Publications by authors named "Kevin W Lobdell"

42 Publications

The STS CABG composite measure: 2021 methodology update.

Ann Thorac Surg 2021 Jul 16. Epub 2021 Jul 16.

Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.

Background: The original STS CABG composite measure uses a 1-year analytic cohort and 98% credible intervals (CrI) to classify better (3-star) or worse (1-star) than expected performance. As CABG volumes per STS participant (e.g., hospital or practice group) have decreased, it has become more challenging to classify performance categories using this approach, especially for lower volume programs, and alternative approaches have been explored.

Methods: Among 990 STS Adult Cardiac Surgery Database participants, performance classifications for the CABG composite were studied using various analytic cohorts: single year (current approach, 2017); 3 years (2015-2017); last 450 cases within 3 years; most recent year (2017) plus additional cases to 450 total. We also compared 98% CrI with 95% CrI (used in other STS composite measures).

Results: Using 3 years of data and 95% CrI's, 113 of 990 participants (11.4%) were classified 1-star and 198 (20%) 3-star. Compared with 1-year analytic cohorts and 98% CrI, the absolute and relative increases in the proportion of 3-star participants were 14 percentage points and 233% (n=198[20%] versus n=59[6%]). Corresponding changes for 1-star participants were 6.5 percentage points and 133% (n=113[11.4%] versus n=48[4.9%]). These changes were particularly notable among lower volume (<199 CABG/year) participants. Measure reliability with the 3-year, 95% CrI modification is 0.78.

Conclusions: Compared with current STS CABG composite methodology, a 3-year analytic cohort and 95% CrI increases the number and proportion of better or worse than expected outliers, especially among lower-volume ACSD participants. This revised methodology is also now consistent with other STS procedure composites.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2021.06.036DOI Listing
July 2021

Failure to Rescue: A New Society of Thoracic Surgeons Quality Metric for Cardiac Surgery.

Ann Thorac Surg 2021 Jul 6. Epub 2021 Jul 6.

Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts.

Background: Failure to rescue (FTR) focuses on the ability to prevent death among patients who experience postoperative complications. The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed a new, risk- adjusted FTR quality metric for adult cardiac surgery.

Methods: The study population was taken from 1118 STS Adult Cardiac Surgery Database participants including patients who underwent isolated CABG, aortic valve replacement +/- CABG, or mitral valve repair/replacement, +/- CABG between January, 2015 and June, 2019. The FTR analysis was derived from patients who experienced ≥ 1 of the following complications: prolonged ventilation, stroke, reoperation, and renal failure. Data were randomly split into 70% training (n=89,059) and 30% validation samples (n=38,242),Risk variables included STS predicted risk of mortality, operative procedures, and intraoperative variables (cardiopulmonary bypass and cross-clamp times, unplanned procedures, need for circulatory support, and massive transfusion).

Results: Overall mortality for the for patients undergoing any of the index operations during the study period was 2.6% (27,045/1,058,138), with mortality of 0.9% (8,316/930,837), 8.0% (7,618/94,918), 30.6% (8,247/26,934), 51.9%(2,661/5,123), and 62.3% (203/326) among patients suffering none, one, two, three or four complications. FTR risk model calibration was excellent, as were model discrimination (c-statistic 0.806) and the Brier score (0.102). Using 95% Bayesian credible intervals, 62 (5.6%) participants performed worse and 53 (4.7%) participants performed better than expected.

Conclusions: A new risk-adjusted FTR metric has been developed which complements existing STS performance measures. The metric specifically assesses institutional effectiveness of postoperative care, allowing hospitals to target quality improvement efforts.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2021.06.025DOI Listing
July 2021

Selecting Elements for a Cardiac Enhanced Recovery Protocol.

J Cardiothorac Vasc Anesth 2021 May 11. Epub 2021 May 11.

University of Massachusetts-Baystate, Heart, Vascular and Critical Care Units, Baystate Medical Center, Springfield, MA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.jvca.2021.05.006DOI Listing
May 2021

Goal-Directed Therapy for Cardiac Surgery.

Crit Care Clin 2020 Oct 12;36(4):653-662. Epub 2020 Aug 12.

Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, Giessen 35392, Germany; Charity Medical University, Berlin, Germany. Electronic address: https://twitter.com/Mich_San_d.

Goal-directed therapy couples therapeutic interventions with physiologic and metabolic targets to mitigate a patient's modifiable risks for death and complications. Goal-directed therapy attempts to improve quality-of-care metrics, including length of stay, rate of readmission, and cost per case. Debate persists around specific parameters and goals, the risk profiles that may benefit, and associated therapeutic strategies. Goal-directed therapy has demonstrated reduced complication rates and lengths of stay in noncardiac surgery studies. Establishing goal-directed therapy's early promise and role in cardiac surgery-namely, producing fewer complications and deaths-will require larger studies, including those with greater focus on high-risk patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ccc.2020.06.004DOI Listing
October 2020

Cardiac Surgery-Enhanced Recovery Programs Modified for COVID-19: Key Steps to Preserve Resources, Manage Caseload Backlog, and Improve Patient Outcomes.

J Cardiothorac Vasc Anesth 2020 Dec 10;34(12):3218-3224. Epub 2020 Aug 10.

University of Massachusetts-Baystate and Medical Director of the Heart, Vascular and Critical Care Units, Baystate Medical Center, Springfield, MA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.jvca.2020.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416680PMC
December 2020

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2019 Update on Research.

Ann Thorac Surg 2019 11 11;108(5):1293-1298. Epub 2019 Sep 11.

Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

The Society of Thoracic Surgeons (STS) Workforce on Research Development and the STS Research Center currently offer 3 outcomes research platforms using the STS General Thoracic Surgery Database: (1) the traditional Access and Publications Program supports STS-sponsored projects with data analysis conducted at an STS-approved data analytic center, (2) the STS Task Force for Funded Research supports STS investigators pursuing extramural research funding for projects incorporating STS National Database data linked to other data sets such as Centers for Medicare and Medicaid Services, and (3) the Participant User File (PUF) program that provides deidentified patient-level data files from the STS General Thoracic Surgery Database to investigators with approved projects to be analyzed at their institution. This report includes an updated review of each program in addition to an outline of 2019-based articles published or accepted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2019.09.001DOI Listing
November 2019

Commentary: Cardiac surgery, nutrition, and recovery-First define the problem.

J Thorac Cardiovasc Surg 2019 10 4;158(4):1109-1110. Epub 2019 Apr 4.

Heart & Vascular Program, Baystate Health, Springfield, Mass. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2019.03.065DOI Listing
October 2019

Multiple arterial, minimally invasive coronary surgery (MA-MICS).

Ann Cardiothorac Surg 2018 Jul;7(4):564-566

Sanger Heart & Vascular Institute, Department of Cardiothoracic and Vascular Surgery, Atrium Health, Charlotte, NC, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/acs.2018.06.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082782PMC
July 2018

Preoperative serum ST2 level predicts acute kidney injury after adult cardiac surgery.

J Thorac Cardiovasc Surg 2018 09 11;156(3):1114-1123.e2. Epub 2018 Apr 11.

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH; Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Community and Family Medicine, Geisel School of Medicine, Lebanon, NH. Electronic address:

Objective: The purpose of this study was to evaluate the relationship between preoperative levels of serum soluble ST2 (ST2) and acute kidney injury (AKI) after cardiac surgery. Previous research has shown that biomarkers facilitate the prediction of AKI and other complications after cardiac surgery.

Methods: Preoperative ST2 proteins were measured in 1498 patients undergoing isolated coronary artery bypass graft surgery at 8 hospitals participating in the Northern New England Biomarker Study from 2004 to 2007. AKI severity was defined using the Acute Kidney Injury Network (AKIN) definition. Preoperative ST2 levels were measured using multiplex assays. Ordered logistic regression was used to examine the relationship between ST2 levels and levels of AKI severity.

Results: Participants in this study showed a significant association between elevated preoperative ST2 levels and acute kidney risk. Before adjustment, the odds of patients developing AKIN stage 2 or 3, compared with AKIN stage 1, are 2.43 times higher (95% confidence interval, 1.86-3.16; P < .001) for patients in the highest tercile of preoperative ST2. After adjustment, patients in the highest tercile of preoperative ST2 had significantly greater odds of developing AKIN stage 2 or 3 AKI (odds ratio, 1.99; 95% confidence interval, 1.50-2.65; P < .001) compared with patients with AKIN stage 1.

Conclusions: Preoperative ST2 levels are associated with postoperative AKI risk and can be used to identify patients at higher risk of developing AKI after cardiac surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2018.03.149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6098731PMC
September 2018

The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery Risk Models: Part 1-Background, Design Considerations, and Model Development.

Ann Thorac Surg 2018 05 22;105(5):1411-1418. Epub 2018 Mar 22.

Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.

Background: The last published version of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) risk models were developed in 2008 based on patient data from 2002 to 2006 and have been periodically recalibrated. In response to evolving changes in patient characteristics, risk profiles, surgical practice, and outcomes, the STS has now developed a set of entirely new risk models for adult cardiac surgery.

Methods: New models were estimated for isolated coronary artery bypass grafting surgery (CABG [n = 439,092]), isolated aortic or mitral valve surgery (n = 150,150), and combined valve plus CABG procedures (n = 81,588). The development set was based on July 2011 to June 2014 STS ACSD data; validation was performed using July 2014 to December 2016 data. Separate models were developed for operative mortality, stroke, renal failure, prolonged ventilation, reoperation, composite major morbidity or mortality, and prolonged or short postoperative length of stay. Because of its low occurrence rate, a combined model incorporating all operative types was developed for deep sternal wound infection/mediastinitis.

Results: Calibration was excellent except for the deep sternal wound infection/mediastinitis model, which slightly underestimated risk because of higher rates of this endpoint in the more recent validation data; this will be recalibrated in each feedback report. Discrimination (c-index) of all models was superior to that of 2008 models except for the stroke model for valve patients.

Conclusions: Completely new STS ACSD risk models have been developed based on contemporary patient data; their performance is superior to that of previous STS ACSD models.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2018.03.002DOI Listing
May 2018

The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery Risk Models: Part 2-Statistical Methods and Results.

Ann Thorac Surg 2018 05 22;105(5):1419-1428. Epub 2018 Mar 22.

Department of Surgery and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: The Society of Thoracic Surgeons (STS) uses statistical models to create risk-adjusted performance metrics for Adult Cardiac Surgery Database (ACSD) participants. Because of temporal changes in patient characteristics and outcomes, evolution of surgical practice, and additional risk factors available in recent ACSD versions, completely new risk models have been developed.

Methods: Using July 2011 to June 2014 ACSD data, risk models were developed for operative mortality, stroke, renal failure, prolonged ventilation, mediastinitis/deep sternal wound infection, reoperation, major morbidity or mortality composite, prolonged postoperative length of stay, and short postoperative length of stay among patients who underwent isolated coronary artery bypass grafting surgery (n = 439,092), aortic or mitral valve surgery (n = 150,150), or combined valve plus coronary artery bypass grafting surgery (n = 81,588). Separate models were developed for each procedure and endpoint except mediastinitis/deep sternal wound infection, which was analyzed in a combined model because of its infrequency. A surgeon panel selected predictors by assessing model performance and clinical face validity of full and progressively more parsimonious models. The ACSD data (July 2014 to December 2016) were used to assess model calibration and to compare discrimination with previous STS risk models.

Results: Calibration in the validation sample was excellent for all models except mediastinitis/deep sternal wound infection, which slightly underestimated risk and will be recalibrated in feedback reports. The c-indices of new models exceeded those of the last published STS models for all populations and endpoints except stroke in valve patients.

Conclusions: New STS ACSD risk models have generally excellent calibration and discrimination and are well suited for risk adjustment of STS performance metrics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2018.03.003DOI Listing
May 2018

Decision Making, Evidence, and Practice.

Ann Thorac Surg 2018 04;105(4):994-999

Department of Cardiothoracic Surgery, Stanford University, Stanford, California.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2018.01.054DOI Listing
April 2018

The Society for Translational Medicine: clinical practice guidelines for the postoperative management of chest tube for patients undergoing lobectomy.

J Thorac Dis 2017 Sep;9(9):3255-3264

Charité Kompetenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.

The Society for Translational Medicine and The Chinese Society for Thoracic and Cardiovascular Surgery conducted a systematic review of the literature in an attempt to improve our understanding in the postoperative management of chest tubes of patients undergoing pulmonary lobectomy. Recommendations were produced and classified based on an internationally accepted GRADE system. The following recommendations were extracted in the present review: (I) chest tubes can be removed safely with daily pleural fluid of up to 450 mL (non-chylous and non-sanguinous), which may reduce chest tube duration and hospital length of stay (2B); (II) in rare instances, e.g., persistent abundant fluid production, the use of PrR <0.5 when evaluating fluid output to determine chest tube removal might be beneficial (2B); (III) it is recommended that one chest tube is adequate following pulmonary lobectomy, except for hemorrhage and space problems (2A); (IV) chest tube clearance by milking and stripping is not recommended after lung resection (2B); (V) chest tube suction is not necessary for patients undergoing lobectomy after first postoperative day (2A); (VI) regulated chest tube suction [-11 (-1.08 kPa) to -20 (1.96 kPa) cmHO depending upon the type of lobectomy] is not superior to regulated seal [-2 (0.196 kPa) cmHO] when electronic drainage systems are used after lobectomy by thoracotomy (2B); (VII) chest tube removal recommended at the end of expiration and may be slightly superior to removal at the end of inspiration (2A); (VIII) electronic drainage systems are recommended in the management of chest tube in patients undergoing lobectomy (2B).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/jtd.2017.08.165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708414PMC
September 2017

Physician Burnout: Are We Treating the Symptoms Instead of the Disease?

Ann Thorac Surg 2017 Oct;104(4):1117-1122

Baylor Scott & White Research Institute, The Heart Hospital Baylor Plano, Plano, Texas; Department of Cardiothoracic Surgery, The Heart Hospital Baylor Plano, Plano, Texas. Electronic address:

Despite increasing recognition of physician burnout, its incidence has only increased in recent years, with nearly half of physicians suffering from symptoms of burnout in the most recent surveys. Unfortunately, most burnout research has focused on its profound prevalence rather than seeking to identify the root cause of the burnout epidemic. Health care organizations throughout the United States are implementing committees and support groups in an attempt to reduce burnout among their physicians, but these efforts are typically focused on increasing resilience and wellness among participants rather than combating problematic changes in how medicine is practiced by physicians in the current era. This report provides a brief review of the current literature on the syndrome of burnout, a summary of several institutional approaches to combating burnout, and a call for a shift in the focus of these efforts toward one proposed root cause of burnout.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2017.08.009DOI Listing
October 2017

Cardiothoracic Critical Care.

Surg Clin North Am 2017 Aug;97(4):811-834

Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA, USA.

High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.suc.2017.03.001DOI Listing
August 2017

Investigating the Causes of Adverse Events.

Ann Thorac Surg 2017 Jun;103(6):1693-1699

Department of Cardiothoracic Surgery, Stanford University, Stanford, California.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2017.04.001DOI Listing
June 2017

Invited Commentary.

Authors:
Kevin W Lobdell

Ann Thorac Surg 2017 04;103(4):1237-1238

Sanger Heart and Vascular Institute, Carolinas HealthCare System, PO Box 32861, Charlotte, NC 28232. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2016.07.058DOI Listing
April 2017

Axillary Versus Femoral Arterial Cannulation During Repair of Type A Aortic Dissection?: An Old Problem Seeking New Solutions.

Aorta (Stamford) 2016 Aug 1;4(4):115-123. Epub 2016 Aug 1.

Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut, USA.

Background: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute Type A aortic dissection with axillary or femoral artery cannulation.

Methods: A total of 305 patients from five academic medical centers underwent acute Type A aortic dissection repair via axillary ( = 107) or femoral ( = 198) artery cannulation between January 2000 and December 2010. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality, and Cox regression hazard ratios were calculated to determine predictors of long-term mortality.

Results: Operative mortality was not influenced by cannulation site (16% for axillary cannulation vs. 19% for femoral cannulation, p = 0.64). In multivariate logistic regression analysis, hemodynamic instability (p < 0.001) and prolonged cardiopulmonary bypass time (>200 min; p = 0.05) emerged as independent predictors of operative mortality. Stroke rates were comparable between the two techniques (14% for axillary and 17% for femoral cannulation, p = 0.52). Five-year actuarial survival was comparable between the groups (55.1% for axillary and 65.7% for femoral cannulation, p = 0.36). In Cox regression analysis, predictors of long-term mortality were: age (p < 0.001), stroke (p < 0.001), prolonged cardiopulmonary bypass time (p = 0.001), hemodynamic instability (p = 0.002), and renal failure (p = 0.001).

Conclusions: The outcomes of femoral versus axillary arterial cannulation in patients with acute Type A aortic dissection are comparable. The choice of arterial cannulation site should be individualized based on different patient risk profiles.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12945/j.aorta.2016.16.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217728PMC
August 2016

Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection.

Aorta (Stamford) 2016 Apr 1;4(2):33-41. Epub 2016 Apr 1.

Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut, USA.

Background: The goal of this study was to compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute Type A aortic dissection, including aortic valve (AV) resuspension, aortic valve replacement (AVR), and a root replacement procedure.

Methods: All patients who underwent acute Type A aortic dissection repair between January 2000 and October 2010 at four academic institutions were compiled from each institution's Society of Thoracic Surgeons Database. This included 189 patients who underwent a concomitant aortic valve (AV) procedure; 111, 21, and 57 patients underwent AV resuspension, AVR, and the Bentall procedure, respectively. The median age of patients undergoing a root replacement procedure was significantly younger than the other two groups. Early clinical outcomes and 10-year actuarial survival rates were compared. Trends in outcomes and surgical techniques throughout the duration of the study were also analyzed.

Results: The operative mortality rates were 17%, 29%, and 18%, for AV resuspension, AVR, and root replacement, respectively. Operative mortality ( = 0.459) was comparable between groups. Hemorrhage related re-exploration did not differ significantly between groups ( = 0.182); however, root replacement procedures tended to have decreased rates of bleeding when compared to AVR ( = 0.067). The 10-year actuarial survival rates for the AV resuspension, Bentall, and AVR groups were 72%, 56%, and 36%, respectively (log-rank = 0.035).

Conclusions: The 10-year actuarial survival was significantly lower in those receiving AVR compared to those receiving root replacement procedures or AV resuspension. Operative mortality was comparable between the three groups.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12945/j.aorta.2016.14.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5054754PMC
April 2016

"What's the Risk?" Assessing and Mitigating Risk in Cardiothoracic Surgery.

Ann Thorac Surg 2016 Oct 2;102(4):1052-8. Epub 2016 Sep 2.

Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2016.08.051DOI Listing
October 2016

Comparison between antegrade and retrograde cerebral perfusion or profound hypothermia as brain protection strategies during repair of type A aortic dissection.

Ann Cardiothorac Surg 2016 Jul;5(4):328-35

Department of Cardiac Surgery, Hartford Hospital, Hartford, CT, USA.

Background: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute type A aortic dissection by the method of cerebral perfusion used.

Methods: A total of 324 patients from five academic medical centers underwent repair of acute type A aortic dissection between January 2000 and December 2010. Of those, antegrade cerebral perfusion (ACP) was used for 84 patients, retrograde cerebral perfusion (RCP) was used for 55 patients, and deep hypothermic circulatory arrest (DHCA) was used for 184 patients during repair. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality and Cox Regression hazard ratios were calculated to determine the predictors of long term mortality.

Results: Operative mortality was not influenced by the type of cerebral protection (19% for ACP, 14.5% for RCP and 19.1% for DHCA, P=0.729). In multivariable logistic regression analysis, hemodynamic instability [odds ratio (OR) =19.6, 95% confidence intervals (CI), 0.102-0.414, P<0.001] and CPB time >200 min(OR =4.7, 95% CI, 1.962-1.072, P=0.029) emerged as independent predictors of operative mortality. Actuarial 5-year survival was unchanged by cerebral protection modality (48.8% for ACP, 61.8% for RCP and 66.8% for no cerebral protection, log-rank P=0.844).

Conclusions: During surgical repair of type A aortic dissection, ACP, RCP or DHCA are safe strategies for cerebral protection in selected patients with type A aortic dissection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.21037/acs.2016.04.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4973129PMC
July 2016

Failure to Rescue Rates After Coronary Artery Bypass Grafting: An Analysis From The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

Ann Thorac Surg 2016 Aug 22;102(2):458-64. Epub 2016 Jun 22.

Department of Surgery/Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts.

Background: Failure to rescue (FTR) is increasingly recognized as an important quality indicator in surgery. The Society of Thoracic Surgeons National Database was used to develop FTR metrics and a predictive FTR model for coronary artery bypass grafting (CABG).

Methods: The study included 604,154 patients undergoing isolated CABG at 1,105 centers from January 2010 to January 2014. FTR was defined as death after four complications: stroke, renal failure, reoperation, and prolonged ventilation. FTR was determined for each complication and a composite of the four complications. A statistical model to predict FTR was developed.

Results: FTR rates were 22.3% for renal failure, 16.4% for stroke, 12.4% for reoperation, 12.1% for prolonged ventilation, and 10.5% for the composite. Mortality increased with multiple complications and with specific combinations of complications. The multivariate risk model for prediction of FTR demonstrated a C index of 0.792 and was well calibrated, with a 1.0% average difference between observed/expected (O/E) FTR rates. With centers grouped into mortality terciles, complication rates increased modestly (11.4% to 15.7%), but FTR rates more than doubled (6.8% to 13.9%) from the lowest to highest terciles. Centers in the lowest complication rate tercile had an FTR O/E of 1.14, whereas centers in the highest complication rate tercile had an FTR O/E of 0.91.

Conclusions: CABG mortality rates vary directly with FTR, but complication rates have little relation to death. FTR rates derived from The Society of Thoracic Surgeons data can serve as national benchmarks. Predicted FTR rates may facilitate patient counseling, and FTR O/E ratios have promise as valuable quality metrics.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2016.04.051DOI Listing
August 2016

Effects of Gender on Outcomes and Survival Following Repair of Acute Type A Aortic Dissection.

Int J Angiol 2015 Jun;24(2):93-8

Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut.

Previous studies have demonstrated gender-related differences in early and late outcomes following type A dissection diagnosis. However, it is widely unknown whether gender affects early clinical outcomes and survival after repair of type A aortic dissection. The goal of this study was to compare the early and late clinical outcomes in women versus men after repair of acute type A aortic dissections. Between January 2000 and October 2010 a total of 251 patients from four academic medical centers underwent repair of acute type A aortic dissection. Of those, 79 were women and 172 were men with median ages of 67 (range, 20-87 years) and 58 years (range, 19-83 years), respectively (p < 0.001). Major morbidity, operative mortality, and 10-year actuarial survival were compared between the groups. Operative mortality was not significantly influenced by gender (19% for women vs. 17% for men, p = 0.695). There were similar rates of hemodynamic instability (12% for women vs. 13% men, p = 0.783) between the two groups. Actuarial 10-year survival rates were 58% for women versus 73% for men (p = 0.284). Gender does not significantly impact early clinical outcomes and actuarial survival following repair of acute type A aortic dissection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0034-1396341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4452609PMC
June 2015

Improved clinical outcomes and survival following repair of acute type A aortic dissection in the current era.

Interact Cardiovasc Thorac Surg 2014 Dec 21;19(6):971-6. Epub 2014 Aug 21.

Department of Cardiac Surgery, Hartford Hospital, Hartford, USA.

Objectives: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute type A aortic dissection during 2000-2005 and 2006-2010.

Methods: A total of 251 patients from four academic medical centres underwent repair of acute type A aortic dissection between January 2000 and October 2010. Of those, 111 patients underwent repair during 2000-2005, whereas 140 patients underwent repair during 2006-2010. Median ages were 62 years (range 20-83) and 58 years (range 30-80) for patients repaired from 2000-2005 compared with those repaired during 2006-2010, respectively (P = 0.180). Major morbidity, operative mortality and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality.

Results: Operative mortality was strongly influenced by surgical era (24% for 2000-2005 vs 12% for 2006-2010, P = 0.013). In multivariable logistic regression analysis, haemodynamic instability [odds ratio (OR) = 17.8, 95% confidence intervals (CIs) = 0.05-0.35, P <0.001], cardiopulmonary bypass time >200 min (OR = 9.5, 95% CI = 0.14-0.64, P = 0.002) and earlier date of surgery (OR = 5.8, 95% CI = 1.18-5.14, P = 0.016) emerged as independent predictors of operative mortality. Actuarial 5-year survival was worse for earlier compared with later date of surgery (64% for 2000-2005 vs 77% for 2006-2010, log-rank P <0.001).

Conclusions: Surgical era significantly impacts early outcomes and actuarial survival following repair of acute type A aortic dissection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/icvts/ivu268DOI Listing
December 2014

Aortic root surgery in the United States: a report from the Society of Thoracic Surgeons database.

J Thorac Cardiovasc Surg 2015 Jan 21;149(1):116-22.e4. Epub 2014 May 21.

Department of Cardiothoracic Surgery, Missouri Baptist Medical Center, St Louis, Mo.

Objective: The purpose of the present study was to evaluate the early clinical outcomes of aortic root surgery in the United States.

Methods: The Society of Thoracic Surgeons database was queried to identify all patients who had undergone aortic root replacement from 2004 to early 2010 (n = 13,743). The median age was 58 years (range, 18-96); 3961 were women (29%) and 12,059 were white (88%). The different procedures included placement of a mechanical valve conduit (n = 4718, 34%), stented pericardial (n = 879, 6.4%) or porcine (n = 478, 3.5%) bioprosthesis, stentless root (n = 4309, 31%), homograft (n = 498, 3.6%), and valve sparing root replacement (n = 1918, 14%).

Results: The median number of aortic root surgeries per site was 2, and only 5% of sites performed >16 aortic root surgeries annually. An increased trend to use biostented (porcine or pericardial) valves during the study period (7% in 2004 vs 14% in 2009). The operative (raw) mortality was greater among the patients with aortic stenosis (6.2%) who had undergone aortic root replacement, independent of age. Mortality was greater in patients who had undergone concomitant valve or coronary artery bypass grafting or valve surgery (21%). The lowest operative mortality was observed in patients who had undergone aortic valve sparing procedures (1.9%).

Conclusions: Most cardiac centers performed aortic root surgery in small volumes. The unadjusted operative mortality was greater for patients >80 years old and those with aortic stenosis, regardless of age. Valve sparing root surgery was associated with the lowest mortality. A trend was seen toward an increased use of stented tissue valves from 2004 to 2009.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2014.05.042DOI Listing
January 2015

Effects of Hemodynamic Instability on Early Outcomes and Late Survival Following Repair of Acute Type A Aortic Dissection.

Aorta (Stamford) 2014 Feb 1;2(1):22-7. Epub 2014 Feb 1.

Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut.

Background: The goal of this study was to compare operative mortality and actuarial survival between patients presenting with and without hemodynamic instability who underwent repair of acute Type A aortic dissection. Previous studies have demonstrated that hemodynamic instability is related to differences in early and late outcomes following acute Type A dissection occurrence. However, it is unknown whether hemodynamic instability at the initial presentation affects early clinical outcomes and survival after repair of Type A aortic dissection.

Methods: A total of 251 patients from four academic medical centers underwent repair of acute Type A aortic dissection between January 2000 and October 2010. Of those, 30 presented with hemodynamic instability while 221 patients did not. Median ages were 63 years (range 38-82) and 60 years (range 19-87) for patients presenting with hemodynamic instability compared to patients without hemodynamic instability, respectively (P = 0.595). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups.

Results: Operative mortality was profoundly influenced by hemodynamic instability (patients with hemodynamic instability 47% versus 14% for patients without hemodynamic instability, P < 0.001). Actuarial 10-year survival rates for patients with hemodynamic instability were 44% versus 63% for patients without hemodynamic instability (P = 0.007).

Conclusions: Hemodynamic instability has a profoundly negative impact on early outcomes and operative mortality in patients with acute Type A aortic dissection. However, late survival is comparable between hemodynamically unstable and non-hemodynamically unstable patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12945/j.aorta.2014.13-055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4682687PMC
February 2014

Differences in clinical characteristics, management, and outcomes of intraoperative versus spontaneous acute type A aortic dissection.

Ann Thorac Surg 2013 Jan 22;95(1):41-5. Epub 2012 Oct 22.

Department of Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, Grand Rapids, Michigan, USA.

Background: The clinical characteristics, management, and outcomes of patients who had intraoperative aortic dissection (IAD) have not been thoroughly investigated. This study compared early and late clinical outcomes in patients with IAD vs spontaneous (non-IAD) acute type A aortic dissection.

Methods: Between January 1, 2000, and July 1, 2008, 251 patients from 4 academic medical centers underwent repair of acute type A aortic dissection; of those, 11 had IAD. The mean age was 72 ± 9 years for patients experiencing IAD and 59 ± 13 years for those with non-IAD (p = 0.001). Patients with IAD were more likely to have coronary artery disease (p = 0.003) and a history of arrhythmia (p = 0.038). Rates for major morbidity, operative mortality, and 5-year actuarial survival were compared between groups.

Results: Operative mortality was not adversely influenced by IAD (27% IAD vs 17% non-IAD, p = 0.42). There were no differences in the rates of reoperation for bleeding (10% IAD vs 20% non-IAD, p = 0.69), stroke (18% IAD vs 18% non-IAD, p ≥ 0.99), or acute renal failure (9% IAD vs 22% non-IAD, p = 0.47) between the two groups. Actuarial 5-year survival was 64% for IAD patients vs 73% for non-IAD patients (p = 0.33).

Conclusions: IAD does not adversely influence early outcomes and actuarial 5-year survival of patients with type A dissection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.athoracsur.2012.08.050DOI Listing
January 2013

Hospital-acquired infections.

Surg Clin North Am 2012 Feb 5;92(1):65-77. Epub 2011 Dec 5.

Sanger Heart and Vascular Institute, Carolinas HealthCare System, PO Box 32861, Charlotte, NC 28232, USA.

Health-acquired infection (HAI) is defined as a localized or systemic condition resulting from an adverse reaction to the presence of infectious agents or its toxins. This article focuses on HAIs that are well studied, common, and costly (direct, indirect, and intangible). The HAIs reviewed are catheter-related bloodstream infection, ventilator-associated pneumonia, surgical site infection, and catheter-associated urinary tract infection. This article excludes discussion of Clostridium difficile infections and vancomycin-resistant Enterococcus.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.suc.2011.11.003DOI Listing
February 2012

Hypoglycemia with intensive insulin therapy after cardiac surgery: predisposing factors and association with mortality.

J Thorac Cardiovasc Surg 2011 Jul 12;142(1):166-73. Epub 2011 Mar 12.

Department of Thoracic and Cardiovascular Surgery, Missouri Baptist Medical Center, St Louis, Mo, USA.

Background: Intensive insulin therapy has become a major therapeutic target in cardiac surgery patients. It has been associated, however, with an increased risk of hypoglycemia compared with conventional insulin therapy. Our study sought to identify the factors predisposing to hypoglycemia with intensive insulin therapy and investigate its effect on early clinical outcomes after cardiac surgery.

Methods: A concurrent cohort study of 2,538 consecutive patients undergoing cardiac surgery (coronary artery bypass grafting, valve, or bypass grafting and valve surgery) from January 2005 to March 2010 was carried out. Multivariable logistic regression analysis and propensity score matching were used (1) to identify the risk factors for developing hypoglycemia (blood glucose < 60 mg/dL) after cardiac surgery and (2) to compare major morbidity, operative mortality, and actuarial survival between patients in whom hypoglycemia developed (n = 77) and those in whom it did not (n = 2461). The propensity score-adjusted sample included 61 patients in whom hypoglycemia developed and 305 patients in whom it did not (1 to 5 matching).

Results: Risk factors for hypoglycemia included female gender (odds ratio [OR] = 2.3, 95% confidence intervals [CI] = 1.4-3.7; P < .001), diabetes (OR = 2.8, CI = 1.7-4.5; P < .001), hemodialysis (OR = 3.0, CI = 1.3-6.8; P = .009), intraoperative blood product transfusion (OR = 2.0, CI = 1.2-3.4; P = .010), and earlier date of surgery (years of surgery, 2005-2007; OR = 2.1, CI = 1.2-3.7; P = .007) . Hypoglycemia increased the risk for operative mortality in univariate (hypoglycemic 10% vs normoglycemic patients 2%; P < .001) but not in propensity score- adjusted analysis (OR= 2.5, 0.9-6.7; P = .11). The propensity score-adjusted analysis demonstrated a significant increase in hemorrhage-related reexploration (P = .048), pneumonia (P < .001), reintubation (P < .001), prolonged ventilatory support (P < .001), hospital length of stay (P < .001), and intensive care unit length of stay (P < .001) for the hypoglycemic compared with normoglycemic patients. Five-year actuarial survival was similar in the compared patient groups (hypoglycemic 75% vs normoglycemic 75%; P = .22).

Conclusions: Hypoglycemia with intensive insulin therapy is independently associated with increased risk for respiratory complications and prolonged hospital and intensive care unit lengths of stay after cardiac surgery. In our study, hypoglycemia was not independently associated with increased risk of death.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jtcvs.2010.09.064DOI Listing
July 2011
-->