Transaortic aortomitral junction reconstruction and mitral valve leaflet repair for recurrent endocarditis.

Transaortic interventions on the mitral valve are rarely performed, but offer advantages over traditional approaches in certain circumstances, including either extensive involvement of the aortomitral junction with endocarditis or the patient requiring reoperation for aortic and mitral disease. Herein is presented a case of recurrent endocarditis involving aortomitral continuity, reconstructed using a transaortic mitral valve repair and reconstruction of the aortic and mitral annuli with a pericardial patch, followed by aortic root replacement.

General and acute care surgical procedures in patients with left ventricular assist devices.

BACKGROUND: Left ventricular assist devices (LVADs) have become common as a bridge to heart transplant as well as destination therapy. Acute care surgical (ACS) problems in this population are prevalent but remain ill-defined. Therefore, we reviewed our experience with ACS interventions in LVAD patients. METHODS: A total of 173 patients who received HeartMate(®) XVE or HeartMate(®) II (HMII) LVADs between December 2001 and March 2010 were studied. Patient demographics, presentation of ACS problem, operative intervention, co-morbidities, transplantation, complications, and survival were analyzed. RESULTS: A total of 47 (27 %) patients underwent 67 ACS procedures at a median of 38 days after device implant (interquartile range 15-110), with a peri-operative mortality rate of 5 % (N = 3). Demographics, device type, and acuity were comparable between the ACS and non-ACS groups. A total of 21 ACS procedures were performed emergently, eight were urgent, and 38 were elective. Of 29 urgent and emergent procedures, 28 were for abdominal pathology. In eight patients, the cause of the ACS problem was related to LVADs or anticoagulation. Cumulative survival estimates revealed no survival differences if patients underwent ACS procedures (p = 0.17). Among HMII patients, transplantation rates were unaffected by an ACS intervention (p = 0.2). CONCLUSIONS: ACS problems occur frequently in LVAD patients and are not associated with adverse outcomes in HMII patients. The acute care surgeon is an integral member of a comprehensive approach to effective LVAD management.

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.

The spectrum of complications following left ventricular assist device placement.

INTRODUCTION: Left ventricular assist device (LVAD) support is associated with many complications, but relatively few studies have examined the full spectrum of complications beyond infectious and bleeding events. METHODS: We conducted a retrospective review of patients receiving either a pulsatile-flow Heartmate XVE (HM1; Thoratec Corp., Pleasanton, CA, USA) or continuous-flow Heartmate II (HM2; Thoratec Corp.) LVAD at our institution (June 2000 to March 2012). Frequency and date of onset of nonbleeding, noninfectious complications were examined. RESULTS: One hundred eighty-two LVADs were implanted, 49 HM1, and 133 HM2. Support duration was longer for HM2s (median 358 vs. 112 days; p = 0.0003). Overall, the most frequent complications were respiratory failure, ventricular arrhythmia, atrial arrhythmia, right heart failure, and renal failure. Respiratory failure, arrhythmias, severe psychiatric events, and renal failure all occurred with median date of onset ≤ seven days postprocedure. Right heart failure, hepatic failure, thromboembolism, and transient ischemic attacks had a median date of onset 8 to 30 days postprocedure. Stroke, hemolysis, and device failure occurred mostly more than a month postoperatively. Right heart failure, hepatic failure, and device failure were more frequent in HM1 patients than in HM2 patients. Several events, including stroke, had much later onset in HM2 patients. CONCLUSION: In this 10-year review of complications following LVAD implantation, the most common adverse events tended to occur early after implantation. As pulsatile-flow HM1s showed greater frequency and earlier onset of some adverse events, our data suggest better overall outcomes with the continuous-flow HM2s.

Allograft cardiectomy and biventricular assist device placement as a salvage maneuver in a heart transplant recipient.

End-stage allograft failure following cardiac transplantation is a devastating problem, and retransplantation offers the only chance for survival. We present the case of a young man with a failing cardiac allograft who underwent allograft cardiectomy, atrial pouch formation, and biventricular assist device (BiVAD) placement as a salvage maneuver.

Validation of the United States-derived Index for Mortality Prediction After Cardiac Transplantation (IMPACT) using international registry data.

BACKGROUND: We previously derived and validated the Index for Mortality Prediction After Cardiac Transplantation (IMPACT) using United Network for Organ Sharing (UNOS) data. This study aimed to validate the IMPACT score using international data. METHODS: International Society for Heart and Lung Transplantation (ISHLT) data were used to identify orthotopic heart transplantation (OHT) patients between 2001 and 2010. The primary outcome was all-cause 1-year post-OHT mortality. Secondary outcomes included 30-day and 5-year mortality. Logistic regression, weighted regression, and Kaplan-Meier analyses evaluated the predictive accuracy of the IMPACT score. A sub-analysis of OHTs performed from 2009 to 2010 examined patients completely external to the original UNOS derivation cohort. RESULTS: We identified 29,242 OHT recipients. Their mean IMPACT score was 5.1 ± 3.6. The IMPACT score was highly predictive of 1-year mortality (odds ratio [OR], 1.14, p < 0.001), a finding that persisted after adjusting for donor age and ischemic time (OR, 1.13; p < 0.001). A significant correlation was found between the expected 1-year mortality rates for each IMPACT score based on the original derivation cohort and the actual 1-year mortality rates in the ISHLT cohort (r = 0.87, p < 0.001). Kaplan-Meier 1-year survival by IMPACT score was 92.3% for a score < 5, 88.5% for scores of 5 to 10, and 75.1% for scores > 10 (p < 0.001). The IMPACT score also accurately predicted 30-day and 5-year mortality (each p < 0.001). These results were confirmed in the sub-analysis. CONCLUSIONS: This study validates the use of the IMPACT score as a predictor of short- and long-term mortality after OHT. Strong consideration should be given to broadly implementing and prospectively using the IMPACT score to predict mortality after OHT.

Insurance and education predict long-term survival after orthotopic heart transplantation in the United States.

BACKGROUND: Insurance status and education are known to affect health outcomes. However, their importance in orthotopic heart transplantation (OHT) is unknown. The United Network for Organ Sharing (UNOS) database provides a large cohort of OHT recipients in which to evaluate the effect of insurance and education on survival. METHODS: UNOS data were retrospectively reviewed to identify adult primary OHT recipients (1997 to 2008). Patients were stratified by insurance at the time of transplantation (private/self-pay, Medicare, Medicaid, and other) and college education. All-cause mortality was examined using multivariable Cox proportional hazard regression incorporating 15 variables. Survival was modeled using the Kaplan-Meier method. RESULTS: Insurance for 20,676 patients was distributed as follows: private insurance/self-pay, 12,298 (59.5%); Medicare, 5,227 (25.3%); Medicaid, 2,320 (11.2%); and "other" insurance, 831 (4.0%). Educational levels were recorded for 15,735 patients (76.1% of cohort): 7,738 (49.2%) had a college degree. During 53 ± 41 months of follow-up, 6,125 patients (29.6%) died (6.7 deaths/100 patient-years). Survival differed by insurance and education. Medicare and Medicaid patients had 8.6% and 10.0% lower 10-year survival, respectively, than private/self-pay patients. College-educated patients had 7.0% higher 10-year survival. On multivariable analysis, college education decreased mortality risk by 11%. Medicare and Medicaid increased mortality risk by 18% and 33%, respectively (p ≤ 0.001). CONCLUSIONS: Our study examining insurance and education in a large cohort of OHT patients found that long-term mortality after OHT is higher in Medicare/Medicaid patients and in those without a college education. This study points to potential differences in the care of OHT patients based on education and insurance status.

Adult-derived Index for Mortality Prediction After Cardiac Transplantation (IMPACT) risk score predicts short-term mortality after pediatric heart transplantation.

BACKGROUND: We have previously derived and validated the Index for Mortality Prediction After Cardiac Transplantation (IMPACT), which predicts short-term mortality after adult orthotopic heart transplantation (OHT). This study evaluated the predictive accuracy of the IMPACT score in pediatric OHT. METHODS: The United Network for Organ Sharing registry was used to identify pediatric (< 18 years) OHT patients from 2000 to 2008. The IMPACT score was calculated for each patient. The association of IMPACT score with 1-year mortality was evaluated with univariate and multivariable logistic regression analysis. The correlation coefficient between predicted and actual 1-year mortality was determined for each IMPACT score. Kaplan-Meier survival estimates were calculated and stratified by IMPACT score. RESULTS: We identified 2,518 eligible pediatric OHT patients (1,128 girls [44.8%]). Mean IMPACT score was 10.3 ± 6.3 (range, 0 to 38). A total of 297 patients (11.8%) died within the first year after OHT. Each point increase in the IMPACT score increased the odds of 1-year mortality by 13% (odds ratio, 1.13; 95% confidence interval, 1.11 to 1.15; p < 0.001). The correlation coefficient between predicted and actual 1-year mortality was 0.93 (p < 0.001). One-year survival by disjoint categories of the IMPACT score was 0 to 4 (96.7%), 5 to 9 (92.9%), 10 to 14 (87.6%), 15 to 19 (81.3%), and 20 or more (64.2%; p < 0.001). CONCLUSIONS: In this large-cohort analysis, the IMPACT score accurately predicted mortality following pediatric OHT. The IMPACT score could therefore be useful to providers for organ allocation and prognostication in this patient population.

Institutional volume and the effect of recipient risk on short-term mortality after orthotopic heart transplant.

OBJECTIVE: We developed a validated 50-point recipient risk index predicting short-term mortality after orthotopic heart transplant (OHT). This study examined the relationship between institutional volume and recipient risk on post-OHT mortality. METHODS: We used United Network for Organ Sharing (UNOS) data to identify primary OHT recipients between January 2000 and April 2010. Centers were stratified by mean annual volume. Preoperative Index for Mortality Prediction After Cardiac Transplantation risk scores were calculated for each patient with our validated 50-point system. Primary outcomes were 30-day and 1-year survivals. Multivariable logistic regression analysis included interaction terms to examine effect modification of risk and volume on mortality. RESULTS: In all, 18,226 patients underwent transplant at 141 centers: 1173 (6.4%) recipients at low-volume centers (<7 procedures/y), 5353 (29.4%) at medium-volume centers (7-15 procedures/y), and 11,700 (64.2%) at high-volume centers (>15 procedures/y). Low center volume was associated with worse 1-year mortality (odds ratio, 1.58; 95% confidence interval, 1.30-1.92; P < .001). For 1-year survival, there was significant positive interaction between center volume and recipient risk score (odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .02), indicating effect of risk on mortality at low-volume centers greater than from either variable analyzed individually. Among high-risk recipients (score ≥10), 1-year survival was improved at high-volume centers (high, 79%; medium, 75%; low, 64%). CONCLUSIONS: In analysis of UNOS data with our validated recipient risk index, institutional volume acted as an effect modifier on association between risk and mortality. High-risk patients had higher mortality at low-volume centers; differences dissipated among lower-risk recipients. These data support a mandate for high-risk transplants at higher-volume centers.

Development of a quantitative donor risk index to predict short-term mortality in orthotopic heart transplantation.

BACKGROUND: No standard index based on donor factors exists for predicting mortality after orthotopic heart transplantation (OHT). We utilized United Network for Organ Sharing (UNOS) data to develop a quantitative donor risk score for OHT. METHODS: We examined a prospectively collected open cohort of 22,252 patients who underwent primary OHT (1996 to 2007). Of the 284 donor-specific variables, those associated with 1-year (year) mortality (exploratory p-value < 0.2) were incorporated into a multivariate (MV) logistic regression model. The final model contained donor factors that improved the explanatory power (by pseudo-R2, area under the curve and likelihood ratio test). A quantitative donor risk score was created using odds ratios (ORs) from the final model. For external validity, a cross-validation strategy was employed whereby the score was generated using a randomly generated subset of cases (n = 17,788) and then independently validated on the remaining patients (n = 4,464). RESULTS: A 15-point scoring system incorporated 4 variables: ischemic time; donor age; race mismatching; and blood urea nitrogen (BUN)/creatinine ratio. Derivation and validation cohort scores ranged from 1 to 15 and 1 to 12, respectively (mean 4.0 ± 2.1 for each). Each increase of 1 point increased the risk of 1-year death by 9% (OR = 0.09 [1.07 to 0.12]) in the derivation cohort and 13% (OR = 0.13 [1.08 to 0.18]) in the validation cohort (each p < 0.001). The odds of 1-year mortality by increments of 3 points were: 0 to 2 points (reference); 3 to 5 points (OR = 0.25 [1.12 to 0.40], p < 0.001); 6 to 8 pts (OR = 0.77 [1.56 to 2.02], p < 0.001); and 9 to 15 points (OR = 1.92 [1.54 to 2.39], p < 0.001). Donor risk score was predictive for 30-day mortality (OR = 0.11 [1.08 to 0.14], p < 0.001) and 5-year cumulative mortality (OR = 0.11 [1.09 to 0.13], p < 0.001). CONCLUSIONS: We present a novel donor risk index for OHT predicting short- and long-term mortality. This donor risk score may prove valuable for donor heart allocation and prognosis after OHT.

Should patients 60 years and older undergo bridge to transplantation with continuous-flow left ventricular assist devices?

BACKGROUND: Although left ventricular assist devices (LVADs) are now commonly used as a bridge to orthotopic heart transplantation (OHT), the upper patient age limit for this therapy has not been defined. Smaller studies have suggested that advanced age should not be a contraindication to bridge to transplantation (BTT) LVAD placement. The purpose of this study was to examine outcomes in patients 60 years and older undergoing BTT with continuous-flow LVADs. METHODS: The United Network for Organ Sharing (UNOS) database was reviewed to identify first-time OHT recipients 60 years of age and older (2005-2010). Patients were stratified by preoperative support: continuous-flow LVAD, intravenous inotropic agents, and direct transplantation. Survival after OHT was modeled using the Kaplan-Meier method. All-cause mortality was examined using multivariable Cox proportional hazard regression. RESULTS: Of 2,554 patients, 1,142 (44.7%) underwent direct transplantation, 264 (10.3%) had LVAD BTT, and 1,148 (45.0%) had BTT with inotropic agents. The mean age was 64±3 years, and 460 (18.0%) patients were women. Mean follow-up was 29±19 months. Survival differed significantly among the 3 groups. Patients with LVAD BTT had significantly lower survival after OHT compared with the other groups at 30 days and 1 year. This survival difference was no longer significant at 2 years after OHT or when deaths in the first 30 days were censored. LVAD BTT increased the hazard of death at 1 year by 50% (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.05-2.15; p=0.03), compared with patients who underwent direct transplantation. CONCLUSIONS: This study represents the largest modern cohort in which survival after OHT has been evaluated in patients 60 years or older who received BTT. Older patients have lower short-term survival after OHT when BTT is carried out with a continuous-flow LVAD compared with inotropic agents or direct transplantation.

Should orthotopic heart transplantation using marginal donors be limited to higher volume centers?

BACKGROUND: This study examined whether institutional volume impacts outcomes after orthotopic heart transplantation (OHT) utilizing marginal donors. METHODS: Adult patients undergoing OHT with the use of marginal donors between 2000 and 2010 were identified in the United Network for Organ Sharing database. A previously derived and validated donor risk score (range, 1 to 15) was used to define marginal donors as those in the 90th percentile of risk (score≥7). Patients were stratified into equal-size tertiles based on overall institutional OHT volume. Posttransplant outcomes were compared between these center cohorts. RESULTS: A total of 3,176 OHTs utilizing marginal donors were identified. In Cox regression analysis, recipients undergoing OHT at low-volume centers were at significantly increased risk of 30-day (hazard ratio 1.82 [1.31 to 2.54], p<0.001), 1-year (hazard ratio 1.40 [1.14 to 1.73], p=0.002), and 5-year posttransplant mortality (hazard ratio 1.29 [1.10 to 1.52], p=0.02). These findings persisted after adjusting for recipient risk, differences in donor risk score, and year of transplantation (each p<0.05). In Kaplan-Meier analysis, there was a similar trend of decreasing 1-year survival with decreasing center volume: high (86.0%), intermediate (85.7%), and low (81.2%; log rank p=0.003). Drug-treated rejection within the first post-OHT year was more common in low-volume versus high-volume centers (34.3% versus 24.2%, p<0.001). At an overall mean follow-up of 3.4±2.9 years, low-volume centers also had higher incidences of death due to malignancy (2.8% versus 1.3%, p=0.01) or infection (6.2% versus 4.1%, p=0.02). CONCLUSIONS: Consolidating the use of marginal donors to higher volume centers may be prudent in improving post-OHT outcomes in this higher risk patient subset.

Preoperative recipient cytokine levels are associated with early lung allograft dysfunction.

BACKGROUND: Primary graft dysfunction (PGD) is a morbid complication after lung transplant (LTx). Recipient before and after cytokine and chemokine profiles may be associated with a recipient's propensity to have PGD. METHODS: Serum samples were obtained from adult (more than 17 years old) primary LTx recipients (2002 to 2007) at two time points: (1) pre-reperfusion of transplanted lungs, and (2) within 24 hours after reperfusion. Interleukin (IL)-6, IL-8, IL-10, chemokine ligand (CCL)-2, and matrix metalloproteinase (MMP)-9 levels were determined. A PaO2/FiO2 ratio less than 300 at 48 hours (International Society for Heart and Lung Transplantation PGD grade 2 or more) was used to stratify patients. Follow-up was obtained through August 2009. Cytokine levels at both time points and the change in levels were assessed for association with PGD grade 2 or more. Outcomes and clinical characteristics were analyzed. RESULTS: Of 28 patients, 8 (28.6%) had PGD grade 2 or more. Median follow-up was 23 months (interquartile range, 16 to 31). Demographics, clinical data, and pre-LTx diagnoses did not differ between the groups. Patients who had PGD grade 2 or more had higher baseline levels of IL-10, IL-8, IL-6, and CCL-2 (all p<0.05). Within 24 hours, PGD grade 2 or more patients had higher IL-10 (p=0.02) and CCL-2 (p=0.04) levels. The PGD grade 2 or more patients were more likely to have had cardiopulmonary bypass during LTx (p=0.002) and blood products administered: platelets (p=0.004), plasma (p=0.05), and packed red blood cells (p=0.03)]. The PGD grade 2 or more patients had longer length of stay, duration of mechanical ventilation, and total intensive care unit days. CONCLUSIONS: Higher before and after transplant cytokine/chemokine levels were found in LTx recipients who subsequently had PGD grade 2 or more. Our study demonstrates that the recipient's inflammatory state at the time of LTx may impact early allograft function. That could represent a potential target for pretransplant pharmacologic intervention.

Insurance status is an independent predictor of long-term survival after lung transplantation in the United States.

BACKGROUND: Socioeconomic factors such as education, health insurance, and race are known to affect health outcomes. The United Network for Organ Sharing (UNOS) database provides a large cohort of lung transplant (LTx) recipients in which to evaluate the effect of insurance on survival. METHODS: We retrospectively reviewed UNOS data for 11,385 adult primary LTx patients (1998-2008). Patients were stratified by insurance (private/self-pay, Medicare, Medicaid, and other type). All-cause mortality was examined with Cox proportional hazard regression incorporating 14 variables. The Kaplan-Meier method was used to model survival after LTx. RESULTS: Of 11,385 recipients, 7,100 (62.4%) had private insurance/self-pay; 2,966 (26.1%) had Medicare; 815 (7.2%) had Medicaid; and 504 (4.4%) had other type insurance. During the study, 4,943 patients (43.4%) died. Medicare and Medicaid patients had 7.0% and 8.1% lower 10-year survival than did private insurance/self-pay patients, respectively. Insurance did not affect 30-day, 90-day, or 1-year survival. Medicare and Medicaid patients had decreased survival at 3 years and longer. In multivariable analyses, Medicare (hazard ratio, 1.10; 95% confidence interval, 1.03-1.19) and Medicaid (hazard ratio, 1.29; 95% confidence interval, 1.15-1.45) significantly increased risk of death. When deaths in the first year were excluded, survival differences persisted. CONCLUSIONS: This study represents the largest cohort evaluating the effect of insurance on post-LTx survival. Medicare and Medicaid patients have worse survival after LTx compared with private insurance/self-paying patients.

Impact of the lung allocation score on resource utilization after lung transplantation in the United States.

BACKGROUND: The United States lung allocation score (LAS) allows rapid organ allocation to higher acuity patients. Although, wait-list time and wait-list mortality have improved, the costs of lung transplantation (LTx) in these higher acuity patients are largely unknown. We hypothesize that LTx in high LAS recipients is associated with increased charges and resource utilization. METHODS: Clinical and financial data for LTx patients at our institution in the post-LAS era (May 2005 to 2009) were reviewed with follow-up through December 2009. Patients were stratified by LAS quartiles (Q). Total hospital charges for index admission and all admissions within 1 year of LTx were compared between Q4 vs Q1-3 using rank-sum and Kruskal-Wallis tests, as charge data were not normally distributed. RESULTS: Eighty-four LTxs were performed during the study period. Sixty-three (75%) patients survived 1 year; 10 (11.9%) died during the index admission. Median LAS was 37.5 (interquartile range [IQR] 34.3 to 44.8). LAS quartiles were: Q1, 30.1 to 34.3, n = 21; Q2, 34.4 to 37.5, n = 21; Q3, 37.6 to 44.8, n = 21; and Q4, 44.9 to 94.3, n = 21. Charges for index admission were: Q4, $276,668 (IQR 191,301 to 300,156) vs Q1-3, $153,995 (IQR 129,796 to 176,849) (p < 0.001). Index admission median length of stay was greater in Q4 (Q4: 35-day IQR 23 to 46 vs Q1-3: 15-day IQR 11 to 22, p = 0.003). For 1-year charges: Q4, $292,247 (IQR 229,192 to 421,597) vs Q1-3, $188,342 (IQR 153,455 to 252,045) (p = 0.002). Index admission and 1-year charges in Q4 were higher than for other quartiles when examined individually. CONCLUSIONS: This is the first study to show increased charges in high LAS patients. Charges for the index admission and hospital care in the year post-LTx were higher in the highest LAS quartile compared with patients in the lowest 75% of LAS.

Cardiothoracic surgeon management of postoperative cardiac critical care.

OBJECTIVE: To determine whether postoperative cardiac care by cardiothoracic surgeons in a semiclosed intensive care unit model could be distinguished from that given by intensivists who are not board certified in cardiothoracic surgery. DESIGN: From January 2007 to February 2009, we retrospectively examined data on patients after cardiac operations from 2 consecutive periods during which full-time management of intensive care was changed from noncardiothoracic intensivists (period 1, 168 patients) to cardiothoracic surgeons (period 2, 272 patients). MAIN OUTCOME MEASURES: Variables measured included Society of Thoracic Surgeons observed and expected mortality, central venous line infections, ventilator-acquired pneumonia, red blood cell exposure, adherence to blood glucose level target at 6 am on the first and second postoperative days, length of stay, and intensive care unit pharmacy costs. Results were compared using a 2-sample t test or 2-tailed Fisher exact test. RESULTS: In similar populations, as witnessed by equivalent Society of Thoracic Surgeons operative risk, cardiothoracic surgeons providing postoperative critical care led to a mean (SD) decrease in hospital length of stay from 13.4 (0.9) to 11.2 (0.4) days (P = .01) and decreased drug costs from $4300 (1000) to $1800  (200) (P < .001). These improvements occurred without losing benefits in other quality measures. CONCLUSIONS: By virtue of their cardiac-specific operative and nonoperative training, cardiothoracic surgeons may be uniquely qualified to provide postoperative cardiac critical care. In a semiclosed unit where care of the patient is codirected, the improvements noted may have been facilitated by the commonalities between surgeons and intensivists associated with similar training and experiences.

The impact of volume reduction on early and long-term outcomes in surgical ventricular restoration for severe heart failure.

BACKGROUND: Recent published results suggest no additive benefit to surgical ventricular restoration (SVR) when combined with coronary artery bypass grafting. However, there may still be a subgroup of patients with severe heart failure who can benefit from this procedure. We reviewed our institutional experience with SVR to determine early and late outcomes based on volume reduction. METHODS: We retrospectively reviewed our SVR patients (January 2002 to April 2008) with follow-up to March 2009. Baseline comorbidities, operative data, and postoperative outcomes were assessed by chart review, phone calls, and mailings. Survival was modeled using the Kaplan-Meier method. Cardiac magnetic resonance imaging, myocardial perfusion scans, and echocardiography assessed cardiac function, candidacy for SVR, and volume reduction. RESULTS: We reviewed 87 consecutive SVR patients (69 men). Mean age at operation was 61.1 years. Preoperatively, all patients had congestive heart failure, with 80 (92%) at New York Heart Association III/IV. All patients underwent preoperative viability studies. Three-vessel occlusion exceeding 50% was present in 69 (79%). After SVR, ejection fraction improved from 0.236 to 0.332 (p<0.001). Preoperative and postoperative magnetic resonance imaging in 26 patients (30.0%) showed a 30.8% reduction in left ventricular end systolic volume index. At follow-up, 51 of 66 (77%) improved to New York Heart Association I/II. One intraoperative death occurred. Preoperative left ventricular end systolic volume index of 80 to 120 was associated with improved survival (73% at 3 years). CONCLUSIONS: SVR is a surgical option for appropriately selected patients with severe congestive heart failure. In these high-risk patients, SVR successfully increased ejection fraction and decreased symptoms. A left ventricular end systolic volume index of 80 to 120 may be the ideal range for SVR procedures.

Creation of a quantitative recipient risk index for mortality prediction after cardiac transplantation (IMPACT).

BACKGROUND: No recipient risk index exists predicting short-term mortality after orthotopic heart transplantation (OHT). We utilized United Network for Organ Sharing (UNOS) data to develop a novel quantitative recipient risk score for use in OHT. METHODS: A prospectively collected open cohort of 21,378 primary OHT patients (1997 to 2008) was randomly divided into subgroups. The training cohort (n=17,079) was used for score derivation and the test cohort (n=4,299) was used for independent validation. Recipient specific variables associated with 1-year mortality (exploratory p value<0.2) were incorporated stepwise into a multivariable logistic regression model. The final model contained variables which maximized explanatory power (assessed by pseudo R2, area under the curve, and likelihood-ratio test). A risk index was created by apportioning points approximating the relative impact of variables on 1-year mortality. The Kaplan-Meier method was used to assess impact of risk score on short-term survival. RESULTS: The 50-point scoring system incorporated 12 recipient specific variables. Derivation and validation cohort scores ranged from 0 to 33 and 0 to 27, respectively (mean 6.1±3.7 and 6.1±3.7). Each point increased the odds of 1-year death by 14% in the derivation cohort (odds ratio 1.14 [1.13 to 1.15], p<0.001) and 15% in the validation cohort (odds ratio 1.15 [1.12 to 1.17], p<0001). One-year survivals in the validation cohort (by increments of 3 points) were the following: 0 to 2 (92.5%); 3 to 5 (89.9%); 7 to 9 (86.3%); and 10 or greater (74.9%); p<0.001. Patients transplanted with risk scores of 20 or higher had 1-year mortality rates greater than 50%. CONCLUSIONS: We present a novel internally validated OHT recipient risk score, which is highly predictive of 1-year mortality. This risk index may prove valuable for patient prognosis, organ allocation, and research stratification in OHT.

Infectious complications after pulsatile-flow and continuous-flow left ventricular assist device implantation.

BACKGROUND: Infection is a significant source of morbidity and mortality after left ventricular assist device (LVAD) implantation. Newer generation continuous-flow (CF) LVADs are smaller, requiring smaller pump pockets and drive-line exit sites as compared with pulsatile-flow (PF) devices. With their recent adoption, CF device patients benefit from improved provider experience in the detection and treatment of infectious complications. Given these advances in design and experience, we examined the incidence of infectious complications in patients receiving CF and PF devices. METHODS: We reviewed patients who received CF or PF LVADs (June 2000 to May 2009) at our institution. Incidences and timing of systemic infections (bacteremia, sepsis, severe sepsis, septic shock), device-associated infections (drive-line, LVAD pocket, sternal wound) and non-device-associated infections (catheter-related bloodstream, pneumonia, urinary tract) were compared between devices. Primary outcomes were sepsis, severe sepsis, a composite of drive-line and LVAD pocket infection, and catheter-related bloodstream infection. RESULTS: Of 133 LVADs, 86 were CF. CF patients had lower pre-operative risk, more recent device implantation, and longer LVAD support time. Device type was highly correlated with reduced infections; however, on multivariate analysis, implantation date appeared to drive this association. Kaplan-Meier estimates of freedom from all primary outcomes were improved with more recent implantation (p < 0.05). On multivariate analysis, implantation date was predictive of all primary outcomes except severe sepsis, for which advanced age and worse Seattle Heart Failure Model score were predictive. CONCLUSION: In this institutional review of post-LVAD infections, a decrease in infectious complications in CF patients was likely related to increased provider experience associated with a more recent date of implantation.

Bleeding complications and blood product utilization with left ventricular assist device implantation.

BACKGROUND: Bleeding complications are a major source of morbidity and reoperation after left ventricular assist device (LVAD) implantation, yet remain poorly characterized in patients receiving LVADs. We assessed bleeding complications in an institutional cohort of LVAD patients. METHODS: We reviewed patients who received continuous-flow (CF) LVADs at our institution (October 2004 to May 2009). Intraoperative and postoperative transfusion requirements (packed red blood cells, fresh frozen plasma, and platelets), chest tube output, and reoperation for bleeding complications were assessed. Univariate and multivariable Cox proportional hazard analysis assessed the impact of intraoperative bleeding on mortality. A subset of our patient population underwent delayed sternal closure as opposed to primary closure and an analysis of reoperation for bleeding was undertaken stratifying patients by approach to closure. RESULTS: Eighty-six CF LVADs were implanted over our study period. Patients had poor preoperative cardiac function and high preoperative risk indices. Patients receiving LVADs had high intraoperative (11.6 ± 7.5 units) and postoperative (15.6 [±12.6] units in the first week) blood product requirements, as well as significant chest tube output (5,880 [±4,480] milliliters in the first week). On multivariable analysis, intraoperative packed red blood cell transfusions were a significant predictor of mortality. Eleven (28%) patients undergoing primary sternal closure required reoperation for bleeding, while delayed sternal closure patients generally had resolution of bleeding prior to sternal closure. The incidence of gastrointestinal bleeding was 28% at one year. CONCLUSIONS: On multivariable analysis, intraoperative packed red blood cell transfusions were a significant predictor of 30-day and one-year mortality, while chest tube output during the first postoperative 48 hours predicted 30-day but not one-year mortality.