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ABSTRACT: BACKGROUND: The aim of this study was to evaluate nationwide outcomes of ventricular assist device (VAD) implantation in elderly patients in the United States. METHODS: Patients undergoing VAD implantation between 2003 and 2008 were identified in the Nationwide Inpatient Sample. The primary outcome was inpatient mortality following VAD implantation. Secondary outcomes included disposition following discharge and costs of care. After stratification based on primary versus postcardiotomy VAD support, outcomes were compared between controls aged 60-69 years and elderly patients aged ≥70 years. RESULTS: A total of 2787 patients aged 60-69 years and 1472 patients aged ≥70 years underwent VAD implantation during the study period. Unadjusted mortality rates were comparable between elderly and control patients in both primary support (35.7% vs. 32.1%, p = 0.61) and postcardiotomy support (58.1% vs. 56.1%, p = 0.70). Similarly, in risk-adjusted multivariable logistic regression analysis incorporating clinically relevant variables, age ≥70 did not exert an independent effect on inpatient mortality for either indication. Inpatient costs in the elderly were lower than controls in the primary support cohort, although costs per day were similar, with comparable overall costs between age groups in the postcardiotomy cohort. Elderly survivors were discharged to a facility more frequently than control survivors (primary: 49.9% vs. 29.6%, p = 0.007; postcardiotomy: 67.4% vs. 45.7%, p = 0.03). CONCLUSIONS: This large-cohort population-based analysis provides a useful framework for inpatient prognosis and resource utilization in elderly patients undergoing VAD implantation. Although mortality rates and costs were found to be comparable between elderly patients and those aged 60-69 years, these rates were nonetheless significant. This combined with more frequent discharge-to-facility in elderly survivors underscores the importance of careful patient selection in this population.
Journal of Cardiac Surgery 02/2013; · 0.87 Impact Factor
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ABSTRACT: BACKGROUND: Computed tomography (CT) scans of the head without contrast are routinely obtained to evaluate neurologic deficits after cardiac surgery, but their utility is unknown. We evaluated our experience with this imaging modality to determine its value. METHODS: We retrospectively identified cardiac surgery patients with postoperative neurologic deficits occurring during the first week after surgery between January 2000 and December 2012. Stroke was defined by neurologist's determination, whereas a nonfocal deficit (NFD) was defined by the presence of seizure, delirium, or cognitive impairment. We defined early noncontrast head CT as occurring within 7 days of surgery. Outcomes included positive findings on CT, in-hospital mortality, and length of stay. Multivariate logistic regression identified predictors of positive findings on head CT. RESULTS: Within the population of 11,070 postoperative patients, 451 had early noncontrast head CT scans (4%). Two hundred two (44.7%) were associated with stroke, and 249 (55.2%) were associated with NFD. Among stroke patients, 40 of 202 (20%) showed acute infarction, 17 of 202 (8%) showed subacute infarction, and 5 of 202 (2%) showed hemorrhage. Among NFD patients, 1 of 248 (0.4%) showed acute infarction, 4 of 248 (1.6%) showed subacute infarction, and 1 of 248 (0.4%) showed hemorrhage. There was no difference in in-hospital mortality (stroke, 42 of 201 [21%] versus NFD, 41 of 248 [16%]; p = 0.2) or length of stay (stroke, 24 d versus NFD, 22 d; p = 0.5). On multivariable logistic regression, only focal deficits and aortic procedures predicted a positive finding on CT scan. CONCLUSIONS: This study reviewed the utility of early postoperative noncontrast head CT in cardiac surgery patients. With focal neurologic deficits, this imaging modality was positive for approximately one third of patients, but rarely positive for NFD. Its use in this setting has limited utility.
The Annals of thoracic surgery 12/2012; · 3.74 Impact Factor
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ABSTRACT: : To evaluate the contribution of institutional volume and other unmeasured institutional factors beyond volume to the between-center variability in outcomes after orthotopic heart transplantation (OHT).
: It is unclear if institutional factors beyond volume have a significant impact on OHT outcomes.
: The United Network for Organ Sharing registry was used to identify OHTs performed between 2000 and 2010. Separate mixed-effect logistic regression models were constructed, with the primary endpoint being post-OHT mortality. Model A included only individual centers, model B added validated recipient and donor risk indices as well as the year of transplantation, and model C added institutional volume as a continuous variable to model B. The reduction in between-center variability in mortality between models B and C was used to define the contribution of institutional volume. Kaplan-Meier survival curves were also compared after stratifying patients into equal-size tertiles based on center volume.
: A total of 119 centers performed OHT in 19,156 patients. After adjusting for transplantation year and differences in recipient and donor risk, decreasing center volume was associated with an increased risk of 1-year mortality (P < 0.001). However, procedural volume only accounted for 16.7% of the variability in mortality between centers, and significant between-center variability persisted after adjusting for institutional volume (P<0.001). In Kaplan-Meier analysis, there was significant variability in 1-year survival between centers within each volume category: low-volume (66.7%-96.6%), intermediate-volume (80.7%-97.3%), and high-volume (83.8%-93.9%). These trends were also observed with 5-year mortality.
: This large-cohort analysis demonstrates that although institutional volume is a significant predictor of post-OHT outcomes, there are other unmeasured institutional factors that contribute substantially to the between-center variability in outcomes. Institutional volume should therefore not be the sole indicator of "center quality" in OHT.
Annals of surgery 09/2012; 256(4):616-23. · 7.90 Impact Factor
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ABSTRACT: OBJECTIVE: We evaluated the combined effect of hospital and surgeon volume on operative outcomes of mitral valve surgery in the United States. METHODS: The Nationwide Inpatient Sample was used to identify adult patients undergoing isolated mitral valve surgery for mitral regurgitation from 2003 to 2008. Hospitals and surgeons were separately stratified into equal-size tertiles according to annual overall mitral valve operative volumes. Multivariate logistic regression analysis was conducted, adjusting for multiple patient, hospital, and operative data, to determine the separate and combined effects of hospital and surgeon volume on operative outcomes. RESULTS: A total of 50,152 eligible patients were identified during the study period. Although both hospital and surgeon volume correlated significantly with operative mortality in separate risk-adjusted analyses, only lower surgeon volume persisted as a significant risk factor in the combined risk-adjusted analysis. Moreover, although hospital volume only accounted for 10.7% of the surgeon volume effect on increased mortality for low-volume surgeons, surgeon volume accounted for 74.5% of the hospital volume effect on increased mortality in low-volume hospitals. Surgeon, but not hospital, volume correlated with inpatient costs. Also, significant trends were seen with repair rates, with increasing surgeon volume demonstrating a relatively stronger correlation with the odds of repair (P < .001) than hospital volume (P = .01). CONCLUSIONS: The effect of hospital volume on operative outcomes of mitral valve surgery was largely driven by the individual surgeon volumes within that hospital. Conversely, surgeon volume affected these outcomes independently of hospital volume. Identifying the processes by which higher volume surgeons attain better outcomes in mitral valve surgery would therefore be prudent.
The Journal of thoracic and cardiovascular surgery 08/2012; · 3.41 Impact Factor
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ABSTRACT: The aim of this study was to derive and validate a risk score for rejection after orthotopic heart transplantation.
The United Network for Organ Sharing registry was used to identify patients undergoing orthotopic heart transplantation between 1998 and 2008. A total of 14 265 eligible patients were randomly divided into derivation (80%; n=11 412) and validation (20%; n=2853) cohorts. The primary outcome was drug-treated rejection within 1 year of orthotopic heart transplantation. Covariates found to be associated (exploratory univariate P<0.2) with rejection were entered into a multivariable logistic regression model. Inclusion of each variable in the model was assessed by improvement in the McFadden pseudo-R(2), likelihood ratio test, and c index. A risk score was then generated through the use of relative magnitudes of the odds ratios from the derivation cohort, and its ability to predict rejection was tested independently in the validation cohort. A 13-point risk score incorporating 4 variables (age, race, sex, HLA matching) was created. The mean scores in the derivation and validation cohorts were 8.3±2.2 and 8.4±2.1, respectively. Predicted 1-year rejection rates based on the derivation cohort ranged from 16.2% (score=0) to 50.7% (score=13; P<0.001). In weighted regression analysis, there was a strong correlation between these predicted rates of rejection and actual, observed rejection rates in the validation cohort (r(2)=0.96, P<0.001). Logistic regression analysis also demonstrated a significant association (odds ratio, 1.13; P<0.001). The c index of the composite score was equivalent in both the derivation and validation cohorts (c=0.67).
This novel 13-point risk score is highly predictive of clinically significant rejection episodes within 1 year of orthotopic heart transplantation. It has potential utility in tailoring immunosuppressive regimens and in research stratification in orthotopic heart transplantation.
Circulation 05/2012; 125(24):3013-21. · 14.74 Impact Factor
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ABSTRACT: The leading causes of constrictive pericarditis have changed over time leading to a commensurate change in the indications and complexity of surgical pericardiectomy. We evaluated our single-center experience to define the etiologies, risk factors, and outcomes of pericardiectomy in a modern cohort.
We retrospectively reviewed our institutional database for all patients who underwent total or partial pericardiectomy. Demographic, comorbid, operative, and outcome data were evaluated. Survival was assessed by the Kaplan-Meier method. Multivariable Cox proportional hazards regression models examined risk factors for mortality.
From 1995 to 2010, 98 adults underwent pericardiectomy for constrictive disease. The most common etiologies were idiopathic (n=44), postoperative (n=30), and post radiation (n=17). Total pericardiectomy was performed in 94 cases, most commonly through a sternotomy (n=93). Thirty-three cases were redo sternotomies, 34 underwent a concomitant procedure, and 34 required cardiopulmonary bypass. Overall in-hospital, 1-year, 5-year, and 10-year survival rates were 92.9%, 82.5%, 64.3%, and 49.2%, respectively. Survival differed sharply by etiology with idiopathic, postoperative, and post-radiation 5-year survivals of 79.8%, 55.9%, and 11.0%, respectively (p<0.001). On multivariable analysis, only the need for cardiopulmonary bypass (hazard ratio [HR]: 21.2, p=0.02) was predictive of 30-day mortality while post-radiation etiology (HR: 3.19, p=0.02) and hypoalbuminemia (HR: 0.57, p=0.03) were associated with increased 10-year mortality.
Although survival varies significantly by etiology, pericardiectomy continues to be a safe operation for constrictive pericarditis. Post-radiation pericarditis and hypoalbuminemia are significant risk factors for decreased long-term survival.
The Annals of thoracic surgery 05/2012; 94(2):445-51. · 3.74 Impact Factor
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ABSTRACT: Both stroke and encephalopathy are associated with significantly longer lengths of stay in the hospital and with significantly
higher rates of mortality. Those at risk for either stroke or encephalopathy, or both of these adverse outcomes after surgery,
can be identified prior to surgery using information available to physicians. For those at higher risk for these outcomes,
we suggest the following: 1) An imaging study of the brain, performed prior to surgery, may indicate the degree of cerebrovascular
disease. At present we do not have this information on most patients. 2) The status of arteriosclerotic disease of the aorta
should be determined prior to surgery or at the time of surgery. 3) For those with significant aortic and cerebrovascular
disease, alternatives to the conventional ways of performing coronary artery bypass grafting (CABG) should be considered.
These alternatives include percutaneous transluminal coronary angioplasty, off-pump surgery, and CABG using filters or inputs
from the pump that selectively protect the brain.
Current Treatment Options in Cardiovascular Medicine 04/2012; 6(3):171-178.
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New England Journal of Medicine 01/2012; 366(3):250-7. · 53.30 Impact Factor
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ABSTRACT: No standard index based on donor factors exists for predicting mortality after orthotopic heart transplantation (OHT). We utilized United Network for Organ Sharing (UNOS) data to develop a quantitative donor risk score for OHT.
We examined a prospectively collected open cohort of 22,252 patients who underwent primary OHT (1996 to 2007). Of the 284 donor-specific variables, those associated with 1-year (year) mortality (exploratory p-value < 0.2) were incorporated into a multivariate (MV) logistic regression model. The final model contained donor factors that improved the explanatory power (by pseudo-R2, area under the curve and likelihood ratio test). A quantitative donor risk score was created using odds ratios (ORs) from the final model. For external validity, a cross-validation strategy was employed whereby the score was generated using a randomly generated subset of cases (n = 17,788) and then independently validated on the remaining patients (n = 4,464).
A 15-point scoring system incorporated 4 variables: ischemic time; donor age; race mismatching; and blood urea nitrogen (BUN)/creatinine ratio. Derivation and validation cohort scores ranged from 1 to 15 and 1 to 12, respectively (mean 4.0 ± 2.1 for each). Each increase of 1 point increased the risk of 1-year death by 9% (OR = 0.09 [1.07 to 0.12]) in the derivation cohort and 13% (OR = 0.13 [1.08 to 0.18]) in the validation cohort (each p < 0.001). The odds of 1-year mortality by increments of 3 points were: 0 to 2 points (reference); 3 to 5 points (OR = 0.25 [1.12 to 0.40], p < 0.001); 6 to 8 pts (OR = 0.77 [1.56 to 2.02], p < 0.001); and 9 to 15 points (OR = 1.92 [1.54 to 2.39], p < 0.001). Donor risk score was predictive for 30-day mortality (OR = 0.11 [1.08 to 0.14], p < 0.001) and 5-year cumulative mortality (OR = 0.11 [1.09 to 0.13], p < 0.001).
We present a novel donor risk index for OHT predicting short- and long-term mortality. This donor risk score may prove valuable for donor heart allocation and prognosis after OHT.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 11/2011; 31(3):266-73. · 3.54 Impact Factor
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George J Arnaoutakis,
Timothy J George,
Kevin K Wang,
Mary Ann Wilson,
Jeremiah G Allen,
Chase W Robinson,
Kara A Haggerty,
Eric S Weiss,
Mary E Blue,
Charles C Talbot,
Juan C Troncoso,
Michael V Johnston, William A Baumgartner
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ABSTRACT: Ubiquitin carboxyl-terminal esterase-L1 (UCHL1) is a protein highly selectively expressed in neurons and has been linked to neurodegenerative disease in humans. We hypothesize that UCHL1 would be an effective serum biomarker for brain injury as tested in canine models of hypothermic circulatory arrest (HCA) and cardiopulmonary bypass (CPB).
Dogs were exposed to CPB (n = 14), 1 hour of HCA (1h-HCA; n = 11), or 2 hours of HCA (2h-HCA; n = 20). Cerebrospinal fluid and serum were collected at baseline, 8 hours, and 24 hours after treatment. UCHL1 levels were measured using a sandwich enzyme-linked immunosorbent assay. Neurologic function and histopathology were scored at 24 hours, and UCHL1 immunoreactivity was examined at 8 hours.
Baseline UCHL1 protein levels in cerebrospinal fluid and serum were similar for all groups. In serum, UCHL1 levels were elevated at 8 hours after treatment for 2h-HCA subjects compared with baseline values (P < .01) and also compared with CPB dogs at 8 hours (P < .01). A serum UCHL1 level above 3.9 ng/(mg total protein) at 8 hours had the best discriminatory power for predicting functional disability. In cerebrospinal fluid, UCHL1 was elevated in all groups at 8 hours after treatment compared with baseline (P < .01). However, UCHL1 levels in cerebrospinal fluid remained elevated at 24 hours only in 2h-HCA subjects (P < .01). Functional and histopathologic scores were closely correlated (Pearson coefficient, 0.66; P < .01) and were significantly worse in 2h-HCA animals.
This is the first report associating elevated serum UCHL1 with brain injury. The novel neuronal biomarker UCHL1 is increased in serum 8 hours after severe neurologic insult in 2h-HCA animals compared with CPB animals. These results support the potential for use in cardiac surgery patients and form the basis for clinical correlation in humans.
The Journal of thoracic and cardiovascular surgery 10/2011; 142(4):902-910.e1. · 3.41 Impact Factor
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ABSTRACT: Insurance status and education are known to affect health outcomes. However, their importance in orthotopic heart transplantation (OHT) is unknown. The United Network for Organ Sharing (UNOS) database provides a large cohort of OHT recipients in which to evaluate the effect of insurance and education on survival.
UNOS data were retrospectively reviewed to identify adult primary OHT recipients (1997 to 2008). Patients were stratified by insurance at the time of transplantation (private/self-pay, Medicare, Medicaid, and other) and college education. All-cause mortality was examined using multivariable Cox proportional hazard regression incorporating 15 variables. Survival was modeled using the Kaplan-Meier method.
Insurance for 20,676 patients was distributed as follows: private insurance/self-pay, 12,298 (59.5%); Medicare, 5,227 (25.3%); Medicaid, 2,320 (11.2%); and "other" insurance, 831 (4.0%). Educational levels were recorded for 15,735 patients (76.1% of cohort): 7,738 (49.2%) had a college degree. During 53 ± 41 months of follow-up, 6,125 patients (29.6%) died (6.7 deaths/100 patient-years). Survival differed by insurance and education. Medicare and Medicaid patients had 8.6% and 10.0% lower 10-year survival, respectively, than private/self-pay patients. College-educated patients had 7.0% higher 10-year survival. On multivariable analysis, college education decreased mortality risk by 11%. Medicare and Medicaid increased mortality risk by 18% and 33%, respectively (p ≤ 0.001).
Our study examining insurance and education in a large cohort of OHT patients found that long-term mortality after OHT is higher in Medicare/Medicaid patients and in those without a college education. This study points to potential differences in the care of OHT patients based on education and insurance status.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 09/2011; 31(1):52-60. · 3.54 Impact Factor
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ABSTRACT: Large national registries lack information on social support, which is increasingly recognized as an important factor associated with improved outcomes after solid-organ transplantation. We examined our institutional database to identify social factors associated with improved outcomes after orthotopic heart transplantation (OHT).
Outcomes of OHT patients from 1995 to 2010 at our institution were retrospectively reviewed. Clinical data and social information were extracted from medical records. Patients were stratified by marital status at time of OHT listing. The examined outcome was 5-year survival, excluding deaths within 60 days, modeled using the Kaplan-Meier method. A Cox multivariable hazard regression model was constructed to assess the effect on 5-year survival.
Of 260 OHT recipients, 176 (68%) were men. Mean age was 49 ± 12 years and mean body mass index was 26.8 ± 5.0 kg/m(2). At the time of OHT listing, 175 patients (68%) were married. Before OHT, 25% were supported with ventricular assist devices and 17% were in the intensive care unit. Conditional Kaplan-Meier analysis revealed improved 5-year survival for married patients (84%) compared with unmarried patients (69%). After risk-adjustment with Cox analysis, being married improved 5-year survival (hazard ratio [HR], 0.47; 95% confidence interval [CI], 0.23-0.97; p = 0.042) and also improved 1-year survival (p = 0.02). Other social support variables (children, grandchildren, living arrangements, education, race, employment status) were not associated with mortality.
Married patients have improved survival after OHT compared with unmarried patients. Being married confers a powerful 5-year survival advantage after OHT. This benefit appears mediated by an improvement in survival during the first post-transplant year.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 09/2011; 30(12):1389-94. · 3.54 Impact Factor
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ABSTRACT: Despite significant advances in cardiac allograft preservation, the optimal preservative solution is unknown. We evaluated the impact of the most commonly used solutions in the USA, the University of Wisconsin solution (UW) and Celsior solution (CS), on outcomes after orthotopic heart transplantation (OHT).
We retrospectively reviewed adult OHT recipients in the United Network for Organ Sharing (UNOS) database. Primary stratification was by preservation solution. The primary end-point was short-term survival (30 days and 1 year). Secondary end-points included common post-operative complications. Subgroup analysis was performed in high-risk allografts (donor age >50 years or ischemic time >4 hours). Risk-adjusted multivariate Cox proportional hazard regression was used to assess survival.
From 2004 to 2009, 4,910 patients (3,107 UW and 1,803 CS) with sufficient preservation solution information for analysis underwent OHT. Baseline characteristics were well-matched between the two groups. UW was associated with a small but significantly improved survival compared with CS at 30 days (96.7% vs 95.4%, p = 0.02) and 1 year (89.6% vs 87.0%, p < 0.01). These survival differences persisted on multivariate analysis at 30 days (HR 1.47 [1.02 to 2.13], p < 0.05) and 1 year (HR 1.40 [1.14 to 1.73], p < 0.01). In the 1,455 patients with high-risk allografts, preservation with UW was associated with improved survival compared with CS at 30 days (94.3% vs 91.3%, p < 0.01) and at 1 year (84.2% vs 80.19%, p < 0.01), a difference that was significant according to multivariate Cox analysis at 30 days (HR 2.29 [1.39 to 3.76], p < 0.01) and 1 year (HR 1.61 [1.17 to 2.21], p < 0.01).
Preservation with UW solution is associated with improved short-term survival compared with CS. Patients undergoing OHT with high-risk allografts have a similar survival benefit.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 06/2011; 30(9):1033-43. · 3.54 Impact Factor
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ABSTRACT: Recent emphasis on systems-based approaches to patient safety has led to several studies demonstrating worse outcomes associated with surgery at night.
To evaluate whether operative time of day was associated with thoracic organ transplant outcomes, hypothesizing that it would not be associated with increased morbidity or mortality.
We conducted a retrospective cohort study of adult heart and lung transplant recipients in the United Network for Organ Sharing database from January 2000 through June 2010. Primary stratification was by operative time of day (night, 7 PM-7 AM; day, 7 AM-7 PM).
Primary end points were short-term survival, assessed by the Kaplan-Meier method at 30, 90, and 365 days. Secondary end points encompassed common postoperative complications. Risk-adjusted multivariable Cox proportional hazards regression examined mortality.
A total of 27,118 patients were included in the study population. Of the 16,573 who underwent a heart transplant, 8346 (50.36%) did so during the day and 8227 (49.64%) during the night. Of the 10,545 who underwent a lung transplant, 5179 (49.11%) did so during the day and 5366 (50.89%) during the night. During a median follow-up of 32.2 months (interquartile range, 11.2-61.1 months), 8061 patients (28.99%) died. Survival was similar for organ transplants performed during the day and night. Survival rates at 30 days for heart transplants during the day were 95.0% vs 95.2% during the night (hazard ratio [HR], 1.05; 95% confidence interval, 0.83-1.32; P = .67) and for lung transplants during the day were 96.0% vs 95.5% during the night (HR, 1.22; 95% CI, 0.97-1.55; P = .09). At 90 days, survival rates for heart transplants were 92.6% during the day vs 92.7% during the night (HR, 1.05; 95% CI, 0.88-1.26; P = .59) and for lung transplants during the day were 92.7% vs 91.7% during the night (HR, 1.23; 95% CI, 1.04-1.47; P = .02). At 1 year, survival rates for heart transplants during the day were 88.0% vs 87.7% during the night (HR, 1.05; 95% CI, 0.91-1.21; P = .47) and for lung transplants during the day were 83.8% vs 82.6% during the night (HR, 1.08; 95% CI, 0.96-1.22; P = .19). Among lung transplant recipients, there was a slightly higher rate of airway dehiscence associated with nighttime transplants (57 of 5022 [1.1%] vs 87 of 5224 [1.7%], P = .02).
Among patients who underwent thoracic organ transplants, there was no significant association between operative time of day and survival up to 1 year after organ transplant.
JAMA The Journal of the American Medical Association 06/2011; 305(21):2193-9. · 30.03 Impact Factor
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ABSTRACT: The impact of Society of Thoracic Surgeons predicted mortality risk score on resource use has not been previously studied. We hypothesize that increasing Society of Thoracic Surgeons risk scores in patients undergoing aortic valve replacement are associated with greater hospital charges.
Clinical and financial data for patients undergoing aortic valve replacement at The Johns Hopkins Hospital over a 10-year period (January 2000 to December 2009) were reviewed. The current Society of Thoracic Surgeons formula (v2.61) for in-hospital mortality was used for all patients. After stratification into risk quartiles, index admission hospital charges were compared across risk strata with rank-sum and Kruskal-Wallis tests. Linear regression and Spearman's coefficient assessed correlation and goodness of fit. Multivariable analysis assessed relative contributions of individual variables on overall charges.
A total of 553 patients underwent aortic valve replacement during the study period. Average predicted mortality was 2.9% (±3.4) and actual mortality was 3.4% for aortic valve replacement. Median charges were greater in the upper quartile of patients undergoing aortic valve replacement (quartiles 1-3, $39,949 [interquartile range, 32,708-51,323] vs quartile 4, $62,301 [interquartile range, 45,952-97,103], P < .01]. On univariate linear regression, there was a positive correlation between Society of Thoracic Surgeons risk score and log-transformed charges (coefficient, 0.06; 95% confidence interval, 0.05-0.07; P < .01). Spearman's correlation R-value was 0.51. This positive correlation persisted in risk-adjusted multivariable linear regression. Each 1% increase in Society of Thoracic Surgeons risk score was associated with an added $3000 in hospital charges.
This is the first study to show that increasing Society of Thoracic Surgeons risk score predicts greater charges after aortic valve replacement. As competing therapies, such as percutaneous valve replacement, emerge to treat high-risk patients, these results serve as a benchmark to compare resource use.
The Journal of thoracic and cardiovascular surgery 04/2011; 142(3):650-5. · 3.41 Impact Factor
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ABSTRACT: Anemia has been associated with adverse cerebrovascular outcomes, particularly after cardiac operations. This study was conducted to determine if hemoglobin levels during and after cardiopulmonary bypass (CPB) predict postoperative stroke in cardiac surgical patients, independent of transfusion requirements.
Individuals who had sustained a clinical postoperative stroke (cases) were matched 1:2 with controls by age, sex, surgical procedure, and year of operation. In 617 patients, conditional logistic regression was performed to analyze associations between hemoglobin levels before and after CPB, and stroke.
After adjustment for potentially confounding vascular risk factors, lower hemoglobin after CPB was associated with a higher risk of stroke, even after adjustment for the amount of packed red blood cells transfused (adjusted odds ratio, 1.28; 95% confidence interval, 1.00 to 1.64, per point of lower hemoglobin level; adjusted odds ratio for stroke per higher quartile of packed red blood cells transfused in this model, 1.37; 95% confidence interval, 1.02 to 1.83). Similar associations were not found for hemoglobin concentrations preoperatively nor change in hemoglobin from before to after CPB. A post-CPB hemoglobin level below the median was associated with 37% increased odds of a postoperative stroke occurring (p = 0.02).
Lower postoperative hemoglobin levels and higher intraoperative transfusion requirements are each independently associated with a higher risk of stroke. Reduced cerebral oxygen delivery due to anemia may contribute to cerebral injury after coronary artery bypass grafting.
The Annals of thoracic surgery 04/2011; 91(4):1113-8. · 3.74 Impact Factor
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ABSTRACT: The United States lung allocation score (LAS) allows rapid organ allocation to higher acuity patients. Although, wait-list time and wait-list mortality have improved, the costs of lung transplantation (LTx) in these higher acuity patients are largely unknown. We hypothesize that LTx in high LAS recipients is associated with increased charges and resource utilization.
Clinical and financial data for LTx patients at our institution in the post-LAS era (May 2005 to 2009) were reviewed with follow-up through December 2009. Patients were stratified by LAS quartiles (Q). Total hospital charges for index admission and all admissions within 1 year of LTx were compared between Q4 vs Q1-3 using rank-sum and Kruskal-Wallis tests, as charge data were not normally distributed.
Eighty-four LTxs were performed during the study period. Sixty-three (75%) patients survived 1 year; 10 (11.9%) died during the index admission. Median LAS was 37.5 (interquartile range [IQR] 34.3 to 44.8). LAS quartiles were: Q1, 30.1 to 34.3, n = 21; Q2, 34.4 to 37.5, n = 21; Q3, 37.6 to 44.8, n = 21; and Q4, 44.9 to 94.3, n = 21. Charges for index admission were: Q4, $276,668 (IQR 191,301 to 300,156) vs Q1-3, $153,995 (IQR 129,796 to 176,849) (p < 0.001). Index admission median length of stay was greater in Q4 (Q4: 35-day IQR 23 to 46 vs Q1-3: 15-day IQR 11 to 22, p = 0.003). For 1-year charges: Q4, $292,247 (IQR 229,192 to 421,597) vs Q1-3, $188,342 (IQR 153,455 to 252,045) (p = 0.002). Index admission and 1-year charges in Q4 were higher than for other quartiles when examined individually.
This is the first study to show increased charges in high LAS patients. Charges for the index admission and hospital care in the year post-LTx were higher in the highest LAS quartile compared with patients in the lowest 75% of LAS.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 01/2011; 30(1):14-21. · 3.54 Impact Factor
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ABSTRACT: Cardiac surgical procedures such as coronary artery bypass grafting (CABG), valvular replacement and heart transplantation,
as well as many others are life-saving procedures for hundreds of thousands of US patients each year. However, despite this
clinical utility, many patients who undergo cardiac surgery suffer neurological injury as a result. In addition to the morbidity
and mortality caused by neurological injury, these complications are associated with increases in hospital length of stays,
costs, and admissions to rehabilitation facilities.
12/2010: pages 1-10;
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ABSTRACT: The ideal solution for recovery of donor lungs remains unknown. Low potassium dextran (LPD) solution is most common, but University of Wisconsin (UW) solution is also used. The United Network for Organ Sharing (UNOS) database allows assessment of preservation solutions in a large cohort of lung transplant (LTx) patients.
We retrospectively reviewed the UNOS data set for adult primary LTx patients (2005-2008) whose donor lungs were recovered with UW or LPD solution. Patients were stratified by UW vs LPD, and secondarily grouped by quartiles of the lung allocation score (LAS) to examine high-risk recipients. Kaplan-Meier (KM) short-term mortality (30 days, 90 days, 1 year) and rejection in the first year were examined for intervals with adequate follow-up. Cox proportional hazard regression using 11 variables examined all cause 1-year mortality.
Of 4,455 patients, 4,161 (93.4%) received LPD lungs and 294 (6.6%) received UW lungs, and 1,105 patients (24.8%) died during the study. There was no mortality difference based on flush solution with all patients examined together. However, patients in the upper 2 LAS quartiles (Q3: 37.8-45.4, Q4: > 45.4) receiving LPD lungs had greater 1-year survival of 81.5% vs 73.5% (p = 0.02). On multivariable analysis, flush with UW solution resulted in an increased risk of 1-year mortality (hazard ratio, 1.77. 95% confidence interval, 1.21-2.58; p = 0.003) vs LPD. Preservation solution did not affect rejection rates in the year after LTx. KM modeling demonstrated the effect of flush solution on survival (p = 0.02).
This study is the largest modern cohort to evaluate the effect of donor lung flush solutions on survival in adult LTx. UW solution increases the risk of 1-year mortality in high-risk LTx recipients.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 12/2010; 29(12):1380-7. · 3.54 Impact Factor
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Jeremiah G Allen,
Eric S Weiss,
Mary Ann Wilson,
George J Arnaoutakis,
Mary E Blue,
C Conover Talbot,
Chunfa Jie,
Mary S Lange,
Juan C Troncoso,
Michael V Johnston, William A Baumgartner
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ABSTRACT: Little is known about the molecular mechanisms of neurologic complications after hypothermic circulatory arrest (HCA) with cardiopulmonary bypass (CPB). Canine genome sequencing allows profiling of genomic changes after HCA and CPB alone. We hypothesize that gene regulation will increase with increased severity of injury.
Dogs underwent 2-hour HCA at 18 degrees C (n = 10), 1-hour HCA (n = 8), or 2-hour CPB at 32 degrees C alone (n = 8). In each group, half were sacrificed at 8 hours and half at 24 hours after treatment. After neurologic scoring, brains were harvested for genomic analysis. Hippocampal RNA isolates were analyzed using canine oligonucleotide expression arrays containing 42,028 probes.
Consistent with prior work, dogs that underwent 2-hour HCA experienced severe neurologic injury. One hour of HCA caused intermediate clinical damage. Cardiopulmonary bypass alone yielded normal clinical scores. Cardiopulmonary bypass, 1-hour HCA, and 2-hour HCA groups historically demonstrated increasing degrees of histopathologic damage (previously published). Exploratory analysis revealed differences in significantly regulated genes (false discovery rate < 10%, absolute fold change > or = 1.2), with increases in differential gene expression with injury severity. At 8 hours and 24 hours after insult, 2-hour HCA dogs had 502 and 1,057 genes regulated, respectively; 1-hour HCA dogs had 179 and 56 genes regulated; and CPB alone dogs had 5 and 0 genes regulated.
Our genomic profile of canine brains after HCA and CPB revealed 1-hour and 2-hour HCA induced markedly increased gene regulation, in contrast to the minimal effect of CPB alone. This adds to the body of neurologic literature supporting the safety of CPB alone and the minimal effect of CPB on a normal brain, while illuminating genomic results of both.
The Annals of thoracic surgery 06/2010; 89(6):1965-71. · 3.74 Impact Factor
