer length of stay (11 vs 10 d; p = 0.006) and higher rates of discharge to a facility (34% vs 27%; p < 0.001). LIMITATIONS: This study was limited by its retrospective design and a large data set with a bias toward academic institutions. CONCLUSIONS: In a well-matched colorectal cohort, secondary or delayed wound closure eliminates superficial surgical infections, but there was no decrease in deep or organ space infections. In addition, attention should be given to the possibility for increased resource use associated with open surgical incisions. See Video Abstract at http://links.lww.com/DCR/A560.

Surgeon, not institution, case volume is associated with limb outcomes after lower extremity bypass for critical limb ischemia in the Vascular Quality Initiative.

OBJECTIVE: Studies from large administrative databases have demonstrated associations between institutional case volume and outcomes after lower extremity bypass (LEB). We hypothesized that increased institutional and surgeon volume would be associated with improved outcomes after LEB. Using a national, prospectively collected clinical database, the objective of this study was to determine the effects of both surgeon and institutional volume on outcomes after LEB. METHODS: The Vascular Quality Initiative (VQI) was queried to identify all LEBs for critical limb ischemia or claudication between 2004 and 2014. Average annual case volume was calculated by dividing an institution's or surgeon's total LEB volume by the number of years they reported to the VQI. Institutional and surgeon volumes were analyzed as continuous variables to determine the impact of volume on major adverse cardiac events (MACEs), major adverse limb events (MALEs), graft patency, and amputation-free survival. Hierarchical regression models were used with cases clustered by surgeon and center. Time-dependent outcomes were evaluated with multivariable shared frailty Cox proportional hazards models. RESULTS: From 2004 to 2014, there were 14,678 LEB operations performed at 114 institutions by 587 surgeons. Average annual institutional volume ranged from 1.0 to 137.5 LEBs per year, with a median of 26.9 (interquartile range, 14-45.3). Average annual surgeon volume ranged from 1 to 52 LEBs per year with a median of 5.7 (interquartile range, 2.5-9.3). Institutional LEB volume was not associated with MACEs or MALEs or with loss of patency. However, average annual surgeon volume was independently associated with reduced MALEs and improved primary patency. Institutional and surgeon volume did not predict MACEs. CONCLUSIONS: In contradistinction to previous studies, there was no relationship in this study between institutional LEB volume and outcomes after LEB. However, greater average annual surgeon volume was associated with improved primary patency and decreased risk of MALEs. Open LEB remains a safe and effective procedure for limb salvage. Limb-related outcomes in critical limb ischemia and claudication will be optimized if surgeons maintain adequate volume of LEB.

Vascular Quality Initiative and National Surgical Quality Improvement Program registries capture different populations and outcomes in open infrainguinal bypass.

OBJECTIVE: Both the Vascular Quality Initiative (VQI) and the National Surgical Quality Improvement Program Procedure Targeted (NSQIP-PT) databases aim to track outcomes and to improve quality in vascular surgery. However, both registries are subject to significant selection bias. The objective of this study was to compare the populations and outcomes of a single procedure in VQI and NSQIP-PT and to identify areas of similarity and discrepancy. METHODS: Deidentified regional data were provided by VQI, and the public use files were provided by NSQIP. Patient characteristics and outcomes were compared between data sets with parametric and nonparametric statistical tests as appropriate. For variables with different definitions between VQI and NSQIP-PT, a standardized definition was created to permit comparison across databases. To account for differences in populations of patients between the data sets, VQI and NSQIP-PT records were propensity matched, allowing a comparison of outcomes between databases adjusted for case mix. RESULTS: VQI contained 1358 records from 2011 to 2015, whereas NSQIP-PT contained 5273 complete records from 2011 to 2013. Patients in VQI are younger than those in NSQIP (65 [15] vs 68 [16] years; P < .001) and were less likely to have congestive heart failure (1.7% vs 3.1%; P = .005), to be on dialysis (4.0% vs 6.1%; P = .003), or to be receiving preoperative aspirin (62% vs 79%; P < .001) or statin therapy (63% vs 68%; P < .001). Significant discrepancies were noted in preoperative angina symptoms, prior myocardial infarction, and prior percutaneous coronary intervention, with 0, 1, and 0 NSQIP patients, respectively, having these risk factors compared with 9.4%, 0.7%, and 19.5% of the VQI cohort. Approximately 20% of patients in VQI underwent surgery for acute limb ischemia, which is not a recognized indication in NSQIP-PT. Overall 30-day mortality was equivalent (2.0% vs 1.8%; P = .6), as was composite myocardial infarction/stroke (3.9% vs 3.2%; P = .2). Major amputation (3.3% vs 1.6%; P = .002), return to operating room (16.1% vs 11.5%; P < .001), and wound infection rates (12.8% vs 1.4%; P < .001) were higher in NSQIP relative to VQI. Bleeding rates were higher in VQI (36.5% vs 17.2%; P < .001). Significant differences persisted in the propensity-matched groups. CONCLUSIONS: This is the first study to compare patient characteristics and outcome reported in the VQI and NSQIP-PT registries. These data documented statistically significant differences in demographics and comorbidities as well as in outcomes between databases. Physicians, payers, and the public should consider differences between these databases when reporting on outcomes and quality. Results from these two registries should not be directly compared.

Hybrid repair strategies for acute type B aortic dissection complicating prior standard and complex endovascular aortic repair.

Type B aortic dissection (TBAD) in the presence of an existing aortic endograft is a rare, but potentially catastrophic, event. False lumen pressurization and propagation leads to several failure modes. Endograft collapse can lead to spinal cord, visceral, or lower extremity ischemia, and rupture of a previously sealed aneurysm sac is often fatal. A successful treatment strategy must incorporate the patient's symptoms, urgency of intervention, extent of dissection, and the location and status of the existing graft. In this series, we present three cases of TBAD complicating prior endovascular aortic repairs-infrarenal, iliac branched, and thoracoabdominal branched endografts-successfully treated with tailored, hybrid interventions.

Goal-directed resuscitation following cardiac surgery reduces acute kidney injury: A quality initiative pre-post analysis.

OBJECTIVE: Acute kidney injury (AKI) occurs in 20% of patients following cardiac surgery. To reduce AKI in our institution, we instituted a quality improvement (QI) initiative using a goal-directed volume resuscitation protocol. Our protocol was designed to achieve quantifiable physiologic goals (eg, cardiac index > 2.5 L/min/m2, mean arterial pressure > 65 mm Hg) using fluid and vasoactive agents. The objective of this study was to evaluate AKI in the pre- and post-QI eras, hypothesizing that AKI incidence would decrease in the post-QI era. METHODS: In this observational retrospective cohort study, we identified patients who underwent cardiac operations from July 2011 to July 2015 with a risk score available. Kidney injury was determined using the lowest postoperative GFR within 7 days of surgery and standard Risk, Injury, Failure, Loss of Kidney Function, and End-Stage Kidney Disease (RIFLE) classification criteria. The primary outcome was the rate of AKI, as defined by glomerular filtration rate-based RIFLE classification criteria injury, in the post- versus pre-QI eras. RESULTS: A total of 1979 patients were included, of whom 725 were in the pre-QI cohort, and 1254 in the post-QI cohort. Overall, rates of RIFLE classification criteria risk, injury and failure were 27.5%, 5.9%, and 3.6%, respectively. RIFLE classification criteria injury saw the largest decrease in the post-QI cohort (8.1% vs 4.6%; P = .001). Multivariable analysis demonstrated a 37% reduction in the odds of AKI in the post-QI cohort (adjusted odds ratio, 0.63; 95% confidence interval, 0.43-0.90). CONCLUSIONS: A goal-directed volume resuscitation protocol centered on patient fluid responsiveness is associated with significantly reduced risk for AKI after cardiac surgery. Protocol-driven approaches should be employed in intensive care units to improve outcomes.

Efficacy of Radiofrequency Ablation versus Transarterial Chemoembolization for Patients with Solitary Hepatocellular Carcinoma ≤3 cm.

Optimal treatment for small hepatocellular carcinoma (HCC) ≤ 3 cm remains controversial. Ablation and chemoembolization are considered for nonoperative candidates. This study compares survival among patients with solitary HCC ≤ 3 cm treated with radiofrequency ablation (RFA) and transarterial chemoembolization (TACE). Patients diagnosed with HCC ≤ 3 cm between 2005 and 2014 were included. Kaplan-Meier survival functions with log-rank tests were used to estimate recurrence-free survival and overall survival (OS) survival. Among 161 patients with solitary HCC ≤ 3 cm, 145 patients with mean age of 65.2 years (±9.2) and 95 per cent prevalence of cirrhosis had operative treatment or TACE, and/or RFA. From this cohort, 27 (19%) patients had TACE, 27 (19%) patients had RFA, and 15 (10%) patients had TACE/RFA. The patients treated with definitive TACE, RFA, or TACE/RFA had a similar 1-year recurrence-free survival (23% vs 27% vs 36%, respectively, P = 0.445) and similar 5-year OS (21% vs 24% vs 33%, respectively, P = 0.287). Thirty-five (24%) patients were bridged to transplantation with TACE and/or RFA. The 5-year OS was significantly improved in patients bridged to transplantation (P < 0.001). Survival does not differ between patients with solitary HCC ≤ 3 cm treated with TACE or RFA. Patients who were bridged to transplantation had significantly greater OS compared with patients who were not transplanted.

Good at One or Good at All? Variability of Coronary and Valve Operation Outcomes Within Centers.

BACKGROUND: The technical expertise required for treatment of coronary and structural heart valve disease differs. Correlation between center-specific mortality rates after coronary artery bypass grafting (CABG) and valve operations has not been demonstrated. This study tested the hypothesis that risk-adjusted outcomes between coronary and valve procedures do not correlate within centers. METHODS: Records of patients undergoing isolated CABG, isolated aortic valve replacement (AVR), or isolated mitral valve replacement (MVR) procedures from 2008 to 2015 in a multi-institutional Society of Thoracic Surgeons (STS) database were used to generate observed-to-expected (O/E) ratios for morbidity and death. Ratios were based on the STS predicted risks of morbidity and death and were calculated by procedure for each institution. Linear regression models evaluated the relationship between institutional performance in CABG and valve operations. RESULTS: A total of 22,258 records from 18 institutions were analyzed: 17,026 CABG, 3,238 isolated AVR, and 1,994 MVR procedures. With respect to deaths, the correlation coefficients were weak; for AVR and CABG, it was 0.22 and was 0.26 for MVR and CABG. With respect to morbidity, a strong relationship was seen between the morbidity O/E ratios, with coefficients of 1.03 for AVR and 0.97 for MVR, suggesting a nearly 1:1 relationship between morbidities observed in an institution's CABG and valve operations. CONCLUSIONS: Sites that perform CABG with low mortality rates may not have similarly low mortality rates with valve operations. Most striking, however, is the nearly identical O/E ratio for morbidity for CABG and valve operations at each center. These findings suggest postoperative care as a major determinant for morbidity after cardiac operation.

Roux-en-Y gastric bypass is safe in elderly patients: a propensity-score matched analysis.

BACKGROUND: Numerous studies have established the effectiveness of Roux-en-Y gastric bypass (RYGB) for weight loss and co-morbidity amelioration. However, its safety and efficacy in elderly patients remains controversial. OBJECTIVES: To evaluate outcomes in patients aged ≥60 years who underwent RYGB compared with nonsurgical controls with the hypothesis that RYGB provides weight loss benefits without differences in survival. SETTING: University-affiliated tertiary center. METHODS: All patients who underwent RYGB from 1985 to 2015 were identified and divided into elderly (age ≥60) and nonelderly (age <60) groups. A nonsurgical elderly control population was identified using a clinical data repository of outpatient visits to propensity match elderly patients 4:1 on demographic characteristics, co-morbidities, and relevant preoperative substance/medication use. Unpaired appropriate univariate analyses compared each stratified group. Kaplan-Meier survival curves were fitted based on social security death data. RESULTS: A total of 2306 patients underwent RYGB. The 107 elderly patients had lower median body mass index (47.0 versus 49.9; P = .007) and higher rates of co-morbidities. Rates of complications did not differ between elderly and nonelderly patients. Elderly surgical patients were propensity matched 4:1 (10,044 controls) yielding 428 well-matched nonsurgical controls. The elderly group demonstrated significant percent reduction in excess body mass index compared with the control group (81.8% versus 10.3%; P < .001). Kaplan-Meier survival analysis with log-rank test demonstrated no difference in midterm survival (P = .63). CONCLUSIONS: A significant weight reduction benefit was identified after RYGB in elderly patients without a difference in midterm survival compared with propensity-matched controls, suggesting RYGB is a safe and efficacious weight loss strategy in the elderly.

Outcomes after Falls Continue to Worsen Despite Trauma and Geriatric Care Advancements.

The most common mechanism of traumatic injury is ground-level fall. The objective of this study was to understand how patients sustaining falls and their outcomes have evolved. An institutional trauma database was used to identify adult patients who suffered a fall and were admitted to a Level I trauma center during two distinct time periods: 1998 to 2003 (past) and 2008 to 2013 (current). Data on anticoagulant use and comorbidities was gathered by retrospective chart review of patients treated during 2003 and 2013. Univariable analyses and multivariable regression were used to evaluate demographics and outcomes. A total of 6116 patients were identified, with a 24 per cent increase in number of falls between groups. Current fall patients are older (70 vs 66 years, P < 0.001), more often admitted to intensive care (28 vs 12%, P < 0.001), have longer lengths of stay (5 vs 4 days, P < 0.001), are frequently discharged to skilled nursing facilities (24 vs 8%, P < 0.001), and have higher mortality (5 vs 3%, P = 0.002). The adjusted odds of mortality for patients treated during 2003 and 2013 was associated with age, gender, injury severity score, and Glasgow Coma Scale score. Current fall patients use more health care resources and have worse outcomes, despite advances in trauma and geriatric care.

Methylene Blue for Vasoplegic Syndrome After Cardiac Operation: Early Administration Improves Survival.

BACKGROUND: Vasoplegic syndrome, defined by hypotension despite normal or increased cardiac output, is associated with high mortality rate after cardiopulmonary bypass. Methylene blue (MB) is reported to ameliorate vasoplegic syndrome through the nitric oxide pathway. We hypothesized that early administration of MB would improve outcomes in patients with vasoplegic syndrome after cardiopulmonary bypass. METHODS: All patients that underwent cardiopulmonary bypass at our institution (Jan 1, 2011 to Jun 30, 2016) were identified through our Society of Thoracic Surgery database. Pharmacy records identified patients receiving MB within 72 hours of cardiopulmonary bypass. Multivariate logistic regression identified predictors of major adverse events among patients receiving MB. RESULTS: A total of 118 cardiopulmonary bypass patients (3.3%) received MB for vasoplegic syndrome. These patients had a higher incidence of comorbidities, and these cases were more commonly reoperative (76.1% versus 41.2%, p < 0.0001) and complex (70.3% versus 31.8%, p < 0.0001). The only difference in preoperative medications was that MB patients had a higher rate of amiodarone use (15.3% versus 2.2%, p < 0.0001). MB patients had significantly higher rates of postoperative complications, except atrial fibrillation. Early (operating room, 40.7%) versus late (intensive care unit, 59.3%) administration of MB was associated with significantly reduced operative mortality rate (10.4% versus 28.6%, p = 0.018) and risk-adjusted major adverse events (odd ratio 0.35, p = 0.037). CONCLUSIONS: Operative mortality rate is high in patients receiving MB for the treatment of vasoplegia after cardiopulmonary bypass. Early administration of MB improves survival and reduces the risk-adjusted rate of major adverse events in these patients.

Outcomes for Low-Risk Surgical Aortic Valve Replacement: A Benchmark for Aortic Valve Technology.

BACKGROUND: Two large, randomized trials are underway evaluating transcatheter aortic valve replacement (AVR) against conventional surgical AVR. We analyzed contemporary, real-world outcomes of surgical AVR in low-risk patients to provide a practical benchmark of outcomes and cost for evaluating current and future transapical AVR technology. METHODS: From 2010 to 2015, 2,505 isolated AVR operations were performed for severe aortic stenosis at 18 statewide cardiac institutions. Of these, 2,138 patients had a Society of Thoracic Surgeons predicted risk of mortality of less than 4%, and 1,119 met other clinical and hemodynamic criteria as outlined in the PARTNER 3 (The Placement of Transcatheter Aortic Valves) protocol. Patients with endocarditis, end-stage renal disease, ejection fraction of less than 0.45, bicuspid valves, and previous valve replacements were excluded. Outcomes of interest included operative death and postoperative adverse events. RESULTS: The median Society of Thoracic Surgeons predicted risk of mortality for the study-eligible patients was 1.44%, with a median age of 72 years (interquartile range [IQR], 65 to 78 years). Operative mortality was 1.3%, permanent stroke was 1.3%, and pacemaker requirement was 4.2%. The most common adverse events were transfusion of 2 or more units of red blood cells (18%) and atrial fibrillation (28%). The median length of stay was 6 days (IQR, 5 to 8 days). Median total hospital cost was $37,999 (IQR, $30,671 to $46,138). Examination of complications by age younger than 65 vs 65 or older demonstrated a significantly lower need for transfusion (11.2%, p < 0.001) and incidence of atrial fibrillation (17.1%, p < 0.001) but no difference in operative mortality (2.2% vs 0.9%, p = 0.1), major morbidity (10.4% vs 12.6%, p = 0.3), or total hospital costs. CONCLUSIONS: Low-risk patients undergoing surgical AVR in the current era have excellent results. The most common complications were atrial fibrillation and bleeding. These real-world results should provide additional context for upcoming transcatheter clinical trial data.

A New Intraoperative Protocol for Reducing Perioperative Transfusions in Cardiac Surgery.

BACKGROUND: Perioperative anemia and blood product transfusion increases short-term and long-term morbidity and mortality during cardiac surgery. We hypothesized that streamlined cardiopulmonary bypass circuit and rotational thromboelastometry (ROTEM) would reduce blood product usage and improve outcomes. METHODS: All patients with Society of Thoracic Surgeons risk scores at our institution from January 2013 to June 2015 were included. Individuals were chronologically stratified into 2 groups according to institutional changes to a streamlined bypass circuit and ROTEM-guided transfusion. Blood product transfusion, hematocrit, and observed to expected outcomes (O/E) were compared between the groups. RESULTS: Patients were defined as either control group (533 patients, 12 months) or intervention group (804 patients, 18 months). The intervention group was further subdivided into streamlined circuit (290 patients, 6 months) and ROTEM (514 patients, 12 months). Use of streamlined bypass circuit correlated with significantly reduced intraoperative transfusion of packed red blood cells (pRBCs) (23.8% versus 17.9%; p = 0.05) and platelets (28.0% versus 19.3; p = 0.01) with improvement in lowest intraoperative hematocrit (26.0 versus 26.9; p = 0.02). ROTEM was associated with a further reduction in intraoperative pRBCs (17.9% versus 11.28%; p = 0.01) and postoperative transfusion pRBCs (38.3% versus 23.5%; p = 0.02). The combination was associated with reduced intraoperative (44.6% versus 34.1; p < 0.001) and postoperative transfusions (45.6% versus 40.1; p < 0.001) in the intervention group, while maintaining a higher hematocrit at discharge (28.1 versus 29.1; p < 0.001). Finally, the intervention was associated with a statistically significant reduction in the O/E for reoperation (p = 0.003). CONCLUSIONS: Use of streamlined cardiopulmonary bypass circuit and ROTEM may reduce transfusion and reoperation rates and improve perioperative anemia in cardiac surgical patients. This study demonstrates reproducible intraoperative methods for reducing blood product usage and improving outcomes.

Postoperative Hypoglycemia Is Associated With Worse Outcomes After Cardiac Operations.

BACKGROUND: Hypoglycemia is a known risk of intensive postoperative glucose control in patients undergoing cardiac operations. However, neither the consequences of hypoglycemia relative to hyperglycemia, nor the possible interaction effects, have been well described. We examined the effects of postoperative hypoglycemia, hyperglycemia, and their interaction on short-term morbidity and mortality. METHODS: Single-institution Society of Thoracic Surgeons (STS) database patient records from 2010 to 2014 were merged with clinical data, including blood glucose values measured in the intensive care unit (ICU). Exclusion criteria included fewer than three glucose measurements and absence of an STS predicted risk of morbidity or mortality score. Primary outcomes were operative mortality and composite major morbidity (permanent stroke, renal failure, prolonged ventilation, pneumonia, or myocardial infarction). Secondary outcomes included ICU and postoperative length of stay. Hypoglycemia was defined as below 70 mg/dL, and hyperglycemia as above 180 mg/dL. Simple and multivariable regression models were used to evaluate the outcomes. RESULTS: A total of 2,285 patient records met the selection criteria for analysis. The mean postoperative glucose level was 140.8 ± 18.8 mg/dL. Overall, 21.4% of patients experienced a hypoglycemic episode (n = 488), and 1.05% (n = 24) had a severe hypoglycemic episode (<40 mg/dL). The unadjusted odds ratio (UOR) for operative mortality for patients with any hypoglycemic episode compared with those without was 5.47 (95% confidence interval [CI] 3.14 to 9.54), and the UOR for major morbidity was 4.66 (95% CI 3.55 to 6.11). After adjustment for predicted risk of morbidity or mortality and other significant covariates, the adjusted odds (AOR) of operative mortality were significant for patients with any hypoglycemia (AOR 4.88, 95% CI 2.67 to 8.92) and patients with both events (AOR 8.29, 95% CI 1.83 to 37.5) but not hyperglycemia alone (AOR 1.62, 95% CI 0.56 to 4.69). The AOR of major morbidity for patients with both hypoglycemic and hyperglycemic events was 14.3 (95% CI 6.50 to 31.4). CONCLUSIONS: Postoperative hypoglycemia is associated with both mortality and major morbidity after cardiac operations. The combination of both hyperglycemia and hypoglycemia represents a substantial increase in risk. Although it remains unclear whether hypoglycemia is a cause, an early warning sign, or a result of adverse events, this study suggests that hypoglycemia may be an important event in the postoperative period after cardiac operations.

Impact of Transcatheter Technology on Surgical Aortic Valve Replacement Volume, Outcomes, and Cost.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) represents a disruptive technology that is rapidly expanding in use. We evaluated the effect on surgical aortic valve replacement (SAVR) patient selection, outcomes, volume, and cost. METHODS: A total of 11,565 patients who underwent SAVR, with or without coronary artery bypass grafting (2002 to 2015), were evaluated from the Virginia Cardiac Services Quality Initiative database. Patients were stratified by surgical era: pre-TAVR era (2002 to 2008, n = 5,113), early-TAVR era (2009 to 2011, n = 2,709), and commercial-TAVR era (2012 to 2015, n = 3,743). Patient characteristics, outcomes, and resource utilization were analyzed by univariate analyses. RESULTS: Throughout the study period, statewide SAVR volumes increased with median volumes of pre-TAVR: 722 cases/year, early-TAVR: 892 cases/year, and commercial-TAVR: 940 cases/year (p = 0.005). Implementation of TAVR was associated with declining Society of Thoracic Surgeons predicted risk of mortality among SAVR patients (3.7%, 2.6%, and 2.4%; p < 0.0001), despite increasing rates of comorbid disease. The mortality rate was lowest in the current commercial-TAVR era (3.9%, 4.3%, and 3.2%; p = 0.05), and major morbidity decreased throughout the time period (21.2%, 20.5%, and 15.2%; p < 0.0001). The lowest observed-to-expected ratios for both occurred in the commercial-TAVR era (0.9 and 0.9, respectively). Resource utilization increased generally, including total cost increases from $42,835 to $51,923 to $54,710 (p < 0.0001). CONCLUSIONS: At present, SAVR volumes have not been affected by the introduction of TAVR. The outcomes for SAVR continue to improve, potentially due to availability of transcatheter options for high-risk patients. Despite rising costs for SAVR, open approaches still provide a significant cost advantage over TAVR.

Regional Practice Patterns and Outcomes of Surgery for Acute Type A Aortic Dissection.

BACKGROUND: The surgical management of acute type A aortic dissection is evolving, and many aortic centers of excellence are reporting superior outcomes. We hypothesize that similar trends exist in a multiinstitutional regional consortium. METHODS: Records for 884 consecutive patients who underwent aortic operations (2003 to 2015) for acute type A aortic dissection were extracted from a regional The Society of Thoracic Surgeons database. Patients were stratified into three equal operative eras. Differences in outcomes and risk factors for morbidity and mortality were determined. RESULTS: Surgical procedures for type A aortic dissection are increasing in extent and complexity. Aortic root repair was performed in 16% of early era cases compared with 67% currently (p < 0.0001). Similarly, aortic arch repair increased from 27% to 37% cases (p < 0.0001). Cerebral perfusion is currently used in 85% of circulatory arrest cases, most frequently antegrade (57%). Total circulatory arrest times increased (29 minutes vs 31 minutes vs 36 minutes; p = 0.005), but times without cerebral perfusion were stable (12 minutes vs 6 minutes; p = 0.68). Although the operative mortality rate remained stable at 18.9% during the 3 operative eras, there were significant decreases in pneumonia and reoperations (p < 0.05). Predictors of operative mortality and major morbidity are age (odds ratio [OR], 1.04; p < 0.0001), previous stroke (OR, 2.09; p = 0.03), and elevated creatinine (OR, 1.31; p = 0.01). Importantly, the extent of aortic operation did not increase risk for morbidity or mortality. CONCLUSIONS: Operative morbidity and mortality remain significant for type A aortic dissection, but lower than historical outcomes. The extent of aortic surgery has increased, resulting in adaptive cerebral protection changes in contemporary "real-world" practice.

Impact of Medicaid Expansion on Cardiac Surgery Volume and Outcomes.

BACKGROUND: Thirty-one states approved Medicaid expansion after implementation of the Affordable Care Act. The objective of this study was to evaluate the effect of Medicaid expansion on cardiac surgery volume and outcomes comparing one state that expanded to one that did not. METHODS: Data from the Virginia (nonexpansion state) Cardiac Services Quality Initiative and the Michigan (expanded Medicaid, April 2014) Society of Thoracic and Cardiovascular Surgeons Quality Collaborative were analyzed to identify uninsured and Medicaid patients undergoing coronary bypass graft or valve operations, or both. Demographics, operative details, predicted risk scores, and morbidity and mortality rates, stratified by state and compared across era (preexpansion: 18 months before vs postexpansion: 18 months after), were analyzed. RESULTS: In Virginia, there were no differences in volume between eras, whereas in Michigan, there was a significant increase in Medicaid volume (54.4% [558 of 1,026] vs 84.1% [954 of 1,135], p < 0.001) and a corresponding decrease in uninsured volume. In Virginia Medicaid patients, there were no differences in predicted risk of morbidity or mortality or postoperative major morbidities. In Michigan Medicaid patients, a significant decrease in predicted risk of morbidity or mortality (11.9% [8.1% to 20.0%] vs 11.1% [7.7% to 17.9%], p = 0.02) and morbidities (18.3% [102 of 558] vs 13.2% [126 of 954], p = 0.008) was identified. Postexpansion was associated with a decreased risk-adjusted rate of major morbidity (odds ratio, 0.69; 95% confidence interval, 0.51 to 0.91; p = 0.01) in Michigan Medicaid patients. CONCLUSIONS: Medicaid expansion was associated with fewer uninsured cardiac surgery patients and improved predicted risk scores and morbidity rates. In addition to improving health care financing, Medicaid expansion may positively affect patient care and outcomes.

Development of a Transplantation Risk Index in Patients With Mechanical Circulatory Support: A Decision Support Tool.

OBJECTIVES: The aim of this study was to develop a risk index specific to patients on mechanical circulatory support that accurately predicts 1-year mortality after orthotopic heart transplantation using the United Network for Organ Sharing database. BACKGROUND: Few clinical tools are available to aid in the decision between continuing long-term device support and performing transplantation in patients bridging with mechanical circulatory support. METHODS: Using a prospectively collected, open cohort, 6,036 patients receiving mechanical circulatory support who underwent orthotopic heart transplantation between 2000 and 2013 were evaluated and randomly separated into derivation (80%) and validation (20%) groups. Multivariate logistic regression models were constructed using variables that improved the explanatory power of the model, which was determined using multiple methods. Points for a simple additive risk index were apportioned on the basis of relative effect on odds of 1-year mortality. RESULTS: A 75-point scoring system was created from 9 recipient and 4 donor variables. The average score in the validation cohort was 14.4 ± 7.7, and scores ranged from 0 to 57; these values were similar to those in the derivation cohort. Each 1-point increase predicted an 8.3% increase in the odds of 1-year mortality (odds ratio: 1.08; 95% confidence interval: 1.06 to 1.11). Low (0 to 10), intermediate (11 to 20), and high (>20) risk score cohorts were created, with predicted average 1-year mortalities of 8.6%, 12.8%, and 31%, respectively, in the validation cohort. CONCLUSIONS: The investigators present a novel, internally cross-validated risk index that accurately predicts mortality in bridge-to-transplantation patients.

Minimally Invasive Mitral Valve Surgery Provides Excellent Outcomes Without Increased Cost: A Multi-Institutional Analysis.

BACKGROUND: Minimally invasive mitral valve surgery (mini-MVR) has grown in popularity. Although single centers have reported excellent outcomes, data on real-world outcomes and costs of mini-MVR are limited. Moreover, mini-MVR has been criticized as adding additional cost without clear benefit. We hypothesized that mini-MVR provides superior outcomes with incremental increased costs in a multi-institutional cohort. METHODS: Records for patients undergoing mitral valve surgical procedures with or without atrial ablation from 2011 to 2014 were extracted from a multi-institutional, regional Society of Thoracic Surgeons database and stratified according to right chest approach/minimally invasive or conventional sternotomy. Patients undergoing coronary artery bypass grafting or other concomitant procedures were excluded. Patients undergoing isolated mitral surgical procedure were propensity matched according to factors, including age, comorbidities, and preoperative laboratory values; clinical outcomes and cost differences were assessed by approach. RESULTS: A total of 1,304 patients underwent mitral operations, including 425 (32.6%) by minimally invasive approach. In the propensity-matched analysis (n = 355 per group), patients undergoing mini-MVR had similar rates of mortality, stroke, and other complications compared with conventional MVR. Meanwhile, patients with mini-MVR experienced shorter intensive care unit and hospital lengths of stay and fewer transfusions. Importantly, total hospital costs were no different between the two matched groups. CONCLUSIONS: Compared with conventional sternotomy, mini-MVR in the "real world" demonstrated no differences in rates of major morbidity, but it was associated with shorter length of stay and fewer transfusions. Contrary to our hypothesis, mini-MVR can be performed with similar total hospital costs as conventional sternotomy. In summary, minimally invasive mitral surgical procedure in select patients can provide superior outcomes without increased cost.