Paramita Saha-Chaudhuri

Trends and Outcomes of Tricuspid Valve Surgery in North America: An Analysis of More Than 50,000 Patients From The Society of Thoracic Surgeons Database

BACKGROUND This study evaluated trends and outcomes of tricuspid valve surgery (TVS) in North America over the past decade. METHODS Adults undergoing TVS between 2000 and 2010 were identified in The Society of Thoracic Surgeons (STS) National Database. Trends were evaluated using linear regression. Multivariable logistic regression analysis was conducted using covariates from the STS valve risk model to identify significant predictors of operative mortality. RESULTS A total of 54,375 patients underwent TVS during the study period. The majority of cases were repairs (89%; n = 48,322) and were performed concomitant with another major procedure (86%; n = 46,593). The proportion of TVS that were repairs increased from 84.6% in 2000 to 89.8% in 2010 (p = 0.01). Trend analysis revealed significant changes in patient characteristics with time, including increasing age, a higher comorbidity burden, and a higher proportion of emergency cases. Despite worsening risk factors, unadjusted operative mortality for TVS declined from 10.6% in 2000 to 8.2% in 2010 (p < 0.001), and this trend persisted after risk adjustment. In the multivariable model, concomitant procedures involving multiple valves or coronary artery bypass grafting were associated with an increased risk of mortality compared with isolated TVS, although other factors including renal failure, congestive heart failure, nonelective presentation, reoperation, and tricuspid valve replacement exerted equal or stronger effects. CONCLUSIONS During the past decade, repair rates for TVS have increased significantly. Although patients undergoing TVS have demonstrated worsening risk factors, unadjusted and adjusted operative mortalities have declined. Finally, the data suggest that tricuspid valve repair when technically feasible, together with early elective surgical intervention, should be emphasized as potential candidates for continued outcome improvement.

Rates of cardiopulmonary resuscitation training in the United States.

IMPORTANCE Prompt bystander cardiopulmonary resuscitation (CPR) improves the likelihood of surviving an out-of-hospital cardiac arrest. Large regional variations in survival after an out-of-hospital cardiac arrest have been noted. OBJECTIVES To determine whether regional variations in county-level rates of CPR training exist across the United States and the factors associated with low rates in US counties. DESIGN, SETTING, AND PARTICIPANTS We used a cross-sectional ecologic study design to analyze county-level rates of CPR training in all US counties from July 1, 2010, through June 30, 2011. We used CPR training data from the American Heart Association, the American Red Cross, and the Health & Safety Institute. Using multivariable logistic regression models, we examined the association of annual rates of adult CPR training of citizens by these 3 organizations (categorized as tertiles) with a countys geographic, population, and health care characteristics. EXPOSURE Completion of CPR training. MAIN OUTCOME AND MEASURES Rate of CPR training measured as CPR course completion cards distributed and CPR training products sold by the American Heart Association, persons trained in CPR by the American Red Cross, and product sales data from the Health & Safety Institute. RESULTS During the study period, 13.1 million persons in 3143 US counties received CPR training. Rates of county training ranged from 0.00% to less than 1.29% (median, 0.51%) in the lower tertile, 1.29% to 4.07% (median, 2.39%) in the middle tertile, and greater than 4.07% or greater (median, 6.81%) in the upper tertile. Counties with rates of CPR training in the lower tertile were more likely to have a higher proportion of rural areas (adjusted odds ratio, 1.12 [95% CI, 1.10-1.15] per 5-percentage point [PP] change), higher proportions of black (1.09 [1.06-1.13] per 5-PP change) and Hispanic (1.06 [1.02-1.11] per 5-PP change) residents, a lower median household income (1.18 [1.04-1.34] per

Outcomes and Prosthesis Choice for Active Aortic Valve Infective Endocarditis: Analysis of The Society of Thoracic Surgeons Adult Cardiac Surgery Database

10 000 decrease), and a higher median age (1.28 [1.04-1.58] per 10-year change). Counties in the South, Midwest, and West were more likely to have rates of CPR training in the lower tertile compared with the Northeast (adjusted odds ratios, 7.78 [95% CI, 3.66-16.53], 5.56 [2.63-11.75], and 5.39 [2.48-11.72], respectively). CONCLUSIONS AND RELEVANCE Annual rates of US CPR training are low and vary widely across communities. Counties located in the South, those with higher proportions of rural areas and of black and Hispanic residents, and those with lower median household incomes have lower rates of CPR training than their counterparts. These data contribute to known geographic disparities in survival of cardiac arrest and offer opportunities for future community interventions.

Clinical effectiveness of posaconazole versus fluconazole as antifungal prophylaxis in hematology–oncology patients: a retrospective cohort study

BACKGROUND National prosthesis use in active aortic valve infective endocarditis (IE) is unreported. Prosthesis usage and outcomes in patients undergoing an aortic valve operation with active IE was evaluated. METHODS The Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to identify patients with active IE who underwent an aortic valve operation from January 1, 2005, to June 30, 2011. All patients with active IE were included. Demographics, procedures, outcomes, and trends were analyzed. RESULTS Of 11,560 patients who were identified as having active IE, 8,421 (73%) had no prior operations (primary) and 3,139 (27%) had a history of any prior cardiac operation (reoperative). Operations for primary vs reoperative patients included isolated replacement in 88.5% vs 58.7% and root replacement in 7.2% vs 29.9%. Major morbidity was 60.8% vs 68%, and the unadjusted mortality rate was 9.8% vs 21.1%. Over time, for primary operations, biologic valve use increased (57% to 67%), and mechanical and homograft valve use decreased (30% to 24% and 9% to 6%; p < 0.001). For reoperations, biologic valve use increased (38% to 52%), and mechanical and homograft use decreased (20% to 17% and 38% to 28%; p < 0.001). Homografts were used more often in reoperations (32% vs 7%). CONCLUSIONS Morbidity and mortality rates death are high for operations for active IE. Biologic valves were increasingly used vs mechanical and homograft valves. Homograft valves were used more often in reoperative patients after any prior cardiac operation. The mortality rate varied among prosthesis groups but may be related to the severity of infection and type of procedure performed.

Mortality characteristics of aortic root surgery in North America

In preventing invasive fungal disease (IFD) in patients with acute myelogenous leukemia (AML) or myelodysplastic syndrome (MDS), clinical trials demonstrated efficacy of posaconazole over fluconazole and itraconazole. However, effectiveness of posaconazole has not been investigated in the United States in real‐world setting outside the environment of controlled clinical trial. We performed a single‐center, retrospective cohort study of 130 evaluable patients ≥18 years of age admitted to Duke University Hospital between 2004 and 2010 who received either posaconazole or fluconazole as prophylaxis during first induction or first reinduction chemotherapy for AML or MDS. The primary endpoint was possible, probable, or definite breakthrough IFD. Baseline characteristics were well balanced between groups, except that posaconazole recipients received reinduction chemotherapy and cytarabine more frequently. IFD occurred in 17/65 (27.0%) in the fluconazole group and in 6/65 (9.2%) in the posaconazole group (P = 0.012). Definite/probable IFDs occurred in 7 (10.8%) and 0 patients (0%), respectively (P = 0.0013). In multivariate analysis, fluconazole prophylaxis and duration of neutropenia were predictors of IFD. Mortality was similar between groups. This study demonstrates superior effectiveness of posaconazole over fluconazole as prophylaxis of IFD in AML and MDS patients. Such superiority did not translate to reductions in 100‐day all‐cause mortality.

Failure to rescue and pulmonary resection for lung cancer

OBJECTIVES Aortic root surgery is transitioning to aortic valve sparing (AVS), but little is known about the relative early outcomes of AVS versus composite graft-valve replacement (CVR). This study assessed mortality differences for AVS versus CVR to guide future practice decisions. METHODS From January 2000 to June 2011, 31 747 patients had aortic root replacement with AVS (n = 3585; 11%) or CVR (n = 28 162; 89%). The cohort of Overall patients was divided into two subgroups: high-risk patients (n = 20 356; 6% AVS) having age >75 years, endocarditis, aortic stenosis, dialysis, multiple valves, reoperation or emergency/salvage status, and the remaining low-risk patients (n = 11 388; 21% AVS). Using logistic regression analysis, outcomes were presented as unadjusted operative mortality (UOM), risk-adjusted operative mortality (AOM) and adjusted odds ratio (AOR) for mortality. RESULTS Baseline characteristics for the Overall group (AVS versus CVR) were: mean age (52 vs 57 years), endocarditis (1 vs 11%), aortic stenosis (4 vs 36%), dialysis (1 vs 2%), multiple valves (7 vs 10%), reoperation (6 vs 17%) and emergency status (14 vs 12%) (all P < 0.0001). In high- and low-risk groups, baseline differences narrowed, and lower mortality was generally observed with AVS: (AVS versus CVR) UOM group Overall (4.5 vs 8.9%)*, group High-risk (10.5 vs 11.7%), group Low-risk (1.4 vs 3.1%)*; AOM group Overall (6.2 vs 8.6%), group High-risk (10.1 vs 11.7%), group Low-risk (2.2 vs 2.8%); AOR group Overall (0.59)*, group High-risk (0.62)*, group Low-risk (0.69). *P < 0.05. CONCLUSIONS Relative risk-adjusted mortality seemed comparable with AVS versus CVR in low- and high-risk subgroups. These data support judicious expansion of aortic valve repair in patients having aortic root replacement.

Prediction of major cardiovascular events after lung resection using a modified scoring system.

OBJECTIVE Failure to rescue is defined as death after an acute inpatient event and has been observed among hospitals that perform general, vascular, and cardiac surgery. This study aims to evaluate variation in complication and failure to rescue rates among hospitals that perform pulmonary resection for lung cancer. METHODS By using the Society of Thoracic Surgeons General Thoracic Surgery Database, a retrospective, multicenter cohort study was performed of adult patients with lung cancer who underwent pulmonary resection. Hospitals participating in the Society of Thoracic Surgeons General Thoracic Surgery Database were ranked by their risk-adjusted, standardized mortality ratio (using random effects logistic regression) and grouped into quintiles. Complication and failure to rescue rates were evaluated across 5 groups (very low, low, medium, high, and very high mortality hospitals). RESULTS Between 2009 and 2012, there were 30,000 patients cared for at 208 institutions participating in the Society of Thoracic Surgeons General Thoracic Surgery Database (median age, 68 years; 53% were women, 87% were white, 71% underwent lobectomy, 65% had stage I). Mortality rates varied over 4-fold across hospitals (3.2% vs 0.7%). Complication rates occurred more frequently at hospitals with higher mortality (42% vs 34%, P < .001). However, the magnitude of variation (22%) in complication rates dwarfed the 4-fold magnitude of variation in failure to rescue rates (6.8% vs 1.7%, P < .001) across hospitals. CONCLUSIONS Variation in hospital mortality seems to be more strongly related to rescuing patients from complications than to the occurrence of complications. This observation is significant because it redirects quality improvement and health policy initiatives to more closely examine and support system-level changes in care delivery that facilitate early detection and treatment of complications.

Development and evaluation of multi-marker risk scores for clinical prognosis

BACKGROUND Cardiovascular complications occur in 10% to 15% of patients after major lung resection. We evaluated the utility of a revised scoring system (thoracic revised cardiac risk index; ThRCRI) in identifying patients at increased risk for major cardiovascular complications. METHODS We analyzed outcomes from the Society of Thoracic Surgeons General Thoracic Database for the period 2003 to 2011 for elective major lung resection. The ThRCRI risk score was based on weighted values for serum creatinine, coronary artery disease, cerebrovascular disease, and extent of lung resection, and was stratified into the following 4 risk categories: 0 (A); 1 to 1.5 (B); 2 to 2.5 (C); and >2.5 (D). Major cardiovascular complications included myocardial infarction, adult respiratory distress syndrome, ventricular arrhythmia requiring treatment, and all-cause death. RESULTS A total of 26,085 patients (mean age 65.4±11.4 years; 51.3% men) underwent lobectomy (21,679; 83.2%), bilobectomy (1,446; 5.5%) or pneumonectomy (1,697; 6.5%). Major cardiovascular complications occurred in 1,125 patients (4.3%). ThRCRI scores in patients without and with major cardiovascular complications were 0.6±0.9 and 1.1±1.1 (p<0.0001). Score categories yielded incremental risks of major cardiovascular complications (A: 2.9%; B: 5.8%; C: 11.9%; D: 11.1%; p<0.0001). CONCLUSIONS The ThRCRI score stratified risk moderately well for major postoperative cardiovascular events after major lung resection. Use of this scoring system might help in identifying patients who would benefit from additional preoperative evaluation and from closer perioperative monitoring.

Quantifying the Safety Benefits of Wedge Resection: A Society of Thoracic Surgery Database Propensity-Matched Analysis

Heart failure research suggests that multiple biomarkers could be combined with relevant clinical information to more accurately quantify individual risk and guide patient-specific treatment strategies. Therefore, statistical methodology is required to determine multi-marker risk scores that yield improved prognostic performance. Development of a prognostic score that combines biomarkers with clinical variables requires specification of an appropriate statistical model and is most frequently achieved using standard regression methods such as Cox regression. We demonstrate that care is needed in model specification and that maximal use of marker information requires consideration of potential non-linear effects and interactions. The derived multi-marker score can be evaluated using time-dependent receiver operating characteristic methods, or risk reclassification methods adapted for survival outcomes. We compare the performance of alternative model accuracy methods using simulations, both to evaluate power and to quantify the potential loss in accuracy associated with use of a sub-optimal regression model to develop the multi-marker score. We illustrate development and evaluation strategies using data from the Penn Heart Failure Study. Based on our results, we recommend that analysts carefully examine the functional form for component markers and consider plausible forms for effect modification to maximize the prognostic potential of a model-derived multi-marker score.

The Association of Chronic Lung Disease With Early Mortality and Respiratory Adverse Events After Aortic Valve Replacement

BACKGROUND Wedge resection is often used instead of anatomic resection in an attempt to mitigate perioperative risk. In propensity-matched populations, we sought to compare the perioperative outcomes of patients undergoing wedge resection with those undergoing anatomic resection. METHODS The Society of Thoracic Surgery database was reviewed for stage I and II non-small cell lung cancer patients undergoing wedge resection and anatomic resection to analyze postoperative morbidity and mortality. Propensity scores were estimated using a logistic model adjusted for a variety of risk factors. Patients were then matched by propensity score using a greedy 5- to 1-digit matching algorithm, and compared using McNemars test. RESULTS Between 2009 and 2011, 3,733 wedge resection and 3,733 anatomic resection patients were matched. The operative mortality was 1.21% for wedge resection versus 1.93% for anatomic resection (p=0.0118). Major morbidity occurred in 4.53% of wedge resection patients versus 8.97% of anatomic resection patients (p<0.0001). A reduction was noted in the incidence of pulmonary complications, but not cardiovascular or neurologic complications. There was a consistent reduction in major morbidity regardless of age, lung function, or type of incision. Mortality was reduced in patients with preoperative forced expiratory volume in 1 second less than 85% predicted. CONCLUSIONS Wedge resection has a 37% lower mortality and 50% lower major morbidity rate than anatomic resection in these propensity-matched populations. The mortality benefit is most apparent in patients with forced expiratory volume in 1 second less than 85% predicted. These perioperative benefits must be carefully weighed against the increase in locoregional recurrence and possible decrease in long-term survival associated with the use of wedge resection for primary lung cancers.