Publications by authors named "Nicholas R Teman"

55 Publications

Progression to Transplant under New Heart Allocation System: The Society of Thoracic Surgeons Intermacs Database.

Ann Thorac Surg 2021 Aug 10. Epub 2021 Aug 10.

Division of Cardiovascular Medicine, University of Virginia, Charlottesville, VA.

Background: Under the new heart allocation policy, durable left ventricular assist devices receive lower priority on the transplant list. We sought to identify predictors of successful heart transplant after durable device implant as a means to inform patient care in the current era.

Methods: All patients (n=25,164) undergoing primary durable left ventricular device implant in the Society of Thoracic Surgeons Intermacs database (2010-2019) were evaluated. Patients identified as bridge to transplant (BTT, n=5242) or bridge to candidacy (BTC, n=6248) were analyzed with the endpoint of transplant before (n=10,588) and after (n=902) the change in the heart allocation system on October 18, 2018. Multivariable hazard modeling was used to assess risk-adjusted time to event associations.

Results: Of 11,490 patients, 45.5% progressed to transplant, (BTT 53.0%, BTC 36.6%), most by 14 months post LVAD. Under the new allocation system, progression to transplant was significantly lower at 14 months (18.6% vs. 34.8%, p<0.001). Factors associated with successful bridge to transplant before the allocation change included BTT status, white race and married. Under the new allocation system, BTT status (HR 1.79 95% CI 1.19-2.69, p<0.0054) remained a positive predictor, while blood type O (HR 0.43, 95% CI 0.28-0.65, p<0.0001) remained a negative predictor.

Conclusions: Despite having priority in the previous allocation system, less than half of BTT/BTC patients progressed to transplant. Under the current system, these numbers are further reduced. Heart teams should consider the implications of longer wait times with a durable left ventricular assist device when determining the optimal bridging strategy.
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http://dx.doi.org/10.1016/j.athoracsur.2021.07.020DOI Listing
August 2021

Venoarterial Extracorporeal Membrane Oxygenation for Acute Massive Pulmonary Embolism: a Meta-Analysis and Call to Action.

J Cardiovasc Transl Res 2021 Jul 19. Epub 2021 Jul 19.

Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA.

Venoarterial extracorporeal membrane oxygenation (ECMO) has been used to treat acute massive pulmonary embolism (PE) patients. However, the incremental benefit of ECMO to standard therapy remains unclear. Our meta-analysis objective is to compare in-hospital mortality in patients treated for acute massive PE with and without ECMO. The National Library of Medicine MEDLINE (USA), Web of Science, and PubMed databases from inception through October 2020 were searched. Screening identified 1002 published articles. Eleven eligible studies were identified, and 791 patients with acute massive PE were included, of whom 270 received ECMO and 521 did not. In-hospital mortality was not significantly different between patients treated with vs. without ECMO (OR = 1.24 [95% CI, 0.63-2.44], p = 0.54). However, these findings were limited by significant study heterogeneity. Additional research will be needed to clarify the role of ECMO in massive PE treatment. In-hospital mortality for patients with acute massive pulmonary embolism was not significantly different (OR of 1.24, p = 0.54) between those treated with and without venoarterial ECMO.
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http://dx.doi.org/10.1007/s12265-021-10158-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8288068PMC
July 2021

Commentary: 4A's for effort: Diagnosing delirium after cardiac surgery.

J Thorac Cardiovasc Surg 2021 Jun 1. Epub 2021 Jun 1.

Division of Cardiac Surgery, University of Virginia Health System, Charlottesville, Va. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.05.038DOI Listing
June 2021

Commentary: Heparin-Induced Thrombocytopenia - Getting Ahead of the Game.

Semin Thorac Cardiovasc Surg 2021 Jun 4. Epub 2021 Jun 4.

Division of Cardiac Surgery, University of Virginia Health System, Charlottesville, Virginia. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2021.05.021DOI Listing
June 2021

Commentary: Cardiac surgery in COVID patients: Figuring it out as we go.

J Thorac Cardiovasc Surg 2021 08 27;162(2):e374-e375. Epub 2021 Apr 27.

Division of Cardiac Surgery, University of Virginia Health System, Charlottesville, Va. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.04.058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118719PMC
August 2021

Prediction of Prolonged Intensive Care Unit Length of Stay Following Cardiac Surgery.

Semin Thorac Cardiovasc Surg 2021 Mar 6. Epub 2021 Mar 6.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Intensive care unit (ICU) costs comprise a significant proportion of the total inpatient charges for cardiac surgery. No reliable method for predicting intensive care unit length of stay following cardiac surgery exists, making appropriate staffing and resource allocation challenging. We sought to develop a predictive model to anticipate prolonged ICU length of stay (LOS). All patients undergoing coronary artery bypass grafting (CABG) and/or valve surgery with a Society of Thoracic Surgeons (STS) predicted risk score were evaluated from an institutional STS database. Models were developed using 2014-2017 data; validation used 2018-2019 data. Prolonged ICU LOS was defined as requiring ICU care for at least three days postoperatively. Predictive models were created using lasso regression and relative utility compared. A total of 3283 patients were included with 1669 (50.8%) undergoing isolated CABG. Overall, 32% of patients had prolonged ICU LOS. Patients with comorbid conditions including severe COPD (53% vs 29%, P < 0.001), recent pneumonia (46% vs 31%, P < 0.001), dialysis-dependent renal failure (57% vs 31%, P < 0.001) or reoperative status (41% vs 31%, P < 0.001) were more likely to experience prolonged ICU stays. A prediction model utilizing preoperative and intraoperative variables correctly predicted prolonged ICU stay 76% of the time. A preoperative variable-only model exhibited 74% prediction accuracy. Excellent prediction of prolonged ICU stay can be achieved using STS data. Moreover, there is limited loss of predictive ability when restricting models to preoperative variables. This novel model can be applied to aid patient counseling, resource allocation, and staff utilization.
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http://dx.doi.org/10.1053/j.semtcvs.2021.02.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8419201PMC
March 2021

Early Versus Delayed Pacemaker for Heart Block After Valve Surgery: A Cost-Effectiveness Analysis.

J Surg Res 2021 03 3;259:154-162. Epub 2020 Dec 3.

Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia.

Background: A significant percentage of patients who acutely develop high-grade atrioventricular block after valve surgery will ultimately recover, yet the ability to predict recovery is limited. The purpose of this analysis was to evaluate the cost-effectiveness of two different management strategies for the timing of permanent pacemaker implantation for new heart block after valve surgery.

Methods: A cost-effectiveness model was developed using costs and probabilities of short- and long-term complications of pacemaker placement, short-term atrioventricular node recovery, intensive care unit stays, and long-term follow-up. We aggregated the total expected cost and utility of each option over a 20-y period. Quality-adjusted survival with a pacemaker was estimated from the literature and institutional patient-reported outcomes. Primary decision analysis was based on an expected recovery rate of 36.7% at 12 d with timing of pacemaker implantation: early placement (5 d) versus watchful waiting for 12 d.

Results: A strategy of watchful waiting was more costly ($171,798 ± $45,695 versus $165,436 ± $52,923; P < 0.0001) but had a higher utility (9.05 ± 1.36 versus 8.55 ± 1.33 quality-adjusted life years; P < 0.0001) than an early pacemaker implantation strategy. The incremental cost-effectiveness ratio of watchful waiting was $12,724 per quality-adjusted life year. The results are sensitive to differences in quality-adjusted survival and rates of recovery of atrioventricular node function.

Conclusions: Watchful waiting for pacemaker insertion is a cost-effective management strategy compared with early placement for acute atrioventricular block after valve surgery. Although this is cost-effective from a population perspective, clinical risk scores predicting recovery will aid in personalized decision-making.
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http://dx.doi.org/10.1016/j.jss.2020.11.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897291PMC
March 2021

Commentary: How Much is Too Much: The Role of Oral Antibiotics Following Completion of Intravenous Therapy for Infective Endocarditis.

Authors:
Nicholas R Teman

Semin Thorac Cardiovasc Surg 2021 Autumn;33(3):699-700. Epub 2020 Nov 7.

University of Virginia Health System, Division of Cardiac Surgery, Charlottesville, Virginia. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2020.10.015DOI Listing
November 2020

Endovascular repair of left ventricular assist device outflow graft defect.

J Card Surg 2020 Nov 24;35(11):3235-3238. Epub 2020 Sep 24.

Division of Cardiac Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.

Outflow graft complications after left ventricular assist device placement are infrequent but highly morbid. In this case report, we describe endovascular repair of multiple outflow graft defects with external hemorrhage in a complex patient using overlapping stent grafts. This approach successfully stopped the outflow graft hemorrhage and temporized the patient for subsequent cardiac transplantation.
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http://dx.doi.org/10.1111/jocs.15005DOI Listing
November 2020

Minimally Invasive vs Open Coronary Surgery: A Multi-Institutional Analysis of Cost and Outcomes.

Ann Thorac Surg 2021 05 19;111(5):1478-1484. Epub 2020 Sep 19.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.

Background: Limited multi-institutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raised concern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort.

Methods: Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis.

Results: Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P = .383) or major morbidity (7.9% open vs 7.2% MICS CABG, P = .795). However, open CABG patients received more blood products (22.2% vs 12.2%, P = .013), and had longer intensive care unit (45 vs 30 hours, P = .049) as well as hospital lengths of stay (7 vs 6 days, P = .005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P < .001) compared with MICS CABG.

Conclusions: Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.136DOI Listing
May 2021

How Big Is Too Big?: Donor Severe Obesity and Heart Transplant Outcomes.

Circ Heart Fail 2020 10 16;13(10):e006688. Epub 2020 Sep 16.

Department of Surgery, University of Virginia Health System, Charlottesville, VA (E.D.K., J.P.B., J.H.M., M.R.T., G.A., L.T.Y.).

Background: As the population becomes increasingly obese, so does the pool of potential organ donors. We sought to investigate the impact of donors with body mass index ≥40 (severe obesity) on heart transplant outcomes.

Methods: Single-organ first-time adult heart transplants from 2003 to 2017 were evaluated from the United Network for Organ Sharing database and stratified by donor severe obesity status (body mass index ≥40). Demographics were compared, and univariate and risk-adjusted analyses evaluated the relationship between severe obesity and short-term outcomes and long-term mortality. Further analysis evaluated the prevalence of severe obesity within the pool of organ donation candidates.

Results: A total of 26 532 transplants were evaluated, of which 939 (3.5%) had donors with body mass index ≥40, with prevalence increasing over time (2.2% in 2003, 5.3% in 2017). Severely obese donors more likely had diabetes mellitus (10.4% versus 3.1%, <0.01) and hypertension (33.3% versus 14.8%, <0.01), and 67.4% were size mismatched (donor weight >130% of recipient). Short-term outcomes were similar, including 1-year survival (10.6% versus 10.7%), with no significant difference in unadjusted and risk-adjusted long-term survival (log-rank =0.67, hazard ratio, 0.928, =0.30). Organ donation candidates also exhibited an increase in severe obesity over time, from 3.5% to 6.8%, with a lower proportion of hearts from severely obese donors being transplanted (19.5% versus 31.6%, <0.01).

Conclusions: Donor severe obesity was not associated with adverse post-transplant outcomes. Increased evaluation of hearts from obese donors, even those with body mass index ≥40, has the potential to expand the critically low donor pool.
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http://dx.doi.org/10.1161/CIRCHEARTFAILURE.119.006688DOI Listing
October 2020

A 30-year analysis of National Institutes of Health-funded cardiac transplantation research: Surgeons lead the way.

J Thorac Cardiovasc Surg 2020 Jul 5. Epub 2020 Jul 5.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va. Electronic address:

Objectives: Obtaining National Institutes of Health funding for heart transplant research is becoming increasingly difficult, especially for surgeons. We sought to determine the impact of National Institutes of Health-funded cardiac transplantation research over the past 30 years.

Methods: National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Results was queried for R01s using 10 heart transplant-related terms. Principal Investigator, total grant funding amount, number of publications, and citations of manuscripts were collected. A citation-based Grant Impact Metric was assigned to each grant: sum of citations for each manuscript normalized by the funding of the respective grant (per $100K). The department and background degree(s) (MD, PhD, MD/PhD) for each funded Principal Investigator were identified from institutional faculty profiles.

Results: A total of 321 cardiac transplantation R01s totaling $723 million and resulting in 6513 publications were analyzed. Surgery departments received more grants and more funding dollars to study cardiac transplantation than any other department (n = 115, $249 million; Medicine: n = 93, $208 million; Pathology: 26, $55 million). Surgeons performed equally well compared with all other Principal Investigators with respect to Grant Impact Metric (15.1 vs 20.6; P = .19) and publications per $1 million (7.5 vs 6.8; P = .75). Finally, all physician-scientists (MDs) have a significantly higher Grant Impact Metric compared with nonclinician researchers (non-MDs) (22.3 vs 16.3; P = .028).

Conclusions: Surgeon-scientists are equally productive and impactful compared with nonsurgeons despite decreasing funding rates at the National Institutes of Health and greater pressure from administrators to increase clinical productivity.
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http://dx.doi.org/10.1016/j.jtcvs.2020.06.076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7782209PMC
July 2020

Reply to Bernard.

Eur J Cardiothorac Surg 2020 11;58(5):1103-1104

Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA.

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http://dx.doi.org/10.1093/ejcts/ezaa202DOI Listing
November 2020

Long-term Implications of Tracheostomy in Cardiac Surgery Patients: Decannulation and Mortality.

Ann Thorac Surg 2021 02 30;111(2):594-599. Epub 2020 Jun 30.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.

Background: The long-term implications of tracheostomy in cardiac surgical patients are largely unknown. We sought to investigate outcomes including decannulation and long-term mortality in a population of post-cardiac surgery patients.

Methods: All patients undergoing cardiac surgery at a single institution between 1997 and 2016 were evaluated for postoperative tracheostomy placement, time to decannulation, and mortality. Patients were stratified by tracheostomy placement, as well as by successful decannulation for comparison. Kaplan-Meier analysis identified time to decannulation and mortality and a Fine-Gray's competing risk regression, accounting for mortality, identified predictors of time to decannulation.

Results: Of 14,600 total cardiac surgery patients, only 309 required tracheostomy. Patients with tracheostomy had high rates of perioperative comorbidities, including 60% with heart failure and 24% with postoperative stroke. Tracheostomy patients had high short-term and long-term mortality, with a median survival of 152 days, 1-year survival of 41%, and 5-year survival of 29.1%. Patients remained with tracheostomy in place for a median of 59 days, with a 1-year decannulation rate of 80% in living patients. Patients with older age (hazard ratio 0.98, P = .01), chronic lung disease (hazard ratio 0.66, P = .03), and preoperative or postoperative dialysis (hazard ratio 0.45, P < .01) were less likely to have their tracheostomy removed.

Conclusions: Tracheostomy is associated with poor long-term survival of cardiac surgery patients. However, patients who do survive have a short duration of tracheostomy with almost all surviving patients eventually decannulated. This finding provides valuable information for pre-procedural counseling for these high-risk patients and their families.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.052DOI Listing
February 2021

Adoption of a dedicated multidisciplinary team is associated with improved survival in acute pulmonary embolism.

Respir Res 2020 Jun 22;21(1):159. Epub 2020 Jun 22.

Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, USA.

Background: Acute pulmonary embolism remains a significant cause of mortality and morbidity worldwide. Benefit of recently developed multidisciplinary PE response teams (PERT) with higher utilization of advanced therapies has not been established.

Methods: To evaluate patient-centered outcomes and cost-effectiveness of a multidisciplinary PERT we performed a retrospective analysis of 554 patients with acute PE at the university of Virginia between July 2014 and June 2015 (pre-PERT era) and between April 2017 through October 2018 (PERT era). Six-month survival, hospital length-of-stay (LOS), type of PE therapy, and in-hospital bleeding were assessed upon collected data.

Results: 317 consecutive patients were treated for acute PE during an 18-month period following institution of a multidisciplinary PE program; for 120 patients PERT was activated (PA), the remaining 197 patients with acute PE were considered as a separate, contemporary group (NPA). The historical, comparator cohort (PP) was composed of 237 patients. These 3 groups were similar in terms of baseline demographics, comorbidities and risk, as assessed by the Pulmonary Embolism Severity Index (PESI). Patients in the historical cohort demonstrated worsened survival when compared with patients treated during the PERT era. During the PERT era no statistically significant difference in survival was observed in the PA group when compared to the NPA group despite significantly higher severity of illness among PA patients. Hospital LOS was not different in the PA group when compared to either the NPA or PP group. Hospital costs did not differ among the 3 cohorts. 30-day re-admission rates were significantly lower during the PERT era. Rates of advanced therapies were significantly higher during the PERT era (9.1% vs. 2%) and were concentrated in the PA group (21.7% vs. 1.5%) without any significant rise in in-hospital bleeding complications.

Conclusions: At our institution, all-cause mortality in patients with acute PE has significantly and durably decreased with the adoption of a PERT program without incurring additional hospital costs or protracting hospital LOS. Our data suggest that the adoption of a multidisciplinary approach at some institutions may provide benefit to select patients with acute PE.
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http://dx.doi.org/10.1186/s12931-020-01422-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7310489PMC
June 2020

History of Serious Mental Illness Is a Predictor of Morbidity and Mortality in Cardiac Surgery.

Ann Thorac Surg 2021 01 13;111(1):109-116. Epub 2020 Jun 13.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Serious mental illness (SMI), defined as a mental disorder causing functional impairment, affects 9.8 million Americans. SMI correlates with earlier onset, more extensive cardiac disease, and reduced life expectancy by 25 years. The impact of SMI on patients undergoing cardiac surgery has not been extensively studied. We hypothesized that patients with SMI have worse cardiac surgery outcomes.

Methods: Using our institution's Society of Thoracic Surgeons database of 16,781 cardiac operations (2002-2017), a total of 1445 (8.7%) patients with SMI were identified and stratified into anxiety, mood disorders, and psychosis. The risk-adjusted impact on morbidity and mortality were evaluated using multivariable regression.

Results: Patients with SMI were more often female patients, were younger, and had more comorbid disease. SMI patients were more likely to have had previous cardiac surgery and require urgent or emergent procedures (both P < .05). Among specific SMI diagnoses, patients with psychosis had worse outcomes compared with the general population, with higher operative mortality (9.1% vs 4.2%; P = .001), major morbidity (30.4% vs 15.8%; P < .0001), and cost ($50,211 vs $38,820; P < .001). After multivariable risk adjustment, SMI and psychosis remained independently associated with composite mortality and major morbidity (odds ratio, 1.21; P = .012; and odds ratio, 1.68; P = .003, respectively).

Conclusions: SMI is independently associated with morbidity and mortality after cardiac surgery. SMI patients, especially the subset with psychosis, are complicated, high-risk, and resource-consuming. Refined strategies to reduce postoperative complications and improve care coordination are necessary in this population.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.118DOI Listing
January 2021

Gastrointestinal Complications After Cardiac Surgery: Highly Morbid but Improving Over Time.

J Surg Res 2020 10 5;254:306-313. Epub 2020 Jun 5.

Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Gastrointestinal complications after cardiac surgery are associated with high morbidity and mortality. We sought to determine the granular impact of individual gastrointestinal complications after cardiac surgery and assess contemporary outcomes.

Materials And Methods: Patients undergoing cardiac surgery from 2010 to 2017 (6070 patients) were identified from an institutional Society of Thoracic Surgeons database. Records were paired with institutional data assessing gastrointestinal complications and cost. Patients were stratified by early (2010-2013) and current (2014-2017) eras.

Results: A total of 280 (4.6%) patients experienced gastrointestinal complications including Clostridiumdifficile infection (94, 33.6%), gastrointestinal bleed (86, 30.7%), hepatic failure (66, 23.6%), prolonged ileus (59, 21.1%), mesenteric ischemia (47, 16.8%), acute cholecystitis (17, 6.0%), and pancreatitis (14, 5.0%). Gastrointestinal complications were associated with higher rates of early postoperative major morbidity [206 (73.6%) versus 773 (13.4%), P < 0.0001], mortality [78 (27.9%) versus 161 (2.8%), P < 0.0001], length of stay (23 versus 6 d, P < 0.0001), and discharge to a facility [115 (41.1%) versus 1395 (24.1%), P < 0.0001]. Patients suffering gastrointestinal complications had worse risk-adjusted long-term survival (hazard ratio: 3.0, P < 0.0001) and higher adjusted cost ($9,173, P = 0.05). Between eras, there was no difference in incidence of gastrointestinal complications [139 (4.4%) versus 141 (4.8%), P = 0.51] or rate of specific complications (all P > 0.05). However, long-term survival increased in modern era (P < 0.0001).

Conclusions: Although incidence of gastrointestinal complications after cardiac surgery has not changed over time, long-term survival has improved. Gastrointestinal complications remain associated with high resource utilization and major morbidity, but patients are now more likely to recover, highlighting the benefit of quality improvement efforts.
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http://dx.doi.org/10.1016/j.jss.2020.02.019DOI Listing
October 2020

Burden of Tricuspid Regurgitation in Patients Undergoing Coronary Artery Bypass Grafting.

Ann Thorac Surg 2021 01 1;111(1):44-50. Epub 2020 Jun 1.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Virginia. Electronic address:

Background: Tricuspid regurgitation (TR) is associated with poor outcomes after cardiac surgery. Guidelines recommend correction of severe TR in patients undergoing left-sided valve surgery but not coronary artery bypass graft surgery (CABG). We sought to evaluate impact of TR on outcomes after CABG.

Methods: All patients (n = 28,027) undergoing CABG in The Society of Thoracic Surgeons (STS) regional database (2011 to 2018) were stratified by TR severity. Primary outcomes included major morbidity or mortality, which were compared using univariate analysis.

Results: Of patients undergoing CABG, 4837 (17%) had mild, 800 (3%) had moderate, and 81 (0.29%) had severe TR. Increased severity was associated with higher rate of preoperative heart failure (none 5162 [23.4%] vs mild 1697 [35%] vs moderate 427 [53%] vs severe 54 [67%], P < .001] and STS predicted risk of mortality (1.0 [0.6 to 1.9) vs 1.4 [0.8 to 2.9] vs 2.8 [1.4 to 5.4] vs 6.2 [2.2 to 11.4], P < .001). Increasing severity was associated with higher postoperative rate of renal failure (426 [1.9%] vs 145 [3%] vs 58 [7.3%] vs 7 [8.6%], P < .001), prolonged ventilation (1652 [7.5%] vs 495 [10.2%] vs 153 [19.1%] vs 22 [27.2%], P < .001), and mortality (344 [1.6%] vs 132 [2.7%] vs 58 [7.3%] vs 9 [11.1%], P < .001). After risk adjustment, mild, moderate, and severe TR remained associated with increased morbidity and mortality (all P < .05).

Conclusions: Increasing TR severity, although independently associated with higher surgical risk, is not accounted for entirely by STS risk calculator. This highlights the importance of TR on operative risk and supports consideration of concurrent tricuspid intervention for patients with significant TR undergoing CABG.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.038DOI Listing
January 2021

Impact of tricuspid regurgitation with and without repair during aortic valve replacement.

J Thorac Cardiovasc Surg 2021 07 19;162(1):44-50.e2. Epub 2020 Feb 19.

Division of Cardiac Surgery, University of Virginia, Charlottesville, Va. Electronic address:

Background: Long-term outcomes of aortic valve replacement (AVR) are worse in patients with tricuspid regurgitation (TR), but the impact of concomitant tricuspid valve intervention remains unclear. The purpose of this study was to determine the effect of tricuspid intervention in patients with TR undergoing AVR.

Methods: Patients undergoing AVR in a regional Society of Thoracic Surgeons database (2001-2017) were stratified by severity of TR and whether or not they underwent concomitant tricuspid intervention. Operative morbidity and mortality were compared between the 2 groups. Further analysis was performed using propensity score-matched pairs.

Results: Among 17,483 patients undergoing AVR, 8984 (51%) had no TR, 7252 (41%) had mild TR, 1060 (6%) had moderate TR, and 187 (1%) had severe TR. Overall, more severe TR was associated with higher morbidity and mortality. Tricuspid intervention was performed in 104 patients (0.6%), including 0.2% of patients with mild TR, 2% of those with moderate TR, and 31% of those with severe TR. In the propensity score-matched analysis, there was not a statistically significant difference in operative mortality between the 2 groups (18% vs 9%; P = .16), but there was significantly higher composite major morbidity (51% vs 26%; P = .006) in the tricuspid intervention group compared with those without surgical TR correction.

Conclusions: Increasing severity of TR is associated with higher rates of morbidity and mortality after AVR. Correction of TR at the time of surgical AVR is not associated with increased operative mortality and has been shown to improve long-term outcomes.
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http://dx.doi.org/10.1016/j.jtcvs.2020.02.033DOI Listing
July 2021

Extracorporeal Membrane Oxygenation in Adults With Sepsis: The Next Frontier?

Authors:
Nicholas R Teman

Ann Thorac Surg 2020 09 28;110(3):878. Epub 2020 Feb 28.

Division of Cardiac Surgery, University of Virginia Health System, PO Box 800679, 1215 Lee St, Charlottesville, VA 22908. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2020.01.038DOI Listing
September 2020

Hospital Variability Drives Inconsistency in Antiplatelet Use After Coronary Bypass.

Ann Thorac Surg 2020 07 11;110(1):13-19. Epub 2020 Feb 11.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Continuation of dual antiplatelet therapy (DAPT) after coronary artery bypass grafting (CABG) after acute myocardial infarction is recommended by current guidelines. We sought to evaluate guideline adherence over time and factors associated with postoperative DAPT within a regional consortium.

Methods: Isolated CABG patients from 2011 to 2017 who had a myocardial infarction within 21 days prior to surgery were included. Patients were stratified by DAPT prescription at discharge and by time period, early (2011-2014) vs late (2015-2017). Hierarchical regressions were then performed to evaluate factors influencing DAPT use after CABG.

Results: A total of 7314 patients were included with an overall rate of DAPT utilization of 31.2% that increased from 29.6% in the early to 33.4% in the late era (P < .01). There was considerable variability in hospital rates of DAPT (range 9.5%-92.1%) and hospital level changes over time (26% increased, 11% decreased, and 63% remained stable). After adjustment for clinical factors, era was not associated with DAPT use but treating hospital remained significantly associated with DAPT use. Other clinical factors associated with increased DAPT utilization included off-pump surgery (odds ratio [OR] 4.48, P < .01) and prior percutaneous coronary intervention (OR 2.02, P < .01), and atrial fibrillation (OR 0.39, P < .01) was associated with decreased utilization.

Conclusions: Dual antiplatelet use has increased between 2011 and 2017, driven primarily by evolving patient demographics. Significant hospital-level variability drives inconsistency in DAPT utilization. Efforts to promote DAPT use for patients treated with CABG after myocardial infarction in concordance with current guidelines should be targeted at the hospital level.
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http://dx.doi.org/10.1016/j.athoracsur.2019.12.064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7306427PMC
July 2020

Outcomes of non-elective coronary artery bypass grafting performed on weekends.

Eur J Cardiothorac Surg 2020 06;57(6):1130-1136

Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA.

Objectives: A weekend effect with increased mortality has previously been reported in surgical patients and those with acute myocardial infarction (MI). We hypothesized that a similar phenomenon may exist in coronary artery bypass grafting (CABG).

Methods: Patients undergoing non-elective isolated CABG (2011-2017) were included from a multicentre regional Society of Thoracic Surgeons database. Patients were stratified by weekend versus weekday operations and further analysed by specific day of the week.

Results: A total of 14 374 patients underwent urgent or emergency isolated CABG with 410 (2.9%) operated on over the weekend. Weekend operations were more often emergency (36.1% vs 5.0%, P < 0.001) and more likely to be in the setting of MI (70.0% vs 51.2%, P < 0.001). Cardiopulmonary bypass times were similar [91 min (71-114) vs 94 min (74-117), P = 0.0749] and the frequency of complete revascularization equivalent (83.4% vs 85.3%, P = 0.284) between weekend and weekday operations. In risk-adjusted analyses, there was no increased odds for mortality in patients operated on over the weekend [odds ratio (OR) 1.07, P = 0.811]; however, there was an increased odds of major morbidity (OR 1.37, P = 0.034). Furthermore, compared with Monday, morbidity increased as the operative day approached the weekend (Tuesday 0.98, P = 0.828; Wednesday 1.07, P = 0.469; Thursday 1.12, P = 0.229; Friday 1.19, P = 0.041; weekend 1.47, P = 0.014).

Conclusions: While patients requiring surgery on the weekend are higher risk, there is no independent effect of weekend surgery on mortality. However, these patients are at increased risk for major morbidity, the causes of which require further investigation.
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http://dx.doi.org/10.1093/ejcts/ezz379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239602PMC
June 2020

Objective measure of learning curves for trainees in cardiac surgery via cumulative sum failure analysis.

J Thorac Cardiovasc Surg 2020 Aug 31;160(2):460-466.e1. Epub 2019 Oct 31.

Department of Surgery, University of Virginia, Charlottesville, Va. Electronic address:

Objectives: Objective measures of cardiac surgery trainee progress are limited despite a push for competency-based assessments. We hypothesized that the cumulative sum failure technique could provide a risk-adjusted, quantitative measure of resident learning curves and competence.

Methods: Records of all coronary artery bypass grafting and valve operations performed by cardiac-track residents from 2007 to 2017 at a single institution were stratified by operative resident. Multivariable regression evaluated the association among resident, case number, and postoperative outcomes. To evaluate performance over time, risk-adjusted cumulative sum failure analysis was performed, taking into account institutional expected values and comparing residents with study-defined "early alert" and "concern" boundaries.

Results: A total of 3937 Society of Thoracic Surgeons Predicted Risk of Mortality cases were evaluated from 19 residents. Observed-to-expected ratios for mortality and combined morbidity-mortality were 0.66 and 0.72, respectively, and each individual resident exhibited better than predicted outcomes (all observed:expected ratios <1). When evaluating cumulative sum failure learning curves, residents exhibited an initial slight increase in complications, followed by improvement and better than expected performance. The "early alert" boundary was crossed by 36.8% of residents at any point in training, with 94.7% of residents under this boundary at the end of training. The higher "concern" boundary was crossed by 2 residents (10.5%), although all residents ended their training below this boundary.

Conclusions: Outcomes for trainee-performed cardiac surgery procedures were excellent, with no association between individual trainees and adverse events. Cumulative sum failure analysis based on postoperative outcomes is a potential tool for objective evaluation of resident proficiency.
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http://dx.doi.org/10.1016/j.jtcvs.2019.09.147DOI Listing
August 2020

Non-vitamin K oral anticoagulant use after cardiac surgery is rapidly increasing.

J Thorac Cardiovasc Surg 2020 11 28;160(5):1222-1231. Epub 2019 Sep 28.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va. Electronic address:

Objective: The prevalence of non-vitamin K oral anticoagulant use after cardiac surgery is unknown, particularly in patients with bioprosthetic valves. We sought to define the contemporary use and short-term safety of non-vitamin K oral anticoagulants after cardiac surgery.

Methods: All patients undergoing bioprosthetic aortic valve replacement, bioprosthetic mitral valve replacement, or isolated coronary artery bypass grafting (2011-2018) were evaluated from a multicenter, regional Society of Thoracic Surgeons database. Patients were stratified by anticoagulant type (non-vitamin K oral anticoagulant vs vitamin K antagonist) and era (early [2011-2014] vs contemporary [2015-2018]).

Results: Of 34,188 patients, 18% (6063) were discharged on anticoagulation, of whom 23% were prescribed non-vitamin K oral anticoagulants. Among those receiving anticoagulation, non-vitamin K oral anticoagulant use has significantly increased from 10.3% to 35.4% in contemporary practice (P < .01). This trend was observed for each operation type (coronary artery bypass grafting 0.86%/year, bioprosthetic aortic valve replacement: 2.15%/year, bioprosthetic mitral valve replacement: 2.72%/year, all P < .01). In patients with postoperative atrial fibrillation receiving anticoagulation, non-vitamin K oral anticoagulant use has increased from 6.3% to 35.4% and 12.3% to 40.3% after bioprosthetic valve replacement and isolated coronary artery bypass grafting, respectively (both P < .01). In patients receiving anticoagulation at discharge, adjusted 30-day mortality (odds ratio, 1.94; P = .12) and reoperation (odds ratio, 0.79; P = .34) rates were not associated with anticoagulant choice, whereas non-vitamin K oral anticoagulant use was associated with an adjusted 0.9-day decrease (P < .01) in postoperative length of stay.

Conclusions: Non-vitamin K oral anticoagulant use after cardiac surgery has dramatically increased since 2011. This trend is consistent regardless of indication for anticoagulation including bioprosthetic valves. Short-term outcomes support their safety in the cardiac surgery setting with shorter postoperative hospital stays. Long-term studies on the efficacy of non-vitamin K oral anticoagulants after cardiac surgery are still necessary.
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http://dx.doi.org/10.1016/j.jtcvs.2019.09.064DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729876PMC
November 2020

Comprehensive National Institutes of Health funding analysis of academic cardiac surgeons.

J Thorac Cardiovasc Surg 2020 06 9;159(6):2326-2335.e3. Epub 2019 Sep 9.

Division of Cardiac Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va. Electronic address:

Objective: To determine trends in National Institutes of Health (NIH) funding for cardiac surgeons, hypothesizing they are at a disadvantage in obtaining funding owing to intensive clinical demands.

Methods: Cardiac surgeons (adult/congenital) currently at the top 141 NIH-funded institutions were identified using institutional websites. The NIH funding history for each cardiac surgeon was queried using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER). Total grant funding, publications, and type was collected. Academic rank, secondary degrees, and fellowship information was collected from faculty pages. Grant productivity was calculated using a validated grant impact metric.

Results: A total of 818 academic cardiac surgeons were identified, of whom 144 obtained 293 NIH grants totaling $458 million and resulting in 6694 publications. We identified strong associations between an institution's overall NIH funding rank and the number of cardiac surgeons, NIH grants to cardiac surgeons, and amount of NIH funding to cardiac surgeons (P < .0001 for all). The majority of NIH funding to cardiac surgeons is concentrated in the top quartile of institutions. Cardiac surgeons had a high conversion rates from K awards (mentored development awards) to R01s (6 of 14; 42.9%). Finally, we demonstrate that the rate of all NIH grants awarded to cardiac surgeons has increased, driven primarily by P and U (collaborative project) grants.

Conclusions: NIH-funded cardiac surgical research has had a significant impact over the last 3 decades. Aspiring cardiac surgeon-scientists may be more successful at top quartile institutions owing to better infrastructure and mentorship.
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http://dx.doi.org/10.1016/j.jtcvs.2019.08.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7546359PMC
June 2020

Impact of Complications After Cardiac Operation on One-Year Patient-Reported Outcomes.

Ann Thorac Surg 2020 01 16;109(1):43-48. Epub 2019 Jul 16.

Division of Thoracic & Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Current reporting on cardiac surgical outcomes focuses on a patient's status at 30 days and lacks long-term meaningful data. The purpose of this study was to determine the impact of complications after cardiac operation on patient-reported outcomes (PROs) at 1 year after surgery.

Methods: All patients undergoing cardiac operation at an academic institution (2014-2015) were contacted 1 year after surgery to obtain vital status, location, and PROs using the validated National Institutes of Health Patient-Reported Outcomes Measurement Information System (NIH-PROMIS). Records were merged with Society of Thoracic Surgeons (STS) data, and multivariate linear regression evaluated the risk-adjusted effects of complications on 1-year PROs.

Results: A total of 782 eligible patients underwent cardiac operation, with PROs data available for 91% of patients alive at 1 year (648 of 716). Mean NIH-PROMIS scores were global physical health (GPH), 48.8 ± 10.2; global mental health (GMH), 51.3 ± 9.5; and physical functioning (PF), 45.5 ± 10.2 (reference score for general adult population, 50 ± 10). Occurrence of an STS Major Morbidity (prolonged ventilation, renal failure, reoperation, stroke, or deep sternal wound infection) significantly reduced 1-year PROs (GPH, 45.4 ± 8.9 [P < .001]; GMH, 48.6 ± 9.5 [P = .01]; PF, 40.9 ± 10.2 [P < .001]). After risk adjustment, incidence of a STS Major Morbidity, prolonged ventilation, or renal failure had a significant adverse effect on 1 or more PRO domains.

Conclusions: Although cardiac surgical patients have PROs scores similar to the general population, complications after cardiac operation continue to negatively influence patient quality of life 1 year after surgery. Use of NIH-PROMIS shows that prolonged ventilation and renal failure have the largest impact on 1-year patient-reported outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2019.05.067DOI Listing
January 2020

Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium.

Clin Appl Thromb Hemost 2019 Jan-Dec;25:1076029619853037

5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients.
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http://dx.doi.org/10.1177/1076029619853037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714903PMC
December 2019

Adenosine 2A Receptor Activation Attenuates Ischemia Reperfusion Injury During Extracorporeal Cardiopulmonary Resuscitation.

Ann Surg 2019 06;269(6):1176-1183

Department of Surgery, University of Virginia, Charlottesville, VA.

Objective: We tested the hypothesis that systemic administration of an A2AR agonist will reduce multiorgan IRI in a porcine model of ECPR.

Summary Background Data: Advances in ECPR have decreased mortality after cardiac arrest; however, subsequent IRI contributes to late multisystem organ failure. Attenuation of IRI has been reported with the use of an A2AR agonist.

Methods: Adult swine underwent 20 minutes of circulatory arrest, induced by ventricular fibrillation, followed by 6 hours of reperfusion with ECPR. Animals were randomized to vehicle control, low-dose A2AR agonist, or high-dose A2AR agonist. A perfusion specialist using a goal-directed resuscitation protocol managed all the animals during the reperfusion period. Hourly blood, urine, and tissue samples were collected. Biochemical and microarray analyses were performed to identify differential inflammatory markers and gene expression between groups.

Results: Both the treatment groups demonstrated significantly higher percent reduction from peak lactate after reperfusion compared with vehicle controls. Control animals required significantly more fluid, epinephrine, and higher final pump flow while having lower urine output than both the treatment groups. The treatment groups had lower urine NGAL, an early marker of kidney injury (P = 0.01), lower plasma aspartate aminotransferase, and reduced rate of troponin rise (P = 0.01). Pro-inflammatory cytokines were lower while anti-inflammatory cytokines were significantly higher in the treatment groups.

Conclusions: Using a novel and clinically relevant porcine model of circulatory arrest and ECPR, we demonstrated that a selective A2AR agonist significantly attenuated systemic IRI and warrants clinical investigation.
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http://dx.doi.org/10.1097/SLA.0000000000002685DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6757347PMC
June 2019

Cost-Effectiveness of Negative Pressure Incision Management System in Cardiac Surgery.

J Surg Res 2019 08 15;240:227-235. Epub 2019 Apr 15.

Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.

Background: Sternal wound infections (SWIs) can be a devastating long-term complication with significant morbidity and health care cost. The purpose of this analysis was to evaluate the cost-effectiveness of negative pressure incision management systems (NPIMS) in cardiac surgery.

Materials And Methods: All cardiac surgery cases at an academic hospital with risk scores available (2009-2017) were extracted from an institutional database (n = 4455). Patients were stratified by utilization of NPIMS, and high risk was defined as above the median. Costs included infection-related readmissions and were adjusted for inflation. Multivariable regression models assessed the risk-adjusted cost of SWI and efficacy of NPIMS use. Cost-effectiveness was modeled using TreeAge Pro using institutional results.

Results: The rate of deep SWI was 0.9% with an estimated cost of $111,175 (P < 0.0001). The rate of superficial SWI was 0.8% at a cost of $7981 (P = 0.08). Risk-adjusted NPIMS use was not significantly associated with reduced SWI (OR 1.2, P = 0.62) and thus not cost-effective. However, in the high-risk cohort with an OR 0.84 (P = 0.72) and SWI rate of 2.3%, NPIMS use cost $205 per patient with an incremental cost-effectiveness ratio of $179,092. Therefore, NPIMS is estimated to be cost-effective with a deep SWI rate over 1.3% or improved efficacy (OR < 0.83).

Conclusions: SWIs are extremely expensive complications with estimates of $111,175 for deep yet only $7981 for superficial. Although NPIMS was not cost-effective for SWI prevention as currently utilized, a protocol for use on patients with a higher risk of sternal infection could be cost-effective.
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http://dx.doi.org/10.1016/j.jss.2019.02.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6536336PMC
August 2019

Outcomes After Acute Type A Aortic Dissection in Patients With Prior Cardiac Surgery.

Ann Thorac Surg 2019 09 2;108(3):708-713. Epub 2019 Apr 2.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Limited prior studies suggest patients with acute type A aortic dissection (ATAAD) and prior cardiac surgery are at increased risk for major complications compared with those without a prior sternotomy. We sought to investigate the impact of prior cardiac surgery on ATAAD outcomes across a multicenter regional consortium.

Methods: Patients undergoing surgical intervention for ATAAD in a regional Society of Thoracic Surgeons database between 2002 and 2017 were stratified by prior cardiac surgery (reoperative) status. Demographics, operative characteristics, outcomes and cost data were compared by univariate analysis. Multivariable regression models assessed risk-adjusted impact of reoperative status on outcomes.

Results: A total of 1,332 patients underwent surgery for ATAAD, of whom 138 (10.4%) were reoperations. Reoperative patients were older (63 vs. 58 years, p < 0.01) with more comorbidities. These patients had longer median cardiopulmonary bypass times (218 vs 177 minutes, p < 0.01) and increased blood product utilization; however rates of aortic arch, root, and valve procedures were similar. On unadjusted analysis operative mortality was higher in reoperative patients (28% vs 15%, p < 0.01) with a longer total length of stay (13 vs 10 days, p = 0.02). Reoperative patients exhibited a trend toward decreased mortality at high-volume centers (25.7% vs 37.9%, p = 0.19). After risk adjustment reoperative status remained associated with mortality (odds ratio, 2.1; p < 0.01) as well as composite morbidity-mortality (odds ratio, 2.2; p < 0.01).

Conclusions: In this multicenter cohort undergoing repair of ATAAD prior cardiac surgery was associated with an increased morbidity and mortality. Centralization to high-volume centers and emerging technologies may improve outcomes in this high-risk population.
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http://dx.doi.org/10.1016/j.athoracsur.2019.02.065DOI Listing
September 2019
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