Joseph S. Carey

Impact of gender on coronary bypass operative mortality

BACKGROUND In spite of many reports investigating the influence of gender on coronary artery operations, it is still uncertain whether gender is an independent risk factor for operative mortality. A major problem of previous reports has centered around the fact that men and women constitute quite different populations, thereby making direct comparisons difficult. METHODS The Society of Thoracic Surgeons National Cardiac Surgery Database was used to retrospectively examine 344,913 patients undergoing coronary artery bypass graft operations from 1994 through the most recent data harvest. The operative mortality of male and female patients was compared for a variety of single risk factors and combinations of risk factors. A logistic risk model was used to account for all important patient parameters so that individuals could be stratified into comparable categories allowing for direct comparisons of risk-matched male and female patients. RESULTS The univariate analysis showed that the 97,153 women carried a significantly higher mortality for each of the risk factors examined. The multivariate analysis and the risk model stratification showed that women had significantly higher mortality as compared to equally matched men in the low- and medium-risk part of the spectrum, but in high-risk patients, there was no difference between male and female mortality. CONCLUSIONS Gender is an independent predictor of operative mortality except for patients in very high-risk categories.

Adverse Events After Coronary Revascularization Procedures in California 2000 to 2010

Public reporting of coronary artery bypass grafting (CABG) mortality in California was initiated in 2003. Drug-eluting stents were widely introduced in the same year. Adverse events after percutaneous coronary intervention (PCI) and CABG were analyzed to study the impact of these events. Annual California hospital discharge data were collected from 2000 through 2010. In-hospital mortality and hospital readmission for adverse events <1 year were determined for patients undergoing isolated CABG, PCI for acute coronary syndrome (PCI-ACS), and all other PCIs (PCI-noACS). CABG volume peaked in 2000 and subsequently decreased by 58%; PCI volume peaked in 2005 and subsequently decreased by 20%. After 2003, in-hospital mortality and 1-year mortality for CABG decreased whereas mortality after PCI remained unchanged. Event rates for acute myocardial infarction and stroke varied little over the decade; acute myocardial infarction at 1 year was 2.5% to 2.8% (CABG), 4.5% to 5.4% (PCI-ACS), and 4.6% to 5.8% (PCI-noACS); stroke rate was 1.4% to 1.7% (CABG), 1.2% to 1.6% (PCI-ACS), and 1.0% to 1.2% (PCI-noACS). Reintervention for PCI decreased markedly, from 18.8% to 12.8% (PCI-ACS) and 22.5% to 13.3% (PCI-noACS). Multiple adverse cardiovascular and cerebral events rate at 1 year decreased from 10.8% to 9.4% (CABG), 26.5% to 21.2% (PCI-ACS), and 26.8% to 18.4% (PCI-noACS). Excluding reinterventions, multiple adverse cardiovascular and cerebral events rate at 1 year was 8.3% (CABG), 14.6% (PCI-ACS), and 10.1% (PCI-noACS) in 2010. In conclusion, the volume of coronary interventions in California decreased whereas adverse event rates decreased after the introduction of public reporting and drug-eluting stents. Lower procedure volume combined with improved outcomes resulted in an annual decrease of >6,000 adverse events by the end of the decade.

Implementation of transcatheter aortic valve replacement in California: Influence on aortic valve surgery

Objective: Transcatheter aortic valve replacement (TAVR) procedures were introduced in 2011. Initially, procedures were limited to patients who were not surgical candidates, but subsequently high‐risk surgical candidates were considered for TAVR. The influence on aortic valve surgery in California is unknown. Methods: The California Office of Statewide Health Planning and Development hospitalized patient discharge database was queried for the years 2009 through 2014. isolated surgical aortic valve and aortic valve/coronary artery bypass graft (SAVR) and TAVR procedures were identified by International Classification of Diseases‐9th revision clinical modification procedure codes. Seven TAVR programs were introduced in 2011, 12 in 2012, 3 in 2013, and 6 in 2014. SAVR procedure volumes were compared from the 2 years before institution with SAVR volumes during the year(s) after institution of the TAVR program in these 28 hospitals. Results: Overall, surgical volumes increased during the first, second, and third years after implementation of TAVR procedures. Among 7 hospitals with 4‐year programs, surgical volumes increased to a maximum of 15.5% during the third year, then began to decrease. The hospital performing the largest number of TAVR procedures showed a marked decrease in SAVR volume by the fourth year, suggesting a shift of SAVR candidates to TAVR. Among all hospitals with 4‐year programs, TAVR exceeded SAVR procedures by the fourth year. In California overall, SAVR increased during 2011 through 2013, due primarily to increasing volume of isolated SAVR procedures. Statewide, isolated SAVR increased from a yearly average of 3111 procedures during 2009‐2010 to 3592 (+15.5%) in 2013, then decreased slightly in 2014. SAVR plus coronary artery bypass graft procedures decreased during the same time period. Conclusions: After implementation of TAVR, hospital SAVR volumes increased moderately, then began to decrease by the fourth year, when TAVR volume exceeded SAVR. Surgical candidates may be identified during evaluation for TAVR, resulting in increased SAVR volume. Increasing SAVR volume may also be related to improved patient and provider awareness of aortic valve disease.