Alan R. Hartman

Do Hospitals and Surgeons With Higher Coronary Artery Bypass Graft Surgery Volumes Still Have Lower Risk-Adjusted Mortality Rates?

Background—Studies that are the basis of recommended volume thresholds for CABG surgery are outdated and not reflective of recent advances in the field. This study examines both hospital and surgeon volume-mortality relations for CABG surgery through the use of a population-based clinical data set. Methods and Results—Data from New York’s clinical CABG surgery registry from 1997 to 1999 (total number of procedures, 57 150) were used to examine the individual and combined impact of annual hospital volume and annual surgeon volume on in-hospital mortality rates after adjusting for differences in severity of illness. Significantly lower risk-adjusted mortality rates occurred above all annual hospital volume thresholds between 200 and 800 and above all surgeon volume thresholds between 50 and 200. The number needed to treat (NNT) at higher-volume providers to avoid a death was minimized for a hospital threshold volume of 100 (NNT=50) and a surgeon threshold volume of 50 (NNT=118). The risk-adjusted mortality rate (RAMR) for patients undergoing surgery performed by surgeons with volumes of ≥125 in hospitals with volumes of ≥600 was 1.89%. The RAMR was significantly higher (2.67%) for patients undergoing surgery performed by surgeons with volumes of <125 in hospitals with volumes of <600. Conclusions—Higher-volume surgeons and hospitals continue to have lower risk-adjusted mortality rates, and patients undergoing surgery performed by higher-volume surgeons in higher-volume hospitals have the lowest mortality rates.

1-Year Results in Patients Undergoing Transcatheter Aortic Valve Replacement With Failed Surgical Bioprostheses

OBJECTIVESnThis study evaluated the safety and effectiveness of self-expanding transcatheter aortic valve replacement (TAVR) in patients with surgical valve failure (SVF).nnnBACKGROUNDnSelf-expanding TAVR is superior to medical therapy for patients with severe native aortic valve stenosis at increased surgical risk.nnnMETHODSnThe CoreValve U.S. Expanded Use Study was a prospective, nonrandomized study that enrolled 233 patients with symptomatic SVF who were deemed unsuitable for reoperation. Patients were treated with self-expanding TAVR and evaluated for 30-day and 1-year outcomes after the procedure. An independent core laboratory was used to evaluate serial echocardiograms for valve hemodynamics and aortic regurgitation.nnnRESULTSnSVF occurred through stenosis (56.4%), regurgitation (22.0%), or a combination (21.6%). A total of 227 patients underwent attempted TAVR and successful TAVR was achieved in 225 (99.1%) patients. Patients were elderly (76.7xa0± 10.8 years), had a Society of Thoracic Surgeons Predicted Risk of Mortality score of 9.0 ± 6.7%, and were severely symptomatic (86.8% New York Heart Association functional class III or IV). The all-cause mortality rate was 2.2% at 30 days and 14.6% at 1 year; major stroke rate was 0.4% at 30 days and 1.8% at 1 year. Moderate aortic regurgitation occurred in 3.5% of patients at 30 days and 7.4% of patients at 1 year, with no severe aortic regurgitation. The rate of new permanent pacemaker implantation was 8.1% at 30 days and 11.0% at 1 year. The mean valve gradient was 17.0 ± 8.8 mmxa0Hg at 30 days and 16.6 ± 8.9 mmxa0Hg at 1 year. Factors significantly associated with higher discharge mean aortic gradients were surgical valve size, stenosis as modality of SVF, and presence of surgical valve prosthesis patient mismatch (all pxa0< 0.001).nnnCONCLUSIONSnSelf-expanding TAVR in patients with SVF at increased risk for surgery was associated with a low 1-year mortality and major stroke rate, significantly improved aortic valve hemodynamics, and low rates of moderate and noxa0severe residual aortic regurgitation, with improved quality of life.

Impact of Preoperative Prealbumin on Outcomes After Cardiac Surgery

BACKGROUNDnPreoperative malnutrition is increasingly prevalent in patients undergoing cardiac surgery. Although prealbumin is a widely used indicator of nutrition status, its use in the preoperative assessment of patients undergoing cardiac surgery is not well defined. The purpose of this study is to determine the impact of preoperative prealbumin levels on outcomes after cardiac surgery.nnnMATERIALS AND METHODSnData were prospectively gathered from February 2013 to July 2013 on 69 patients undergoing cardiac surgery. Prealbumin levels were obtained within 24 hours of surgery. Patients were divided into 2 groups based on a prealbumin cutoff value of 20 mg/dL.nnnRESULTSnOf the 69 patients, 32 (46.4%) had a preoperative prealbumin ≤ 20 mg/dL. There was no correlation between prealbumin levels and body mass index (r = -0.13, P = .28). Likewise, there was no correlation between preoperative albumin and prealbumin levels (r = 0.09, P = .44). Nine of 32 (28.1%) patients with low preoperative prealbumin levels had postoperative infections compared with 2 of 37 (5.4%) patients with high prealbumin levels (P = .010). Patients with low prealbumin levels also had increased risk of postoperative intubation for > 12 hours (P = .010).nnnCONCLUSIONSnPatients undergoing cardiac surgery with preoperative prealbumin levels of ≤ 20 mg/dL have an increased risk for postoperative infections and the need for longer mechanical ventilation. If feasible, nutrition optimization of such patients may be considered prior to cardiac surgery.

Cardiac Surgery Nurse Practitioner Home Visits Prevent Coronary Artery Bypass Graft Readmissions

BACKGROUNDnWe designed and tested an innovative transitional care program, involving cardiac surgery nurse practitioners, to improve care continuity after patient discharge home from coronary artery bypass graft (CABG) operations and decrease the composite end point of 30-day readmission and death.nnnMETHODSnA total of 401 consecutive CABG patients were eligible between May 1, 2010, and August 31, 2011, for analysis. Patient data were entered prospectively into The Society of Thoracic Surgeons database and the New York State Cardiac Surgery Reporting System and retrospectively analyzed with Institutional Review Board approval. The Follow Your Heart program enrolled 169 patients, and 232 controls received usual care. Univariate and multivariate analyses were used to identify readmission predictors, and propensity score matching was performed with 13 covariates.nnnRESULTSnBinary logistic regression analysis identified Follow Your Heart as the only independently significant variable in preventing the composite outcome (p=0.015). Odds ratios for readmission were 3.11 for dialysis patients, 2.17 for Medicaid recipients, 1.87 for women, 1.86 for non-Caucasians, 1.78 for chronic obstructive pulmonary disease, 1.26 for diabetes, and 1.09 for congestive heart failure. Propensity score matching yielded matches for 156 intervention patients (92%). The intervention showed a significantly lower 30-day readmission/death rate of 3.85% (6 of 156) compared with 11.54% (18 of 156) for the usual care matched group (p=0.023).nnnCONCLUSIONSnA home transition program providing continuity of care, communication hub, and medication management by treating hospital nurse practitioners significantly reduced the 30-day composite end point of readmission/death after CABG. More targeted resource allocation based on odds ratios of readmission may further improve results and be applicable to other patient groups.

P2Y12 platelet function assay for assessment of bleeding risk in coronary artery bypass grafting.

The use of platelet function testing has been advocated to individualize the time needed between discontinuation of P2Y12 inhibitors and coronary artery bypass grafting (CABG). However, the use of specific point‐of‐care assays to predict bleeding risk in patients on P2Y12 inhibitors prior to CABG has not been fully validated.

Propensity-matched analysis of the effect of preoperative intraaortic balloon pump in coronary artery bypass grafting after recent acute myocardial infarction on postoperative outcomes

IntroductionThere is substantial variability in the preoperative use of intraaortic balloon pumps (IABPs) in patients undergoing coronary artery bypass grafting post myocardial infarction. The objective of this study is to determine the effect of preoperative IABPs on postsurgical outcomes in this subset of patients.MethodsFrom 2007 to 2012, 877 patients underwent isolated coronary artery bypass post myocardial infarction. Four hundred and six patients were propensity-score matched based on the likelihood of receiving a preoperative balloon pump. Total blood transfusion requirements, composite in-hospital morbidity and/or mortality end point, total hours in the intensive care unit, and length of hospital stay were compared between the two groups.ResultsNo significant differences in demographics, preoperative risk factors, intraoperative variables or length of hospital stay were found between patients with and without balloon pumps after propensity score matching. Compared to patients without balloon pumps, a higher percentage of patients with preoperative IABPs required transfusions. Patients with preoperative balloon pumps were more likely to have the composite end point of in-hospital morbidity (24.1% versus 12.8%, P <0.004), and increased hours in the intensive care unit (median hours: 69.0 versus 46.0, P <0.013) as compared to patients without balloon pumps.ConclusionsThe use of preoperative IABPs in patients undergoing isolated coronary artery bypass grafting after myocardial infarction is associated with increased transfusion requirements, increased in-hospital morbidity and longer postoperative intensive care unit stay as compared to patients without IABPs.

Surgical Repair of a Left Atrial-Esophageal Fistula After Radiofrequency Catheter Ablation for Atrial Fibrillation

Left atrial-esophageal fistula is a highly lethal complication of ablative therapy for atrial fibrillation. Because of its unusual rate of occurrence, there has not been a uniform approach to either the diagnosis or corrective therapy. We offer 1 such surgical option based on presumptive and early diagnosis-left atrial repair with cardiopulmonary bypass followed by repair of the esophagus with an omental wrap and supported with decompressive gastrostomy and feeding jejunostomy.

Alkaptonuria and Aortic Stenosis

Excerpt To the editor: Alkaptonuria, a hereditary disorder related to the absence of homogentisic acid oxidase, may be associated with cardiovascular disease (1-4). Because of its low prevalence in...

Acute surgical pulmonary embolectomy: a 9-year retrospective analysis.

Acute pulmonary embolism is a substantial cause of morbidity and death. Although the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines recommend surgical pulmonary embolectomy in patients with acute pulmonary embolism associated with hypotension, there are few reports of 30-day mortality rates. We performed a retrospective review of acute pulmonary embolectomy procedures performed in 96 consecutive patients who had severe, globally hypokinetic right ventricular dysfunction as determined by transthoracic echocardiography. Data on patients who were treated from January 2003 through December 2011 were derived from health system databases of the New York State Cardiac Surgery Reporting System and the Society of Thoracic Surgeons. The data represent procedures performed at 3 tertiary care facilities within a large health system operating in the New York City metropolitan area. The overall 30-day mortality rate was 4.2%. Most patients (68 [73.9%]) were discharged home or to rehabilitation facilities (23 [25%]). Hemodynamically stable patients with severe, globally hypokinetic right ventricular dysfunction had a 30-day mortality rate of 1.4%, with a postoperative mean length of stay of 9.1 days. Comparable findings for hemodynamically unstable patients were 12.5% and 13.4 days, respectively. Acute pulmonary embolectomy can be a viable procedure for patients with severe, globally hypokinetic right ventricular dysfunction, with or without hemodynamic compromise; however, caution is warranted. Our outcomes might be dependent upon institutional capability, experience, surgical ability, and careful patient selection.

Dose-Dependent Effects of Intraoperative Low Volume Red Blood Cell Transfusions on Postoperative Outcomes in Cardiac Surgery Patients

OBJECTIVEnTo determine the incremental risk associated with each intraoperative red blood cell transfusion in cardiac surgery patients.nnnDESIGNnRetrospective analysis on prospectively collected data.nnnSETTINGnSingle tertiary care hospital.nnnPARTICIPANTSnSeven hundred forty-five patients undergoing on-pump cardiac surgery between January 2010 and June 2012 who received between 1 and 3 units of red blood cell transfusion intraoperatively.nnnINTERVENTIONSnAll patients received between 1 and 3 units of red blood cell transfusions. All transfusions were with leukoreduced blood that had been stored for < 14 days.nnnMEASUREMENTS AND MAIN RESULTSnPostoperative complications and length of intubation were associated with the number of red blood cell units transfused. Transfusion of each additional unit of red blood cells was associated with incrementally worse outcomes. Median length of intubation was 11 hours, 12 hours, and 13 hours in patients receiving 1, 2, and 3 units of red blood cell transfusions, respectively (p < 0.005). Similarly, each additional unit of red blood cell transfusion was associated with increasing postoperative septicemia (0% v 0.35% v 2.29%, p < 0.006) and postoperative pneumonia (0% v 0.70% v 2.29%, p < 0.013).nnnCONCLUSIONSnThere is a step-wise increase in length of postoperative intubation with each red blood cell transfusion in patients undergoing cardiac surgery. Each additional unit of intraoperative RBC transfusion also may increase postoperative infectious complications. Thus, even single-unit reductions in red blood cell transfusions may have significant impact on outcomes.