Esteban Aguayo

Does left atrial appendage ligation during coronary bypass surgery decrease the incidence of postoperative stroke

Objective The study objective was to evaluate the association between surgical left atrial appendage ligation and in‐hospital stroke incidence after coronary artery bypass grafting among patients with atrial fibrillation. Methods A retrospective cohort study was performed by using the Nationwide Inpatient Sample between 2008 and 2014. All atrial fibrillation patients who underwent coronary artery bypass graft were included and categorized as left atrial appendage ligation or control group. Propensity score–weighted regression analyses were performed to assess the impact of left atrial appendage ligation on stroke incidence. Results A total of 234,642 patients were identified, among whom 20,664 (8.81%) received concomitant left atrial appendage ligation. The national postoperative stroke incidence was 0.92%. Results of the propensity‐weighted regression analysis showed no significant association between LAA ligation and control with regard to postoperative stroke (odds ratio [OR], 0.83; confidence interval [CI], 0.57‐1.22; P = .35), pericardial complications (OR, 1.15; CI, 0.88‐1.49; P = .31), hemorrhage and/or hematoma (OR, 1.08; CI, 0.99‐1.17; P = .07), mortality (OR, 1.29; CI, 0.99‐1.68; P = .06), and length of stay (coefficient −0.21; CI, −0.44‐0.02; P = .08). There was no specific CHA2DS2VASC score cutoff above which left atrial appendage ligation was demonstrated to have lower postoperative stroke incidence. Conclusions The postoperative stroke risk after coronary artery bypass grafting was low at approximately 1% among patients with atrial fibrillation in the United States. Concomitant left atrial appendage ligation was not associated with lower postoperative stroke risk.

A nationwide study of treatment modalities for thoracic aortic injury

Background: Thoracic aortic injuries have traditionally been associated with high morbidity and mortality. Thoracic endovascular aortic repair has emerged as a suitable alternative to open repair, but its impact at a national level remains ill defined. This study aimed to analyze the national trends of patient characteristics, outcomes, and resource utilization in the treatment of thoracic aortic injuries. Methods: Patients admitted with thoracic aortic injuries from 2005–2014 were identified in the National Inpatient Sample. Patients were identified as undergoing thoracic endovascular aortic repair, open surgery, or nonoperative management. The primary outcome was in‐hospital mortality, while secondary outcomes included complications and costs. Multivariate regressions accounting for characteristics of the patients and injury characteristics were used to determine predictors of mortality and changes in cost. Results: Of the 11,257 patients admitted for thoracic aortic injuries, 33% received thoracic endovascular aortic repair, 8% open surgery, and 59% nonoperative management. Thoracic endovascular aortic repair had the great largest growth in case volume (P < .001). Compared to open surgery, thoracic endovascular aortic repair patients had greater rates of concomitant brain (17 vs 26%, P=.01), pulmonary (21 vs 33%, P < .001), and splenic injuries (2 vs 4%, P=.031). In‐hospital mortality was greater for open surgery (odds ratio = 3.06, P=.003) and nonoperative management (odds ratio=4.33, P < .001) than thoracic endovascular aortic repair. Over time, mortality rates for thoracic endovascular aortic repair decreased (P=.002), but increased for open surgery (P=.04). Interestingly, total costs with thoracic endovascular aortic repair increased (P=.004), while they decreased for open surgery (P=.031). Conclusion: Our findings indicate the rapid adoption of thoracic endovascular aortic repair over open surgery for management of thoracic aortic injuries. Thoracic endovascular aortic repair is associated with lower mortality rates, but it has greater costs not otherwise explained by other patient factors.

Impact of new-onset postoperative depression on readmission outcomes after surgical coronary revascularization

BACKGROUNDnDepression affects between 10% and 40% of cardiac surgery patients and is associated with significantly worse outcomes. The incidence and impact of new-onsetxa0depression beyond acute follow-up remain ill-defined. The present studyxa0aimed to evaluate the incidence, risk factors, and prognostic implication of depression on 90-d readmission rates after coronary artery bypass grafting (CABG) surgery.nnnMETHODSnA retrospective cohort study was performed identifying adult patients without prior depression who underwent CABG surgery using the 2010-2014 National Readmissions Database. CABG patients who were readmitted more than 2xa0wk but within 90xa0d of discharge were categorized based on the presence of new-onset depression. Association between the development of new-onset depression and rehospitalization were morbidity, mortality, costs, and length of stay (LOS) and were examined using multivariable regression.nnnRESULTSnDuring the study period, 1,001,945 patients underwent CABG. Of these, 11.7% of patients were readmitted after 14 d but within 90xa0d of discharge with 5.1% of these patients having a diagnosis of new-onset depression. Postoperative new-onset depression was not associated with increased readmission morbidity, costs, or LOS. Mortality in new-onset depression readmissions was 1.2%, compared with 2.3% in all readmitted patients (Pxa0=xa00.014). Depression was associated with lower odds of mortality (ORxa0=xa00.56, Pxa0=xa00.02).nnnCONCLUSIONSnNew-onset depression following CABG discharge was not associated with increased odds of mortality, morbidity, costs, or increased LOS on readmission. Rather, new-onset depression is associated with decreased odds of readmission mortality. Overall, CABG readmissions are decreasing, whereas the rate of new-onset depression is slightly increasing. Implementation of routine depression screening tools in postoperative CABG care may aid in early detection and management of depression to enhance postoperative recovery and quality of life.

Incidence and trends of cardiac complications in major abdominal surgery

Introduction: Cardiovascular complications are the leading cause of death after noncardiac surgery. Major abdominal operations represent the largest category of procedures considered to have an increased risk of cardiovascular complications. The current aim was to examine trends in the incidence of mortality, perioperative myocardial infarction, and cardiac arrest to determine the presence of potential volume‐outcome relationships. Methods: We performed a retrospective analysis of the Nationwide Inpatient Sample for patients undergoing elective, open abdominal esophagectomy, gastrectomy, pancreatectomy, nephrectomy, hepatectomy, splenectomy, and colectomy (major abdominal surgery) during 2008–2014. Univariate and multivariate analyses were performed to determine the impact of operative volume on rates of myocardial infarction, cardiac arrest, and mortality. Results: Of the 962,754 elective admissions for major abdominal surgery, 1.4% experienced in‐hospital mortality, 0.7% myocardial infarction, and 0.35% cardiac arrest. Myocardial infarction and cardiac arrest were associated with a 24‐fold increase in risk of perioperative mortality. Compared with institutions that have a very low volume of operations, those hospitals with larger volumes of operations had a decreased risk of cardiac arrest and incident mortality after cardiovascular complications, but the odds of myocardial infarction were greatest at higher operative‐volume hospitals. The annual all‐cause mortality and myocardial infarction rates decreased over time, but the incidence of cardiac arrest increased. Conclusion: Myocardial infarction or cardiac arrest after major abdominal surgery increased the odds of mortality with superior rescue after cardiovascular complications at higher volume institutions. Across all US hospitals performing major abdominal surgery, the rate of cardiac arrest increased without a concomitant increase in myocardial infarction or mortality. Novel targets for risk modification of myocardial infarction and cardiac arrest as well as investigation of processes that facilitate rescue after these complications at higher operative‐volume hospitals are needed to delineate quality improvement opportunities.

Heparin-induced thrombocytopenia in cardiac surgery: Incidence, costs, and duration of stay

Background: Heparin is routinely used in many cardiovascular procedures to prevent thrombosis. An antibody‐mediated process, heparin‐induced thrombocytopenia occurs in a small subset of patients exposed to heparin. Though some have suggested a recent increase in the incidence of heparin‐induced thrombocytopenia, data on the impact of heparin‐induced thrombocytopenia on costs and duration of stay after cardiac surgery is generally lacking. The present study aimed to assess national trends in the incidence and resource use associated with heparin‐induced thrombocytopenia in cardiac surgical patients. Methods: A retrospective cohort study was performed identifying adult cardiac surgery patients with a diagnosis of heparin‐induced thrombocytopenia by using the 2009–2014 National Inpatient Sample Database. Association between development of heparin‐induced thrombocytopenia and complications during hospitalization were evaluated using multivariate regression models. Results: Of the 3,547,883 cardiac surgery patients, 13,943 (0.40%) were diagnosed with heparin‐induced thrombocytopenia. Heparin‐induced thrombocytopenia was associated with significantly longer median index duration of stay (elective 12 vs 6 days, urgent 17 vs 10 days; P < .001) and higher hospitalization costs (elective

Trends in mortality and resource utilization for extracorporeal membrane oxygenation in the United States: 2008–2014

56,230 vs

Readmission and resource utilization after orthotopic heart transplant versus ventricular assist device in the National Readmissions Database, 2010–2014

35,072, urgent

National trends in volume-outcome relationships for extracorporeal membrane oxygenation

75,509 vs

Assessment of Differential Pressures in Chest Drainage Systems: Is What You See What You Get?

42,789; P < .001). Independent predictors of heparin‐induced thrombocytopenia included female sex (elective odds ratio 1.4, 95% confidence interval 1.01–1.03) and history of hypercoagulable condition (elective odd ratio 4.03, 95% confidence interval 1.8–8.9). After adjustment for baseline differences, heparin‐induced thrombocytopenia was independently associated with increased risk of mortality (elective odds ratio 2.0, 95% confidence interval 1.3–3.1; urgent odds ratio 1.8, 95% confidence interval 1.3–2.5), neurologic (elective odds ratio 1.5, 95% confidence interval 1.2–1.9; urgent odds ratio 1.3, 95% confidence interval 1.1–1.6), infectious (elective odds ratio 2.4, 95% confidence interval 1.9–3.0; urgent odds ratio 1.6, 95% confidence interval 1.4–2.0), and respiratory (elective odds ratio 1.4, 95% confidence interval 1.2–1.5; urgent odds ratio 1.4, 95% confidence interval 1.2–1.5) complications. Conclusion: Based on this national analysis of adult cardiac surgical patients, the presence of heparin‐induced thrombocytopenia was associated with higher odds of mortality and morbidity, greater costs, and longer duration of stay. Female gender, history of hypercoagulability, and heart failure, among others, are independent predictors of heparin‐induced thrombocytopenia. These findings have significant implications in the era of value‐based health care delivery. In addition to reducing unnecessary exposure to heparin, proper diagnosis and treatment are essential for favorable outcomes.

Comparison of Frequency of Late Gastrointestinal Bleeding with Transcatheter Versus Surgical Aortic Valve Replacement

Background: Extracorporeal membrane oxygenation is used as a life‐sustaining measure in patients with acute or end‐stage cardiac or respiratory failure. We analyzed national trends in extracorporeal membrane oxygenation use and outcomes and assessed the influence of hospital demographics. Methods: Adult extracorporeal membrane oxygenation patients in the 2008–2014 National Inpatient Sample were evaluated. Patient and hospital characteristics, extracorporeal membrane oxygenation indication, mortality, and hospital costs were analyzed. Results: A total 17,020 adult extracorporeal membrane oxygenation patients were considered: 47.4% respiratory failure, 38.6% postcardiotomy, 5.5% lung transplantation, 5.5% cardiogenic shock, and 3.2% heart transplantation. Admissions rose 361% from 1,026 in 2008 to 4,815 in 2014 (P < .0001), and the fraction of respiratory failure increased 40.5%–49.8% (P < .001). Elixhauser scores rose from 3.1 to 4.1 (P < .0001). Mortality decreased among total admissions from 62.4% to 42.7% (P < .0001) associated with an observed decline in postcardiotomy mortality. Mean hospital costs and length of stay remained stable throughout the study period. Although extracorporeal membrane oxygenation occurred most frequently at large hospitals, small and medium‐sized hospitals showed significant expansion (P < .001). The Northeast exhibited a sustained three‐fold per capita increase in extracorporeal membrane oxygenation rate (P < .0001). Conclusion: The past decade has seen an exponential growth of ECMO extracorporeal membrane oxygenation in the United States, with the fraction for respiratory failure displaying considerable growth. Overall extracorporeal membrane oxygenation patients experienced substantially reduced mortality, driven by improved outcomes for postcardiotomy patients, along with a trend toward an increased risk profile. Disproportionate use of extracorporeal membrane oxygenation in the Northeast warrants investigation of access to this technology across the United States.