Damien J. LaPar

Primary payer status affects mortality for major surgical operations.

Objectives:Medicaid and Uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes following major surgical operations in the United States is dependent on primary payer status. Methods:From 2003 to 2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n = 491,829), Medicaid (n = 40,259), Private Insurance (n = 337,535), and Uninsured (n = 24,035). Multivariate regression models were applied to assess outcomes. Results:Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid (3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to Private Insurance groups (1.3%, P < 0.001). Mortality was lowest for Private Insurance patients independent of operation. After controlling for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid payer status was associated with the longest length of stay and highest total costs (P < 0.001). Medicaid (P < 0.001) and Uninsured (P < 0.001) payer status independently conferred the highest adjusted risks of mortality. Conclusions:Medicaid and Uninsured payer status confers increased risk-adjusted mortality. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors or operation. These differences serve as an important proxy for larger socioeconomic and health system-related issues that could be targeted to improve surgical outcomes for US Patients.

Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery

BACKGROUND Efforts to reduce blood product use have the potential to avoid transfusion-related complications and reduce health care costs. The purpose of this investigation was to determine whether a multi-institutional effort to reduce blood product use affects postoperative events after cardiac surgical operations and to determine the influence of perioperative transfusion on risk-adjusted outcomes. METHODS A total of 14,259 patients (2006-2010) undergoing nonemergency, primary, isolated coronary artery bypass grafting operations at 17 different statewide cardiac centers were stratified according to transfusion guideline era: pre-guideline (n = 7059, age = 63.7 ± 10.6 years) versus post-guideline (n = 7200, age = 63.7 ± 10.5 years). Primary outcomes of interest were observed differences in postoperative events and mortality risk-adjusted associations as estimated by multiple regression analysis. RESULTS Overall intraoperative (24% vs 18%, P < .001) and postoperative (39% vs 33%, P < .001) blood product transfusion were significantly reduced in the post-guideline era. Patients in the post-guideline era demonstrated reduced morbidity with decreased pneumonia (P = .01), prolonged ventilation (P = .05), renal failure (P = .03), new-onset hemodialysis (P = .004), and composite incidence of major complications (P = .001). Operative mortality (1.0% vs 1.8%, P < .001) and postoperative ventilation time (22 vs 26 hours, P < .001) were similarly reduced in the post-guideline era. Of note, after mortality risk adjustment, operations performed in the post-guideline era were associated with a 47% reduction in the odds of death (adjusted odds ratio, 0.57; P < .001), whereas the risk of major complications and mortality were significantly increased after intraoperative (adjusted odds ratio, 1.86 and 1.25; both P < .001) and postoperative (adjusted odds ratio, 4.61 and 4.50, both P < .001) transfusion. Intraoperative and postoperative transfusions were associated with increased adjusted incremental total hospitalization costs (

Initial Experience of Sequential Surgical Epicardial-Catheter Endocardial Ablation for Persistent and Long-Standing Persistent Atrial Fibrillation With Long-Term Follow-Up

4408 and

Natural Killer T Cell–derived IL-17 Mediates Lung Ischemia–Reperfusion Injury

10,479, respectively). CONCLUSIONS Implementation of a blood use initiative significantly improves postoperative morbidity, mortality, and resource utilization. Limiting intraoperative and postoperative blood product transfusion decreases adverse postoperative events and reduces health care costs. Blood conservation efforts are bolstered by collaboration and guideline development.

Postoperative Atrial Fibrillation Significantly Increases Mortality, Hospital Readmission, and Hospital Costs

BACKGROUND Patients with long-standing persistent (LSP) atrial fibrillation (AF) who have previously undergone catheter ablation represent a challenging patient population. Repeat catheter ablation in these patients is arduous and associated with a high failure rate, whereas surgical ablation can be complicated by multiple flutters. We sought to determine if minimally-invasive surgical ablation, followed by catheter ablation of all inducible flutters, would improve success rates over repeat catheter ablation alone. METHODS Fifteen patients (Sequential) with persistent or LSP AF who failed at least one catheter ablation and one anti-arrhythmic drug (AAD) underwent surgical ablation, followed by planned endocardial evaluation and catheter mapping with ablation during the same hospitalization. Sequential patients were matched to 30 patients who had previously failed at least one catheter ablation and underwent a repeat catheter ablation (catheter-alone). The primary end point was event-free survival of any documented AF recurrence or AAD use. RESULTS All patients underwent uncomplicated surgical ablation and electrophysiology procedure. Five Sequential patients had seven inducible flutters that were mapped and ablated. After a mean follow-up of 20.7±4.5 months, 13/15 (86.7%) Sequential patients, but only 16/30 (53.3%) catheter-alone patients, were free of any atrial arrhythmia and off of AAD (p=0.04). On AAD, 14/15 (93.3%) Sequential patients were free of any atrial arrhythmia recurrence, compared to 17/30 (56.7%) catheter-alone patients (p=0.01). CONCLUSIONS For patients with atrial fibrillation who have failed catheter ablation, Sequential minimally invasive epicardial surgical ablation, followed by endocardial catheter-based ablation, has a higher early success rate than repeat catheter ablation alone.

Superiority of moderate control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting

RATIONALE We recently implicated a role for CD4(+) T cells and demonstrated elevated IL-17A expression in lung ischemia-reperfusion (IR) injury. However, identification of the specific subset of CD4(+) T cells and their mechanistic role in IR injury remains unknown. OBJECTIVES We tested the hypothesis that invariant natural killer T (iNKT) cells mediate lung IR injury via IL-17A signaling. METHODS Mice underwent lung IR via left hilar ligation. Pulmonary function was measured using an isolated lung system. Lung injury was assessed by measuring edema (wet/dry weight) and vascular permeability (Evans blue dye). Inflammation was assessed by measuring proinflammatory cytokines in lungs, and neutrophil infiltration was measured by immunohistochemistry and myeloperoxidase levels. MEASUREMENTS AND MAIN RESULTS Pulmonary dysfunction (increased airway resistance and pulmonary artery pressure and decreased pulmonary compliance), injury (edema, vascular permeability), and inflammation (elevated IL-17A; IL-6; tumor necrosis factor-α; monocyte chemotactic protein-1; keratinocyte-derived chemokine; regulated upon activation, normal T-cell expressed and secreted; and neutrophil infiltration) after IR were attenuated in IL-17A(-/-) and Rag-1(-/-) mice. Anti-IL-17A antibody attenuated lung dysfunction in wild-type mice after IR. Reconstitution of Rag-1(-/-) mice with wild-type, but not IL-17A(-/-), CD4(+) T cells restored lung dysfunction, injury, and inflammation after IR. Lung dysfunction, injury, IL-17A expression, and neutrophil infiltration were attenuated in Jα18(-/-) mice after IR, all of which were restored by reconstitution with wild-type, but not IL-17A(-/-), iNKT cells. Flow cytometry and enzyme-linked immunosorbent spot assay confirmed IL-17A production by iNKT cells after IR. CONCLUSIONS These results demonstrate that CD4(+) iNKT cells play a pivotal role in initiating lung injury, inflammation, and neutrophil recruitment after IR via an IL-17A-dependent mechanism.

10-Year Outcomes After Roux-en-Y Gastric Bypass.

BACKGROUND New-onset postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery. However, the magnitude of POAF on length of stay, resource utilization, and readmission rates remains an area of clinical interest. The purpose of this study was to examine the risk-adjusted impact of POAF on measures of mortality, hospital resources, and costs among multiple centers. METHODS A total of 49,264 patient records from a multi-institutional Society of Thoracic Surgeons (STS) certified database for cardiac operations (2001 to 2012) were extracted and stratified by the presence of POAF (19%) versus non-POAF (81%). The influence of POAF on outcomes was assessed by hierarchic regression modeling, adjusted for calculated STS predictive risk indices. RESULTS Mean age was 64±11 years, and median STS predicted risk of mortality for patients who developed POAF were incrementally higher (2% vs 1%, p<0.001) compared with non-POAF patients. The rate of POAF was highest among those undergoing aortic valve replacement+coronary artery bypass grafting, aortic valve, and mitral valve replacement operations. The POAF patients had a higher unadjusted incidence of mortality, morbidity, hospital readmission, longer intensive care unit (ICU) and postoperative length of stay, and higher hospital costs. After risk adjustment, POAF was associated with a twofold increase in the odds of mortality (adjusted odds ratio=2.04, p<0.001), greater hospital resource utilization, and increased costs; POAF was associated with 48 additional ICU hours (p<0.001), 3 additional hospital days (p<0.001), and

Model for End-Stage Liver Disease Predicts Mortality for Tricuspid Valve Surgery

3,000 (p<0.001) and

Hospital procedure volume should not be used as a measure of surgical quality.

9,000 (p<0.001) of increased ICU and total hospital-related costs, respectively. CONCLUSIONS New onset POAF is associated with increased risk-adjusted mortality, hospital costs, and readmission rates. Protocols to reduce the incidence of POAF have the potential to significantly impact patient outcomes and the delivery of high-quality, cost-effective patient care.

Adenosine A2A Agonist Improves Lung Function During Ex Vivo Lung Perfusion

OBJECTIVE Although consensus in cardiac surgery supports tight control of perioperative hyperglycemia (glucose<120 mg/dL), recent studies in critical care suggest moderate glycemic control may be superior. We sought to determine whether tight control or moderate glycemic control is optimal after coronary artery bypass grafting. METHODS From 1995 to 2008, a total of 4658 patients with known diabetes or perioperative hyperglycemia (preoperative glycosylated hemoglobin≥8 or postoperative serum glucose>126 mg/dL) underwent isolated coronary artery bypass grafting at our institution. Patients were stratified into 3 postoperative glycemic groups: tight (≤126 mg/dL), moderate (127-179 mg/dL), and liberal (≥180 mg/dL). Preoperative risk factors, glycemic management, and postoperative outcomes were analyzed. RESULTS Operative mortality was 2.5% (119/4658); major complication rate was 12.5% (581/4658). Relative to moderate group, more patients in tight group had preoperative renal failure (tight 16.4%, 22/134, moderate 8.3%, 232/2785, P=.001) and underwent emergent operations (tight 5.2%, 7/134, moderate 1.9%, 52/2785, P=.007); however, Society of Thoracic Surgeons predicted mortality risk was lower in tight group (P<.001). Moderate group had lowest mortality (tight 2.9%, 4/134, moderate 2.0%, 56/2785, liberal 3.4%, 59/1739, P=.02) and incidence of major complications (tight 19.4%, 26/134, moderate 11.1%, 308/2785, liberate 14.2%, 247/1739, P<.001). Risk-adjusted major complication incidence (adjusted odds ratio 0.7, 95% confidence interval 0.58-0.87) and mortality (adjusted odds ratio 0.6, 95% confidence interval 0.37-0.83) were lower with moderate glucose control than with tight or liberal management. CONCLUSIONS Moderate glycemic control was superior to tight glycemic control, with decreased mortality and major complications, and may be ideal for patients undergoing isolated coronary artery bypass grafting.