Publications by authors named "Michael E Bowdish"

60 Publications

Lack of Awareness of Reimbursement and Compensation Models amongst Cardiothoracic Surgery Trainees.

Ann Thorac Surg 2021 Aug 26. Epub 2021 Aug 26.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA; Department of Population and Public Health Sciences, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA. Electronic address:

Background: The objective of this study was to identify trainee knowledge gaps in reimbursement and compensation, determine the perceived importance of understanding these topics, and to explore if the Thoracic Surgery Curriculum needs additional educational material.

Methods: The Thoracic Surgical Residents Association (TSRA) Executive committee selected the research proposal and distributed an anonymous electronic survey to 531 ACGME cardiothoracic surgery trainees. Standard descriptive statistics and regression analyses were performed.

Results: 114 responses were collected (response rate 21.5%). Most trainees understand little or not at all about how attending surgeons are reimbursed (n=74, 69%). Most trainees reported knowing little or nothing about pay-for-performance compensation (n=73, 67%), bundled care (n=82, 75%) or value-based reimbursement (n=84, 77%). Only approximately 20% of trainees were accurate in estimating surgeon reimbursement for three common cardiothoracic surgery procedures to within 20% of the true reimbursement value, while approximately 30% were accurate to within 50% of the true reimbursement value. No respondent characteristics were found to be associated with a more or less accurate reimbursement response. Additionally, 81% of trainees responded that by the conclusion of training, understanding surgeon reimbursement is very important or extremely important (n=87) and 90% of trainees either somewhat agree or strongly agree with including these topics in the Thoracic Surgical Curriculum (n=95).

Conclusions: Despite acknowledging the importance of understanding physician compensation and reimbursement, cardiothoracic surgery trainees do not understand how the current models work. This study exemplifies the need for a succinct curriculum in this domain for trainees nationwide.
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http://dx.doi.org/10.1016/j.athoracsur.2021.07.078DOI Listing
August 2021

The STS Participant-Level, Multi-Procedural Composite Measure for Adult Cardiac Surgery.

Ann Thorac Surg 2021 Aug 6. Epub 2021 Aug 6.

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

Background: Composite performance measures for STS Adult Cardiac Surgery Database participants (typically hospital departments or practice groups) are currently available only for individual procedures. To assess overall participant performance, STS has developed a composite metric encompassing the most common adult cardiac procedures.

Methods: Analyses included 1-year (July 1, 2018-June 30, 2019) and 3-year (July 1, 2016-June 30, 2019) time windows. Operations included isolated CABG, isolated AVR, isolated mitral valve repair (MVr) or replacement (MVR), AVR+CABG, MVr/MVR+CABG, AVR+MVr/MVR, and AVR+MVr/MVR+CABG. The composite was estimated using Bayesian hierarchical models with risk-adjusted mortality and morbidity endpoints. Star ratings were based on whether the 95% credible interval of a participant's score was entirely below (1-star), overlapped (2-star), or was above (3-star) the STS average composite score.

Results: The North American procedural mix in the 3-year study cohort was 448,569 CABG, 72,067 AVR, 35,708 MVr, 29,953 MVR, 45,254 AVR+CABG, 12,247 MVr+CABG, 10,118 MVR+CABG, 3,743 AVR+MVr, 6,846 AVR+MVR, and 3,765 AVR+(MVr/MVR)+CABG. Mortality and morbidity weightings were similar for 1- and 3-year analyses (76% and 24%, [3-year]), as were composite score distributions (median 94.7%, IQR 93.6% to 95.6%, [3-year]). The 3-year timeframe was selected for operational use because of higher model reliability (0.81 [0.78 - 0.83]) and better outlier discrimination (26% 3-star, 16% 1-star). Risk-adjusted outcomes for 1-, 2-, and 3-star programs were 4.3%, 3.0%, and 1.8% mortality, and 18.4%, 13.4%, and 9.7% morbidity, respectively.

Conclusions: The STS participant-level, multi-procedural composite measure provides comprehensive, highly reliable, overall quality assessment of adult cardiac surgery practices.
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http://dx.doi.org/10.1016/j.athoracsur.2021.06.084DOI Listing
August 2021

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

Was Grandpa Wrong? Maybe simpler isn't better?

Ann Thorac Surg 2021 Jun 28. Epub 2021 Jun 28.

Department of Surgery and Preventive Medicine, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street HC2 Suite 4300 Los Angeles, CA 90033. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2021.06.006DOI Listing
June 2021

SARS-CoV-2-related outcomes after surgical procedures on SARS-CoV-2-positive patients in a large, urban, safety net medical center.

Surg Open Sci 2021 Jul 3;5:10-13. Epub 2021 May 3.

Los Angeles County + University of Southern California (LAC + USC) Medical Center, Los Angeles, CA.

Background: Beginning on March 16, 2020, nonurgent scheduled operations at a large, urban, safety net medical center were canceled. The purpose of this study was to determine complications associated with severe acute respiratory syndrome coronavirus 2 infection for all operations done from March 16 to June 30, 2020.

Study Design: This study was a single-institution, retrospective observational analysis of data for all surgical procedures and all severe acute respiratory syndrome coronavirus 2 tests done in the medical center from March 16 to June 30, 2020. The charts of all severe acute respiratory syndrome coronavirus 2-positive patients who had a surgical procedure during the study time period were retrospectively reviewed to assess the outcomes.

Results: Of 2,208 operations during that time, 29 (1.3%) patients were severe acute respiratory syndrome coronavirus 2-positive and were asymptomatic at the time of their operations. Twenty-four (82.7%) of the 29 required urgent or emergent procedures. The median time between availability of test results and operations for these patients was 0.63 + 1.94 days. With median follow-up of 89 days, none of the 29 patients died from severe acute respiratory syndrome coronavirus 2-related causes, and none developed clinically evident thromboembolism or required reintubation secondary to severe acute respiratory syndrome coronavirus 2-related pneumonia.

Conclusion: By operating on carefully screened, asymptomatic severe acute respiratory syndrome coronavirus 2-positive patients, it was possible to eliminate major complications and mortality due to severe acute respiratory syndrome coronavirus 2 infection.
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http://dx.doi.org/10.1016/j.sopen.2021.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8091810PMC
July 2021

Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease.

J Card Surg 2021 Aug 28;36(8):2636-2643. Epub 2021 Apr 28.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA.

Background: Debate continues in regard to the optimal surgical approach to the mitral valve for degenerative disease.

Methods: Between February 2004 and July 2015, 363 patients underwent mitral valve repair for degenerative mitral valve disease via either sternotomy (sternotomy, n = 109) or small right anterior thoracotomy (minimally invasive, n = 259). Survival, need for mitral valve reoperation, and progression of mitral regurgitation more than two grades were compared between cohorts using time-based statistical methods and inverse probability weighting.

Results: Survival at 1, 5, and 10 years were 99.2, 98.3, and 96.8 for the sternotomy group and 98.1, 94.9, and 94.9 for the minimally invasive group (hazard ratio: 0.39, 95% confidence interval [CI] 0.11-1.30, p = .14). The cumulative incidence of need for mitral valve reoperation with death as a competing outcome at 1, 3, and 5 years were 2.7%, 2.7%, and 2.7% in the sternotomy cohort and 1.5%, 3.3%, and 4.1% for the minimally invasive group (subhazard ratio (SHR) 1.17, 95% CI: 0.33-4.20, p = .81). Cumulative incidence of progression of mitral regurgitation more than two grades with death as a competing outcome at 1, 3, and 5 years were 5.5%, 14.4%, and 44.5% for the sternotomy cohort and 4.2%, 9.7%, and 20.5% for the minimally invasive cohort (SHR: 0.67, 95% CI: 0.28-1.63, p = .38). Inverse probability weighted time-based analyses based on preoperative cohort assignment also demonstrated equivalent outcomes between surgical approaches.

Conclusions: Minimally invasive and sternotomy mitral valve repair in patients with degenerative mitral valve disease is associated with equivalent survival and repair durability.
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http://dx.doi.org/10.1111/jocs.15586DOI Listing
August 2021

Commentary: Just keep spinning.

J Thorac Cardiovasc Surg 2021 Mar 23. Epub 2021 Mar 23.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif; Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.063DOI Listing
March 2021

The Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations.

Ann Thorac Surg 2021 Aug 4. Epub 2021 Aug 4.

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

Background: The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures.

Methods: Using July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration.

Results: C-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample.

Conclusions: New STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.089DOI Listing
August 2021

STS Adult Cardiac Surgery Database: 2021 Update on Outcomes, Quality, and Research.

Ann Thorac Surg 2021 06 29;111(6):1770-1780. Epub 2021 Mar 29.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It has been the foundation for quality measurement and improvement activities in cardiac surgery, facilitated the generation of accurate risk adjusted performance benchmarks and serves as a platform for novel research. Recent enhancements have added to the database's functionality, ease of use, and value to multiple stakeholders. This report is the sixth in a series of annual reports that provide updated volumes, outcomes, database-related developments, quality improvement initiatives, and research summaries using the Adult Cardiac Surgery Database in the past year.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.043DOI Listing
June 2021

Long-term outcomes with the pulmonary autograft inclusion technique in adults with bicuspid aortic valves undergoing the Ross procedure.

J Thorac Cardiovasc Surg 2021 Feb 4. Epub 2021 Feb 4.

Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif; Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif. Electronic address:

Objective: To compare outcomes with wrapped (pulmonary autograft inclusion) versus unwrapped techniques in adults with bicuspid aortic valves undergoing the Ross procedure.

Methods: Between 1992 and 2019, 129 adults with bicuspid aortic valves (aged ≥18 years) underwent the Ross procedure by a single surgeon. Patients were divided into those without autograft inclusion (unwrapped, n = 71) and those with autograft inclusion (wrapped, n = 58). Median follow-up was 10.3 years (interquartile range, 3.0-16.8 years). Need for autograft reintervention was analyzed using competing risks.

Results: Pre- and intraoperative characteristics as well as 30-day morbidity or mortality did not differ between cohorts. Survival at 1, 5, and 10 years, respectively, was 97.2%, 97.2%, and 95.6% in the unwrapped cohort and 100%, 100%, and 100% in the wrapped cohort (P = .15). Autograft valve failure occurred in 25 (35.2%) of the unwrapped and 3 (5.2%) of the wrapped patients. Competing risks analysis demonstrated the wrapped cohort to have a lower need for autograft reintervention (subhazard ratio, 0.28, 95% confidence interval, 0.08-0.91; P = .035). The cumulative incidence of autograft reintervention (death as a competing outcome) at 1, 5, and 10 years, respectively, was 10.2%, 14.9%, and 26.8% in the unwrapped cohort and 4.0%, 4.0%, and 4.0% in the wrapped cohort.

Conclusions: In adults with bicuspid aortic valves, the Ross procedure with pulmonary autograft inclusion stabilizes the aortic root preventing dilatation and reduces the need for reoperation. The autograft inclusion technique allows the Ross procedure to be performed in this population with excellent long-term outcomes.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.101DOI Listing
February 2021

Resident education in congenital heart surgery does not compromise outcomes.

J Thorac Cardiovasc Surg 2021 Jan 11. Epub 2021 Jan 11.

Division of Cardiac Surgery, Children's Hospital Los Angeles, Los Angeles, Calif; Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.

Objective: Most of all congenital cardiac surgical programs participate in public outcomes reporting. The primary end point is transparency. In this era, academic programs with surgical residents face the challenge of producing outstanding results while allowing residents to learn by doing. We sought to understand the effect of education on our surgical outcomes.

Methods: We collected data for all American Board of Thoracic Surgery index cases done at our institution over a 10-year period. We identified 3406 cases and categorized them into 2 groups according to primary surgeon: attending (2269) versus resident (1137). In a multivariable logistic regression model we examined the effect of operating surgeon on in-hospital mortality, major morbidity, and length of stay. We used propensity score matching subsequently to balance differences between cohorts, and multivariable logistic regression was repeated.

Results: Using the entire cohort, multivariable logistic regression model adjusted for age, sex, weight, lack of preoperative comorbidity, presence of preoperative respiratory failure, The Society of Thoracic Surgeons--European Association for Cardio-Thoracic Surgery category, and need for deep hypothermic circulatory arrest, showed a higher odds of survival in the resident cohort (odds ratio, 1.484; 95% confidence interval, 0.998-2.206; P = .05). Propensity score matching identified 1137 pairs of attending and resident cases with well-balanced preoperative variables. Logistic regression modeling using the matched cohort showed equivalent 30-day mortality, 30-day major morbidity, and length of stay.

Conclusions: There was no difference in mortality, major morbidity, or length of stay when similar cases were compared that were operated on by attendings versus those by a resident. Effectively educating congenital heart surgeons without compromising an operation's quality requires thoughtful approach, including case selection and graded responsibility.
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http://dx.doi.org/10.1016/j.jtcvs.2020.12.112DOI Listing
January 2021

Progression of Tricuspid Regurgitation After Surgery for Ischemic Mitral Regurgitation.

J Am Coll Cardiol 2021 02;77(6):713-724

Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.

Objectives: The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.

Methods: Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.

Results: Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).

Conclusions: After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).
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http://dx.doi.org/10.1016/j.jacc.2020.11.066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953587PMC
February 2021

A Neutralizing Monoclonal Antibody for Hospitalized Patients with Covid-19.

N Engl J Med 2021 03 22;384(10):905-914. Epub 2020 Dec 22.

From the CHIP Center of Excellence for Health, Immunity, and Infections (J.D.L., D.D.M.), and the Department of Infectious Diseases (J.D.L., D.D.M., J.-U.J.), Rigshospitalet, Copenhagen, the Department of Infectious Diseases, Copenhagen University Hospital, Amager and Hvidovre (T.B.), the Department of Internal Medicine, Respiratory Medicine Section, Herlev and Gentofte Hospital, University of Copenhagen, Hellerup (J.-U.J.), the Department of Infectious Diseases, Odense University Hospital, Odense (I.S.J.), and the Department of Infectious Diseases, Aarhus University Hospital, Skejby (L.Ø.) - all in Denmark; the School of Statistics (B.G.) and the Division of Biostatistics, School of Public Health (T.A.M., C.R., S.S., D.W., J.D.N.), University of Minnesota, Hennepin Healthcare Research Institute (J.V.B.), and the University of Minnesota (J.V.B.), Minneapolis; the Divisions of Pulmonary, Allergy, and Critical Care Medicine (C.E.B.) and Infectious Disease (T.L.H.), Department of Medicine, Duke University, Durham, and the Department of Internal Medicine, Section on Pulmonary, Critical Care, Allergy, and Immunology, Wake Forest School of Medicine, Winston-Salem (D.C.F.) - both in North Carolina; the Center for Advanced Heart and Lung Disease (R.L.G.) and the Division of Infectious Diseases (U.S.), Baylor University Medical Center, and the Department of Internal Medicine, UT Southwestern Medical Center (M.K.J.), Dallas; the Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray (S.M.B.), and the Department of Internal Medicine, University of Utah (S.M.B., E.S.H.) and Intermountain Healthcare (K.U.K.), Salt Lake City - both in Utah; the Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville (W.H.S.); the Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles (M.E.B.), the Department of Medicine and Anesthesia and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco (M.A.M.), and Gilead Sciences, Foster City (H.C.) - all in California; the Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta (B.G.L.); Denver Public Health, Denver Health and Hospital Authority, Denver (E.M.G.), and the Department of Emergency Medicine, University of Colorado School of Medicine, Aurora (A.A.G.); the Department of Infectious Diseases, Henry Ford Hospital, Detroit (N.M.); the Kirby Institute, University of New South Wales (C.C.C., M.N.P.), and St. Vincent's Hospital (M.N.P.), Sydney; the Department of Veterans Affairs (V.J.D.), the Veterans Affairs Medical Center (V.L.K.), and George Washington University School of Medicine and Health Sciences (V.L.K.), Washington, DC; the Medical Research Council Clinical Trials Unit at UCL (A.G., A.G.B., M.K.B.P.), the Institute of Clinical Trials and Methodology (M.K.B.P.), and the Institute for Global Health (A.N.P.), University College London, and Guy's and St. Thomas' NHS Foundation Trust (A.G.), London; the National Institute of Allergy and Infectious Diseases, Bethesda (E.S.H., H.C.L.), and Leidos Biomedical Research, Frederick (R.L.D., M.T.) - both in Maryland; the Infectious Diseases Department and IrsiCaixa AIDS Research Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain (R.P.); Eli Lilly, Indianapolis (P.K.); the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York (A.C.G.); and the Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston (B.T.T.).

Background: LY-CoV555, a neutralizing monoclonal antibody, has been associated with a decrease in viral load and the frequency of hospitalizations or emergency department visits among outpatients with coronavirus disease 2019 (Covid-19). Data are needed on the effect of this antibody in patients who are hospitalized with Covid-19.

Methods: In this platform trial of therapeutic agents, we randomly assigned hospitalized patients who had Covid-19 without end-organ failure in a 1:1 ratio to receive either LY-CoV555 or matching placebo. In addition, all the patients received high-quality supportive care as background therapy, including the antiviral drug remdesivir and, when indicated, supplemental oxygen and glucocorticoids. LY-CoV555 (at a dose of 7000 mg) or placebo was administered as a single intravenous infusion over a 1-hour period. The primary outcome was a sustained recovery during a 90-day period, as assessed in a time-to-event analysis. An interim futility assessment was performed on the basis of a seven-category ordinal scale for pulmonary function on day 5.

Results: On October 26, 2020, the data and safety monitoring board recommended stopping enrollment for futility after 314 patients (163 in the LY-CoV555 group and 151 in the placebo group) had undergone randomization and infusion. The median interval since the onset of symptoms was 7 days (interquartile range, 5 to 9). At day 5, a total of 81 patients (50%) in the LY-CoV555 group and 81 (54%) in the placebo group were in one of the two most favorable categories of the pulmonary outcome. Across the seven categories, the odds ratio of being in a more favorable category in the LY-CoV555 group than in the placebo group was 0.85 (95% confidence interval [CI], 0.56 to 1.29; P = 0.45). The percentage of patients with the primary safety outcome (a composite of death, serious adverse events, or clinical grade 3 or 4 adverse events through day 5) was similar in the LY-CoV555 group and the placebo group (19% and 14%, respectively; odds ratio, 1.56; 95% CI, 0.78 to 3.10; P = 0.20). The rate ratio for a sustained recovery was 1.06 (95% CI, 0.77 to 1.47).

Conclusions: Monoclonal antibody LY-CoV555, when coadministered with remdesivir, did not demonstrate efficacy among hospitalized patients who had Covid-19 without end-organ failure. (Funded by Operation Warp Speed and others; TICO ClinicalTrials.gov number, NCT04501978.).
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http://dx.doi.org/10.1056/NEJMoa2033130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7781100PMC
March 2021

Reply: Keeping surgical patients safe during the coronavirus disease 2019 (COVID-19) pandemic: Los Angeles versus New York City.

J Thorac Cardiovasc Surg 2021 02 3;161(2):e237-e238. Epub 2020 Aug 3.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif; Los Angeles County + University of Southern California Medical Center, Los Angeles, Calif.

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7397986PMC
February 2021

Risk for non-home discharge following surgery for ischemic mitral valve disease.

J Thorac Cardiovasc Surg 2020 Mar 4. Epub 2020 Mar 4.

Cardiovascular Medicine, Medicine, Vanderbilt University Medical Center, Nashville, Tenn.

Objectives: To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR).

Methods: Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.

Results: NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P < .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P < .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.

Conclusions: NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.
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http://dx.doi.org/10.1016/j.jtcvs.2020.02.084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874266PMC
March 2020

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2020 Update on Outcomes and Research.

Ann Thorac Surg 2020 06 2;109(6):1646-1655. Epub 2020 Apr 2.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive database in cardiac surgery and one of the most respected clinical data registries in health care. It is widely acknowledged for accurately benchmarking risk-adjusted outcomes and serving as the foundation for quality measurement and improvement activities in cardiac surgery. In addition, the database is a valuable resource for novel research. The advent of the database's fourth decade in operation is being heralded with major revisions to its functionality, ease of use, and value to multiple stakeholders. This report is the fifth in a series of annual reports that provides updated national outcomes, volume trends, and database-related developments, as well as a summary of research performed in the past year using data from this valuable repository on quality and performance improvement.
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http://dx.doi.org/10.1016/j.athoracsur.2020.03.003DOI Listing
June 2020

Association of aberrant subclavian arteries with aortic pathology and proposed classification system.

J Vasc Surg 2020 11 29;72(5):1534-1543. Epub 2020 Mar 29.

Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif. Electronic address:

Objective: Aberrant subclavian artery (aSCA) is a rare anatomic variant whose association with other aortic branch variations and aortic pathology has yet to be established. Knowledge of such an association could be relevant to recommendations for screening and awareness as associated variations are important for operative planning. We describe the incidence of aSCA variations, its association with aortic pathology, and a proposed classification system.

Methods: The thoracic cross-sectional imaging database at Keck Hospital of the University of Southern California from 2006 to 2018 was queried for presence of aSCA. Studies were evaluated for aSCA laterality, variant anatomy, and aortic and branch vessel disease. Medical records were reviewed for associated symptoms and diagnoses. The primary outcome was association of aSCA with aortic pathology (aneurysm or dissection). Secondary outcomes were comparison of right and left aSCA, comparison between the sexes, and creation of a proposed classification system.

Results: Of 98,580 axial imaging studies, 810 studies (0.82%) were identified with aSCA in 312 unique patients. Right aSCA made up the majority of cases (90.1%). All aSCAs had a retroesophageal course. Kommerell's diverticulum (KD) was present in 184 (59%) with an average diameter of 1.67 cm (range, 1.2-3.3 cm). KD was more frequent (84% vs 56%; P = .0003) and larger (2.05 cm vs 1.61 cm; P < .0001) in left aSCA patients. When present, KD was more often symptomatic in left aSCA compared with right aSCA (77.4% vs 49.1%; P = .005). Dysphagia, chest pain, reflux, and asthma were all more common in left aSCA patients. KD was also more common in men (73.3% vs 50%; P < .0001) and larger in men (1.81 cm vs 1.54 cm; P < .0001) but with no difference in symptoms between sexes. Our proposed classification system based on aortic arch branching is as follows: type 1, left arch with right aSCA (59.9%); type 2, left arch with common carotid trunk and right aSCA (30.1%); type 3, right arch with left aSCA (9.6%); and type 4, right arch with common carotid trunk and left aSCA (0.3%). Subtypes describe the right vertebral artery (RVA) and left vertebral artery (LVA) origin: subclavian (s, RVA 90.1%, LVA 96.8%), carotid (c, RVA 9.6%, LVA 0.3%), or arch (a, RVA 0.3%, LVA 2.9%). Overall, 9.9% (31/312) had associated aortic pathology, although the study was underpowered to detect a difference between right aSCA and left aSCA (9.3% vs 16.1%; P = .213). Type 3 and type 4 arches more often have associated aortic pathology, KD, and symptoms.

Conclusions: aSCAs are frequently symptomatic and commonly associated with aortic dissection and aneurysm. Our proposed classification scheme depicts all four aSCA arch variants and accounts for vertebral artery origin variation. These variants are common, and vertebral anatomy can differ greatly. Knowledge of these anatomic variations is critical to planning for endovascular and open repair of aortic arch pathology.
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http://dx.doi.org/10.1016/j.jvs.2020.01.042DOI Listing
November 2020

Meaningful Consent From a Willfully Noninformed Patient.

Ann Thorac Surg 2019 12;108(6):1614-1615

Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1016/j.athoracsur.2019.08.012DOI Listing
December 2019

Fortification of Preservation Solution With Nitroprusside Does Not Alter Lung Allograft Survival in Clinical Human Lung Transplantation.

Ochsner J 2019 ;19(3):235-240

Division of Cardiothoracic Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA.

Nitric oxide improves gas exchange following primary lung allograft dysfunction. Nitroprusside, a potent nitric oxide donor, has reduced reperfusion injury and improved oxygenation in experimental lung transplantation. We sought to study the effect on lung allograft outcomes of fortifying the preservation solution with nitroprusside. We conducted a single-center clinical study of 46 consecutive lung recipients between 1998 and 2000: 24 patients received donor organs preserved in modified Euro-Collins solution with prostaglandin E1 (PGE1) (control group), and 22 patients received organs preserved in modified Euro-Collins with PGE1 and nitroprusside (NP group). The primary endpoint was overall survival. Baseline characteristics were similar between the groups except for a significantly longer graft ischemic time in the NP group vs the control group (253.3 ± 52 vs 225.3 ± 41 minutes, respectively, =0.04). No significant differences were found in partial pressure arterial oxygen to fraction inspired oxygen ratio at ≤48 hours, primary graft dysfunction, or bronchiolitis obliterans-free days. Overall survival at 1, 3, and 5 years was 89%, 73%, and 63% in the control group and 76%, 38%, and 23% in the NP group. Log-rank survival analysis showed that the NP group had a significantly increased risk of mortality (=0.034) compared to the control group. : The addition of nitroprusside to the lung transplant perfusate in this clinical trial did not improve survival; however, a large randomized trial would likely reduce confounding ischemia times and increase the power of the study.
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http://dx.doi.org/10.31486/toj.19.0027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6735598PMC
January 2019

Invited Commentary.

Ann Thorac Surg 2019 11 27;108(5):1381-1382. Epub 2019 Jun 27.

Department of Surgery, Keck School of Medicine of USC, Los Angeles, California.

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http://dx.doi.org/10.1016/j.athoracsur.2019.05.017DOI Listing
November 2019

Anatomic suitability for "off-the-shelf" thoracic single side-branched endograft in patients with type B aortic dissection.

J Vasc Surg 2019 12 24;70(6):1776-1781. Epub 2019 Jun 24.

Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck Medical Center at the University of Southern California, Los Angeles, Calif.

Objective: Treatment of type B aortic dissections with thoracic endovascular aortic repair (TEVAR) has been adopted in many centers with the goal of covering the proximal entry tear. Coverage of the left subclavian artery (LSCA) is commonly required to achieve a dissection-free proximal seal zone. A novel thoracic single side-branched (TSSB) endograft device offers a potential off-the-shelf option to achieve total endovascular incorporation of LSCA during zone 2 TEVAR. The aim of this study was to determine what percentage of patients with type B aortic dissection who require zone 2 TEVAR meet the anatomical requirements for this device.

Methods: All consecutive patients undergoing TEVAR for type B aortic dissections at a single institution from 2006 to 2016 were evaluated. Three-dimensional centerline reconstruction of preoperative computed tomography angiography was performed to identify the diameter of the aorta, distances between branch vessels, diameter of the target branch vessel, and location of the primary entry tear. Only patients who met criteria for zone 2 TEVAR were included in the analysis. The primary outcome was percentage of patients that meet all anatomical requirements for TSSB. Individual criteria were evaluated independently, and results were stratified by dissection chronicity.

Results: Eighty-seven patients who underwent TEVAR for Stanford type B aortic dissections were reviewed. Fifty-seven (66%) would have required zone 2 TEVAR. Indications for TEVAR were malperfusion (12), aneurysm (15), persistent pain (22), rupture (3), uncontrolled hypertension (5), and other (3). Mean follow-up was 19 months (range, 1-72 months). Only 16 of the 57 patients (28%) met all the requirements for anatomic suitability. The primary contributor was that only 49% of patients had sufficient length between arch branches to prevent coverage of a proximal branch.

Conclusions: Although the new TSSB device can allow for a more proximal seal zone and eliminate the need for open aortic arch debranching, only 28% of patients with type B dissection who required zone 2 TEVAR met all the anatomic requirements for this device. Future devices will need to account for the short distance between the left carotid and LSCA to be more broadly applicable.
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http://dx.doi.org/10.1016/j.jvs.2019.04.461DOI Listing
December 2019

The ring of fire: Nuances in the surgical management of mitral annular calcification.

J Thorac Cardiovasc Surg 2019 02 10;157(2):570-571. Epub 2018 Oct 10.

Division of Cardiothoracic Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.

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http://dx.doi.org/10.1016/j.jtcvs.2018.09.090DOI Listing
February 2019

Postoperative Serum Troponin Trends in Infants Undergoing Cardiac Surgery.

Semin Thorac Cardiovasc Surg 2019 6;31(2):244-251. Epub 2018 Sep 6.

Division of Cardiology, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital of Los Angeles, Los Angeles, California; Department of Pediatrics, University of Southern California, Los Angeles, California.

Troponin-I (TN-I) levels are elevated following pediatric cardiac surgery with speculation that particular patterns may have prognostic significance. There is lack of procedure-specific data regarding postoperative TN-I levels in infants undergoing cardiac surgery. We hypothesized that TN-I elevation varies with type of surgery and persistent elevation predicts poor prognosis. We prospectively measured serial TN-I levels (preoperatively, 4, 8, 12, 24, and 48 hours postoperatively) in 90 infants (age < 1 year) undergoing cardiac surgery: off cardiopulmonary bypass (CPB) (n = 15), on CPB (n = 43), and on CPB with ventricular incision (CPB with ventricular incision; n = 32). All patients had undetectable baseline TN-I levels. The area under the curve of TN-I levels over the 48-hour period was significantly different among the surgical groups (P < 0.002), and highest in patients with CPB with ventricular incision. Generally, TN-I levels peaked by 4 hours after surgery and returned to near-normal levels within 48 hours. A persistent TN-I rise beyond 8 hours after surgery was a strong predictor of postoperative hypoperfusion injury (defined as a composite endpoint of end-organ injury resulting from inadequate perfusion, odds ratio 21.5; P = 0.001) and mortality (30% in those with persistently high TN-I, compared with 3.5% in the remaining patients; P < 0.001), independent of patient age, anatomy and/or complexity of surgery, and level of postoperative support. Our data provide benchmark values for TN-I levels following cardiac surgery in infants. Extent of TN-I elevation correlates with type of surgery. Persistent TN-I elevation beyond 8 hours after surgery is strongly associated with postoperative hypoperfusion injury and mortality.
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http://dx.doi.org/10.1053/j.semtcvs.2018.08.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6401339PMC
December 2019

Videoesophagography Endoscopy for Prediction of Intraoperative Hiatal Hernia Size.

Am Surg 2018 Mar;84(3):387-391

Magnetic sphincter augmentation is a novel surgical procedure for gastroesophageal reflux disease. Limited dissection at the hiatus is one of the benefits of the procedure, but makes precise and accurate preoperative assessment of even small hiatal hernia critical. Retrospective cohort study of 136 patients having undergone both endoscopy (EGD) and videoesophagography followed by operative assessment for hiatal hernia during magnetic sphincter augmentation. The objective of the study is to determine which preoperative modality more accurately predicts operative hiatal hernia size. Videoesophagography underestimated operative measurement by 0.37 ± 1.41 cm (P = 0.003) and was less accurate in predicting intraoperative hiatal hernia size than EGD on linear regression analysis (β -0.729, SE 0.057, P < 0.001). EGD was less accurate at predicting hiatal hernia size as patient age increased (β -0.018, SE 0.007, P = 0.014) and with larger hernias (β -0.615, standard error (SE) 0.067, P < 0.001); however, endoscopic measurements did not differ significantly from intraoperative measurements (0.93 ± 1.23 cm vs 1.12 ± 1.43 cm, P = 0.12). EGD better predicts the size of small hiatal hernia measured during subsequent laparoscopic surgery.
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March 2018

Resection of Metastatic Hepatocellular Carcinoma in the Ventricular Septum Causing Left Ventricular Outflow Tract Obstruction.

Ann Thorac Surg 2018 03;105(3):e107-e108

Division of Cardiothoracic Surgery, CardioVascular Thoracic Institute, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Isolated cardiac involvement of recurrent metastatic hepatocellular carcinoma (HCC) is extremely rare. We report a patient with left ventricular outflow tract (LVOT) obstruction due to isolated recurrent HCC involving the interventricular septum (IVS). A ventriculotomy with resection of the tumor and patch repair of the IVS was performed with successful relief of LVOT obstruction. The patient was discharged home 6 days later symptom-free.
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http://dx.doi.org/10.1016/j.athoracsur.2017.09.052DOI Listing
March 2018

Invited Commentary.

Ann Thorac Surg 2018 04 23;105(4):1157-1159. Epub 2017 Dec 23.

Department of Cardiothoracic Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo St, Ste 4300, Los Angeles, CA 90033. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2017.12.001DOI Listing
April 2018

Do not underestimate the tricuspid valve.

J Surg Res 2018 01 27;221:222-223. Epub 2017 Sep 27.

Division of Cardiothoracic Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, California. Electronic address:

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http://dx.doi.org/10.1016/j.jss.2017.08.015DOI Listing
January 2018

A Prospective Multi-Institutional Cohort Study of Mediastinal Infections After Cardiac Operations.

Ann Thorac Surg 2018 Feb 7;105(2):461-468. Epub 2017 Dec 7.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California.

Background: Mediastinal infections are a potentially devastating complication of cardiac operations. This study analyzed the frequency, risk factors, and perioperative outcomes of mediastinal infections after cardiac operations.

Methods: In 2010, 5,158 patients enrolled in a prospective study evaluating infections after cardiac operations and their effect on readmissions and mortality for up to 65 days after the procedure. Clinical and demographic characteristics, operative variables, management practices, and outcomes were compared for patients with and without mediastinal infections, defined as deep sternal wound infection, myocarditis, pericarditis, or mediastinitis.

Results: There were 43 mediastinal infections in 41 patients (cumulative incidence, 0.79%; 95% confidence interval [CI] 0.60% to 1.06%). Median time to infection was 20.0 days, with 65% of infections occurring after the index hospitalization discharge. Higher body mass index (hazard ratio [HR] 1.06; 95% CI, 1.01 to 1.10), higher creatinine (HR, 1.25; 95% CI, 1.13 to 1.38), peripheral vascular disease (HR, 2.47; 95% CI, 1.21 to 5.05), preoperative corticosteroid use (HR, 3.33; 95% CI, 1.27 to 8.76), and ventricular assist device or transplant surgery (HR, 5.81; 95% CI, 2.36 to 14.33) were associated with increased risk of mediastinal infection. Postoperative hyperglycemia (HR, 3.15; 95% CI, 1.32 to 7.51) was associated with increased risk of infection in nondiabetic patients. Additional length of stay attributable to mediastinal infection was 11.5 days (bootstrap 95% CI, 1.88 to 21.11). Readmission rates and mortality were five times higher in patients with mediastinal infection than in patients without mediastinal infection.

Conclusions: Mediastinal infection after a cardiac operation is associated with substantial increases in length of stay, readmissions, and death. Reducing these infections remains a high priority, and improving post-operative glycemic management may reduce their risk in patients without diabetes.
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http://dx.doi.org/10.1016/j.athoracsur.2017.06.078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5877809PMC
February 2018

Secondary surgical-site infection after coronary artery bypass grafting: A multi-institutional prospective cohort study.

J Thorac Cardiovasc Surg 2018 04 6;155(4):1555-1562.e1. Epub 2017 Dec 6.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.

Objective: To analyze patient risk factors and processes of care associated with secondary surgical-site infection (SSI) after coronary artery bypass grafting (CABG).

Methods: Data were collected prospectively between February and October 2010 for consenting adult patients undergoing CABG with saphenous vein graft (SVG) conduits. Patients who developed a deep or superficial SSI of the leg or groin within 65 days of CABG were compared with those who did not develop a secondary SSI.

Results: Among 2174 patients identified, 65 (3.0%) developed a secondary SSI. Median time to diagnosis was 16 days (interquartile range 11-29) with the majority (86%) diagnosed after discharge. Gram-positive bacteria were most common. Readmission was more common in patients with a secondary SSI (34% vs 17%, P < .01). After adjustment, an open SVG harvest approach was associated with an increased risk of secondary SSI (adjusted hazard ratio [HR], 2.12; 95% confidence interval [CI], 1.28-3.48). Increased body mass index (adjusted HR, 1.08, 95% CI, 1.04-1.12) and packed red blood cell transfusions (adjusted HR, 1.13; 95% CI, 1.05-1.22) were associated with a greater risk of secondary SSI. Antibiotic type, antibiotic duration, and postoperative hyperglycemia were not associated with risk of secondary SSI.

Conclusions: Secondary SSI after CABG continues to be an important source of morbidity. This serious complication often occurs after discharge and is associated with open SVG harvesting, larger body mass, and blood transfusions. Patients with a secondary SSI have longer lengths of stay and are readmitted more frequently.
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http://dx.doi.org/10.1016/j.jtcvs.2017.10.078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5860945PMC
April 2018
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