Impact of Pulmonary Complications on Outcomes and Resource Use After Elective Cardiac Surgery.

OBJECTIVE: To characterize the impact of pulmonary complications (PCs) on mortality, costs, and readmissions after elective cardiac operations in a national cohort and to test for hospital-level variation in PC. BACKGROUND: PC after cardiac surgery are targets for quality improvement efforts. Contemporary studies evaluating the impact of PC on outcomes are lacking, as is data regarding hospital-level variation in the incidence of PC. METHODS: Adults undergoing elective coronary artery bypass grafting and/or valve operations were identified in the 2016-2019 Nationwide Readmissions Database. PC was defined as a composite of reintubation, prolonged (>24 hours) ventilation, tracheostomy, or pneumonia. Generalized linear models were fit to evaluate associations between PC and outcomes. Institutional variation in PC was studied using observed-to-expected ratios. RESULTS: Of 588,480 patients meeting study criteria, 6.7% developed PC. After risk adjustment, PC was associated with increased odds of mortality (14.6, 95% CI, 12.6-14.8), as well as a 7.9-day (95% CI, 7.6-8.2) increase in length of stay and $41,300 (95% CI, 39,600-42,900) in attributable costs. PC was associated with 1.3-fold greater hazard of readmission and greater incident mortality at readmission (6.7% vs 1.9%, P <0.001). Significant hospital-level variation in PC was present, with observed-to-expected ratios ranging from 0.1 to 7.7. CONCLUSIONS: Pulmonary complications remain common after cardiac surgery and are associated with substantially increased mortality and expenditures. Significant hospital-level variation in PC exists in the United States, suggesting the need for systematic quality improvement efforts to reduce PC and their impact on outcomes.

Retained entrapped coronary stent appearing like an aortic flap.

Entrapment of coronary angioplasty hardware is a rare but serious complication of coronary interventions which may be managed percutaneously or surgically. We described a case of an entrapped coronary stent in a patient with a history of failed coronary intervention with no documents available. In transesophageal echocardiography, there was a linear echo density in the ascending aorta stuck in the right coronary artery resembling a dissection flap but based on the history of failed coronary intervention, this odd structure was supposed to be a retained angioplasty device. The patient underwent surgical removal of the entrapped device which was a fractured stent.

Ruptured mitral valve aneurysm: A devastating complication of aortic valve endocarditis.

Mitral valve aneurysm is a rare clinical entity that is mostly resulted from infective endocarditis, in particular, aortic valve endocarditis. Once mitral valve aneurysm ruptures and severe mitral regurgitation and hemodynamic instability develop, prompt surgery should be considered. Here we report a patient with ruptured mitral valve aneurysm associated with native aortic valve endocarditis that was improved after a successful mitral and aortic valve replacement surgery associated with antibiotic therapy for 6 weeks.

Center-Level Variation in Hospitalization Costs of Transcatheter Aortic Valve Replacement.

BACKGROUND: Using a nationally representative database, the present study evaluated the degree of center-level variation in the cost of transcatheter aortic valve replacement (TAVR). METHODS: All adults undergoing elective, isolated TAVR were identified in the 2016 to 2018 Nationwide Readmissions Database. Multilevel mixed-effects models were used to identify patient and hospital characteristics associated with hospitalization costs. The random intercept for each hospital was generated and considered to be the baseline cost attributable to care at each center. Hospitals in the highest decile of baseline costs were classified as high-cost hospitals. The association of high-cost hospital status with in-hospital mortality and perioperative complications was subsequently assessed. RESULTS: An estimated 119,492 patients, with a mean age of 80 years and a 45.9% prevalence of female sex, met the study criteria. Analysis of random intercepts indicated that 54.3% of variability in costs was attributable to interhospital differences rather than patient factors. Perioperative respiratory failure, neurologic complications, and acute kidney injury were associated with increased episodic expenditure but did not explain the observed center-level variation. The baseline cost associated with each hospital ranged from -$26,000 to $162,000. Notably, high-cost hospital status was not linked to annual TAVR caseload or to odds of mortality (P = .83), acute kidney injury (P = .18), respiratory failure (P = .32), or neurologic complications (P = .55). CONCLUSIONS: The present analysis identified significant variation in the cost of TAVR, which was largely attributable to center-level rather than patient factors. Hospital TAVR volume and occurrence of complications were not drivers of the observed variation.

National clinical and financial outcomes associated with acute kidney injury following esophagectomy for cancer.

BACKGROUND: Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission. METHODS: All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010-2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest. RESULTS: Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62-5.83) and had significantly increased attributable costs ($112,000 vs $54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01-1.32). CONCLUSIONS: AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level.

Extraluminal atherosclerosis: an under-recognised finding in human aortocoronary venous bypass grafts.

BACKGROUND: Coronary artery bypass grafting (CABG) is commonly compromised by graft atherosclerosis. Histopathologic studies confirm various forms of atherosclerosis, including positively remodelled lesions in native coronary arteries but there are no histopathologic reports of extraluminal atherosclerosis in vein grafts. METHODS: We prospectively investigated the histopathologic presence and pattern of extraluminal atherosclerosis in human old vein grafts in a two-year interval among patients undergoing redo-CABG at three university hospitals in Tehran. We separately documented clinical and angiographic findings. RESULTS: We evaluated 100 segments from 20 human old vein grafts obtained during the redo CABG. All but four segments demonstrated some degrees of luminal narrowing. Luminal atherosclerotic plaques were detectable in 61 segments. We detected extraluminal atheroscleoris in seven segments. Mean vessel wall thickness was greater in segments containing extraluminal plaques (1.41±0.26 mm versus 0.91±0.04 mm, P=0.008). Angiographic findings had a modest correlation with presence or absence of luminal atheromatous lesions (Spearman's rho: 0.331, P=0.007). Angiographic degree of stenosis could not predict the presence of positively remodelled atherosclerotic plaques (Spearman's rho: -2.21, P=0.073). CONCLUSION: Previous studies suggested positive remodelling in vein grafts. Out study provides histopathologic evidence on extraluminal atherosclerosis in human aortocoronary vein grafts.

Histopathologic insight into saphenous vein bypass graft disease.

OBJECTIVES: Vein graft disease is a major drawback of coronary artery bypass grafting. However, histopathologic studies of old human aortocoronary grafts are scarce. METHODS: We screened patients undergoing redo coronary artery bypass grafting at three university hospitals and selected those with at least one excisable old vein graft. Native non-grafted saphenous veins were also obtained as controls. Clinical and angiographic data were separately documented. RESULTS: We evaluated 117 segments from 29 veins. All but 4 old graft segments showed degrees of luminal narrowing and fibrointimal proliferation. Moreover, 61 segments demonstrated atherosclerotic plaques. Such plaques were typically concentric and, compared with other segments, more frequently represented necrosis, calcification and giant cells (p < 0.001 for all comparisons) and had a higher inflammatory cell count, predominantly of lymphocytic origin. Native saphenous veins frequently showed fibrosis, but no calcification or active inflammation. Angiographic findings showed moderate correlation with the histological degree of luminal stenosis (Spearman's ρ = 0.564, p < 0.001). CONCLUSIONS: Human vein graft atherosclerosis and arterial atherosclerosis share many features; however, we found lymphocytes to be the dominant inflammatory cells within plaques. Conventional angiography underestimated the atherosclerosis burden in vein grafts. Improved understanding of disease pathophysiology could lead to the development of novel interventions that reduce costly and suboptimal repeat revascularizations.

Predictors and early outcome of prolonged mechanical ventilation in contemporary heart valve surgery.

BACKGROUND: During last decades mechanical ventilation has been an important support in the postoperative management of patients undergoing cardiac surgery. This study was designed to determine the predictors of prolonged mechanical ventilation (PMV) in patients undergoing heart valve surgery. METHODS: This retrospective study considered of 1056 patients who underwent isolated valve surgery at Tehran Heart Center from March 2002 to March 2009. PMV is considered as mechanical ventilation period of > or =24 hours at postoperative hospital stay in this study. RESULTS: PMV occurred in 6.6% of patients. Initial ventilation hours, atrial fibrillation, cardiac arrest and reintubation were the most prevalent postoperative complications. Preoperative renal failure, postoperative stroke, intra aortic balloon pump insertion, emergent operation, complete heart block, longer perfusion time were independent predictors of PMV in our patients. CONCLUSION: PMV is associated with significant comorbidities and increased hospital mortality. Strategies to delineate the patients at risk and to modify these risk factors by prophylactic measures should probably lead to a lower incidence of prolonged mechanical ventilation for patients undergoing isolated valve surgery.

Atherosclerosis and vascular injury: the effect of a perivascular nitric oxide donor in a cholesterol-fed rabbit model.

Nitric oxide (NO) has been shown to prevent neointimal hyperplasia and decrease atherosclerosis in several animal models. It is a major modulator of vascular homeostasis and has vasoprotective effects against atherosclerosis. However, NO-based therapies with such purposes have not been used in the clinical arena. Our objective was to combine a medical grade elastomer and an NO donor, diethylenetriamine NO adduct (DETA/NO), to determine whether its perivascular administration can attenuate atherosclerosis and vascular injury. Aortic intimal injury was produced using paediatric pulmonary valvoplasty catheter in 22 healthy male New Zealand White rabbits, which were fed a high-cholesterol diet for 4 weeks beforehand. A mixture of the elastomer Silastic and DETA/NO was applied locally to cover the aortas in the experiment group. After 6 additional weeks on the high-cholesterol diet, the aortas and blood samples were harvested for pathologic analysis and comparison with the control group. Mean atherosclerosis and vascular injury surface area was 6.68 x 10(5) microm2 in the experiment group, compared with 3.44 x 10(5) microm2 in the controls. However, there was no statistically significant difference in atherosclerotic surface area between the two groups. Perivascular application of the NO donor DETA/NO, in the concentration we used, did not prevent atherosclerosis in high cholesterol-fed rabbits. This finding prompts more careful assessment before possible clinical uses.

Traditional cardiac risk factors profile in Iranian patients undergoing coronary artery bypass surgery.

OBJECTIVE: It is well known that the traditional cardiac risk factors (TCRFs) affect short-term and long-term outcome following coronary artery bypass graft surgery (CABG). The objective of this study was to detect the prevalence of these risk factors i.e., hypertension, diabetes mellitus, hyperlipidaemia, smoking and family history of premature CAD in an Iranian population undergoing coronary artery bypass surgery. METHODS AND RESULTS: From March 2001 to September 2005, we retrospectively analysed prospectively collected data from our registry. Data were achieved regarding TCRFs in 10,622 consecutive patients undergoing elective CABG. Mean age of the patients was 58.75 +/- 9.72 years and 74.4% were men. The majority of the patients were overweight with a body mass index (BMI) > or = 25.0 kg/m2. Hyperlipidaemia was present in 63.9% of the patients. Over half of all the patients had hypertension and over one third diabetes. History of smoking was present in 37.7% of the patients and one third had a family history of CAD. Of all the patients, 91.6% had at least one of the TCRFs. As compared to men, women were more overweight or obese, and had a greater prevalence of hyperlipidaemia, hypertension, diabetes mellitus, and family history of CAD but smoking was much more common in men than in women. CONCLUSION: The current study revealed a high prevalence of most of TCRFs in an Iranian population that underwent CABG.

Determinant factors of renal failure after coronary artery bypass grafting with on-pump technique.

OBJECTIVE: The aim of the present study was to investigate the determinant factors of acute renal failure (ARF) after isolated on-pump coronary artery bypass grafting (CABG). SUBJECTS AND METHODS: This was a retrospective study of 13,315 adult patients who underwent isolated CABG with cardiopulmonary bypass (CPB) in Tehran Heart Center from May 2002 to May 2007. The exclusion criteria were age <18, concomitant cardiac and/or noncardiac surgical operations, history of renal failure before surgery, and chronic renal failure requiring dialysis. Preoperative and operative variables were measured, and a multivariate logistic regression model was constructed to identify the independent risk factors for developing renal failure after on-pump CABG. RESULTS: Of the 13,315 patients, 3,347 (25.4%) and 90,883 (74.6%) were females and males, respectively, with a mean age of 58.63 +/- 9.48 years. ARF was detected in 85 (0.6%) of the patients with isolated on-pump CABG. The mean age of the patients was 58.63 +/- 9.48 years, and 25.5% of them were female. The multivariate logistic regression analysis identified age (OR = 1.035; p = 0.002), female gender (OR = 1.622; p = 0.037), history of peripheral vascular disease (PVD) (OR = 2.579; p = 0.042), diabetes mellitus (OR = 1.918; p < 0.001), emergent and urgent surgery (OR = 1.744 and OR = 7.901, respectively; p = 0.003), CPB time >70 min (OR = 1.944; p = 0.007), and intra-aortic balloon pump (IABP) insertion (OR = 10.181; p < 0.001) as the independent risk factors for ARF. CONCLUSION: The data showed that age, female gender, positive history of diabetes and PVD, urgent and emergent surgery, CPB time >70 min, and need for IABP were the independent determinant factors of ARF after on-pump CABG.

Hydatid cyst of the right ventricle in early pregnancy.

Although hydatic cyst disease rarely involves myocardium and endocardium, cardiac echinococcosis, a potentially life-threatening condition, should be managed promptly. We report a case of right ventricle hydatid cyst detected after syncopal attack in a pregnant woman by using echocardiography.

Floating thrombus in the aortic arch as an origin of simultaneous peripheral emboli.

Few cases of a floating thrombus in a normal aorta have been reported without other underlying reasons for the thrombus formation and its systemic embolic complications. We report a case in which a floating thrombus in the proximal aortic arch was detected after echocardiography and computed tomography angiography as an origin of upper extremities and ophthalmic embolism.

Cardiac and great vessel involvement in "Behcet's disease".

Behcet's disease is a multisystem disorder and classified as "vasculitic syndrome with a wide variety of clinical manifestations." Cardiac involvement is very rare but can occur with different presentations including: pericarditis, cardiomyopathy, endocarditis, endomyocardial fibrosis, intracavitary thrombosis, and coronary artery disease. Great vessel involvement is more common. Recurrent Phlebitis, commonly involving large vessels (superior vena cava, inferior vena cava, hepatic veins) and cerebral veins are the sole presentation in this regard. Arterial involvement is expressed by aneurysm or pseudoaneurysmal formation. Due to the wide variety of cardiovascular manifestations and the resulting high mortality, cardiac surgeons should be familiar with this disease. In this paper we review the articles and introduce our four cases presenting with aneurysm of ascending aorta with free aortic insufficiency, aneurysm of descending aorta, pulmonary artery aneurysm, and pseudoaneurysm of aortic arch.

Early outcomes of double-vessel coronary endarterectomy in comparison with single-vessel coronary endarterectomy.

Our goal was to investigate the safety of single- and double-vessel coronary endarterectomy as an adjunct to coronary artery bypass grafting in patients with diffuse coronary disease. In reviewing the records of 9,443 patients who underwent isolated coronary artery revascularization over a 4-year period, we found 310 patients (3.28%) who underwent concomitant coronary artery endarterectomy, 39 of whom (12.6%) required double endarterectomy (Group 2) and the rest of whom required single endarterectomy (Group 1). Variables of these groups were compared by means of univariate analysis. In Group 1, 76.3% were men, with a mean age of 58.73 +/- 9.36 yr. Regarding postoperative myocardial infarction as evaluated by electrocardiography and the MB isoenzyme of creatine kinase, 13% of the patients in Group 1 and 15.4% in Group 2 were so affected. The early mortality rate was 3.3% in Group 1 and 10.3% in Group 2 (P <0.05). In univariate analysis, the following variables were significant: 3-vessel disease, postoperative atrial fibrillation, dialysis, length of hospital stay, and death. In multivariate analysis of endarterectomized arteries, the vascular combinations most strongly associated with death were left anterior descending coronary artery + right coronary artery and right coronary artery + diagonal. There was no association between endarterectomy of particular vessels and perioperative myocardial infarction. Although coronary endarterectomy has become a safe procedure, adding a 2nd endarterectomy worsens the prognosis dramatically, and surgeons should be especially cautious about such an addition if the 1st endarterectomy is in left anterior descending coronary artery or right coronary artery territory.

Coronary artery bypass grafting in patients with low ejection fraction: the effect of intra-aortic balloon pump insertion on early outcome.

BACKGROUND: Survival benefit with intra-aortic balloon pump (IABP) insertion for coronary artery bypass grafting (CABG) patients with left ventricular dysfunction is controversial. The aim of this study was to assess the early results of CABG that predict 30-day mortality and prolonged length of hospital stay (LOS) after isolated CABG and the role of IABP application as a main predictor in patients with an ejection fraction (EF) of 30% or less. MATERIALS AND METHODS: Eight hundred and thirty-three patients who underwent isolated CABG with EF < or = 30% were entered and compared with 10881 patients with EF > 30% as the control group. Demographic and clinical characteristics and postoperative complications were considered. Data were analyzed using the student's t-test and chi-square test for univariate analysis and the analysis of covariance and logistic regression for multivariate analysis. RESULTS: The thirty-day mortality rate (1.6% vs. 0.7%, P P P = 0.002) and prolonged LOS (P = 0.009). Also, urinary tract infection, prolonged ventilation, and renal failure as postoperative complications were statistically more in the group with the application of IABP. CONCLUSION: Low ejection fraction can positively affect thirty-day mortality and prolonged LOS and ICU stay in patients who undergo CABG. In these patients, IABP insertion is a strong predictor for early complication and mortality.

24-hour in-hospital mortality predictions in coronary artery bypass grafting patients.

BACKGROUND: The purpose of this study was to determine the factors that can help predict risk of mortality in the first 24 h of coronary artery bypass grafting (CABG), because mortality within a few hours of surgery is a disastrous event for surgeons and the patient's family. METHODS: The study population consisted of 120 in-hospital mortality cases (1.07%) from 11,183 patients who underwent CABG from February 2002 to February 2006 by the same group of surgeons in a referral center. One group consisted of 40/120 (about 33.3%) patients who died during the first 24 h after surgery. The second group consisted of 80/120 patients (66.7%) who died between the 2(nd) and 30(th) day postoperatively. A set of data was gathered from the surgery database of the hospital and analyzed in a univariate model. RESULTS: Among the studied variables, only the following factors proved to be significant: previous percutaneous transluminal coronary angioplasty (PTCA), previous cerebrovascular accident (CVA), cardiopulmonary bypass (CBP) time, and postoperative atrial fibrillation (AF) (p

Superficial and deep sternal wound infection after more than 9000 coronary artery bypass graft (CABG): incidence, risk factors and mortality.

BACKGROUND: Sternal wound infection (SWI) is an uncommon but potentially life-threatening complication of cardiac surgery. Predisposing factors for SWI are multiple with varied frequencies in different studies. The purpose of this study was to assess the incidence, risk factors, and mortality of SWI after coronary artery bypass grafting (CABG) at Tehran Heart Center. METHODS: This study prospectively evaluated multiple risk factors for SWI in 9201 patients who underwent CABG at Tehran Heart Center between January 2002 and February 2006. Cases of SWI were confirmed based on the criteria of the Centers for Disease Control and Prevention. Deep SWI (bone and mediastinitis) was categorized according to the Oakley classification. RESULTS: In the study period, 9201 CABGs were performed with a total SWI rate of 0.47 percent (44 cases) and deep SWI of 0.22 percent (21 cases). Perioperative (in-hospital) mortality was 9.1% for total SWI and about 14% for deep SWI versus 1.1% for non-SWI CABG patients. Female gender, preoperative hypertension, high functional class, diabetes mellitus, obesity, prolonged intubation time (more than 48 h), and re-exploration for bleeding were significant risk factors for developing SWI (p = 0.05) in univariate analysis. In multivariate analysis, hypertension (OR = 10.7), re-exploration (OR = 13.4), and female gender (OR = 2.7) were identified as significant predictors of SWI (p < 0.05 for all). The rate of SWI was relatively similar in 3 groups of prophylactic antibiotic regimen (Cefazolin, Cefazolin + Gentamycin and Cefazolin + Amikacin: 0.5%, 0.5%, and 0.34% respectively). CONCLUSION: Rarely reported previously, the two risk factors of hypertension and the female gender were significant risk factors in our study. Conversely, some other risk factors such as cigarette smoking and age mentioned as significant in other reports were not significant in our study. Further studies are needed for better documentation.