Background Surgical pulmonary embolectomy (SPE) has been sparingly used for the successful treatment of massive and submassive pulmonary emboli. To date, all data regarding SPE have been limited to ...single-center experiences. The purpose of this study was to document short-term outcomes after SPE for acute pulmonary emboli (PE) at four high-volume institutions. Methods A retrospective review of multiple local Society of Thoracic Surgeons databases of adults undergoing SPE from 1998 to 2014 for acute PE was performed (n = 214). Demographic, operative, and outcomes data were collected and analyzed. Patients were summarily categorized as having either massive or submassive PEs based on the presence or absence of preoperative vasopressors. Results A total of 214 patients with acute PE were treated by SPE. The mean age was 56.0 ± 14.5 years, and 92 (43.6%) patients were female. Of those, 176 (82.2%) PEs were submassive and 38 (17.8%) were massive. Fifteen (7.0%) patients underwent concomitant cardiac procedures, with 10 (4.7%) having simultaneous valvular interventions and 5 (2.4%) undergoing concomitant bypass grafting. Cardiopulmonary bypass (CPB) was used for all cases. Cardioplegic arrest was used for 80 (37.4%) patients. The median CPB and aortic cross clamp times were 71.5 (interquartile range IQR, 47.0–109.5) and 46.0 (IQR, 26.0–74.5), respectively. Notably, only 25 (11.7%) patients died in the hospital. Mortality was highest among the 28 patients who experienced preoperative cardiac arrest (9, 32.1%) Conclusions These data represent the first multicenter experience with SPE for acute pulmonary emboli. Surgical pulmonary embolectomy for acute massive and submassive PE is safe and can be performed with acceptable in-hospital outcomes; the procedure should be included in the multimodality treatment of life-threatening pulmonary emboli.
Background Thoracic endovascular aortic repair (TEVAR) is the optimal therapy for complicated acute type B aortic dissection (aTBAD). This study examined clinical outcomes and aortic remodeling ...parameters after TEVAR for patients with complicated aTBAD. Methods From January 2012 to December 2015, 51 patients underwent TEVAR for complicated aTBAD. Preoperative and postoperative imaging studies were analyzed for sizes of the true lumen (TL) and false lumen (FL) and for the FL thrombosis status at five locations in the thoracic and abdominal aorta. Results In-hospital and 1-year mortality rates were 3.9% and 5.8%, respectively. The incidence of stroke and paraparesis were 3.9% and 5.8%, respectively. In DeBakey 3a patients, TEVAR resulted in complete FL thrombosis and/or obliteration in 73% of patients. In DeBakey 3b patients, TEVAR resulted in complete FL thrombosis and/or obliteration in 100% of patients in the proximal descending thoracic aorta and 78% in the midpoint of the descending thoracic aorta. The infrarenal FL remained patent in 78% of patients. TEVAR stabilized the size of the proximal descending thoracic aorta (pre-TEVAR 43 ± 9 mm vs post-TEVAR 39 ± 7 mm; p = 0.07). However, significant aortic expansion was observed in all other downstream aortic segments. TEVAR resulted in a significant expansion in the TL volume (pre-TEVAR 99 ± 51 cm3 vs post-TEVAR 185 ± 70 cm3 ; p < 0.01) and total aortic volume (pre-TEVAR 314 ± 97 cm3 vs post-TEVAR 391 ± 120 cm3 ; p = 0.02) while inhibiting expansion of FL volume (pre-TEVAR 215 ± 67 cm3 vs post-TEVAR 204 ± 79 cm3 ; p = 0.91). Conclusions TEVAR for complicated aTBAD results in low 30-day and 1-year mortality rates, with higher reintervention rates than observed with open operations. TEVAR is effective in thrombosing and stabilizing the size of the thoracic FL. The abdominal aortic FL remains patent and must be carefully scrutinized for long-term aneurysm formation.
Background The role of robotic instruments in mitral valve (MV) surgery continues to evolve. The purpose of this study was to assess the safety, efficacy, and scope of MV surgery using a lateral ...endoscopic approach with robotics (LEAR) technique. Methods From 2006 to 2013, a dedicated LEAR team performed 1,257 consecutive isolated MV procedures with or without tricuspid valve repair or atrial ablation. The procedures were performed robotically through five right-side chest ports with femoral artery or ascending aortic perfusion and balloon occlusion. Operative videos and data were recorded on all procedures and reviewed retrospectively. Results The mean age of all patients was 59.3 ± 20.5 years, and 8.4% (n = 105) had previous cardiac surgery. The MV repair was performed in 1,167 patients (93%). The MV replacement was performed in 88 patients (7%), and paravalvular leak repair in 2 patients. Concomitant atrial ablation was performed in 226 patients (18%), and tricuspid valve repair in 138 patients (11%). Operative mortality occurred in 11 patients (0.9%) and stroke in 9 patients (0.7%). Predischarge echocardiograms demonstrated mild or less mitral regurgitation in 98.3% of MV repair patients. At mean follow-up of 50 ± 26 months, 44 patients (3.8%) required MV reoperation. Application of the LEAR technique to all institutional isolated MV procedures increased from 46% in the first year to more than 90% in the last 3 years. Conclusions Mitral valve repair or replacement, including concomitant procedures, can be performed safely and effectively using the LEAR technique. With a dedicated robotic team, the vast majority of patients with MV disorders, either isolated or with concomitant problems, can be treated using the LEAR technique.
Objectives
Pregnancy-associated hypertension (PAH) includes gestational hypertension, preeclampsia and eclampsia. Although a protective effect of multi-parity on PAH has been reported in previous ...studies, the association has not been examined among Asian American women in the U.S.
Methods
Using data from 2014 U.S. National Vital Statistics System, we examined the prevalence of PAH among Asian American women who had singleton live births (N = 235,303), and its association with parity (number of previous pregnancies including live births and fetal deaths) controlling for potential confounders. We estimated adjusted odds ratios (aORs) and 95% confidence intervals (CI) using multivariable logistic regression analysis.
Results
Overall, 2.72% (95% CI 2.66%, 2.79%) of Asian American women were recorded to have PAH during pregnancy. Parity was inversely associated with PAH in our study, where Asian American women who had 1–2 and 3 or more previous pregnancies had significantly lower odds of PAH (aOR 0.61, 95% CI 0.58, 0.65; and aOR 0.62, 95% CI 0.57, 0.68, respectively) compared to nulliparous women, after controlling for potential confounders.
Conclusions
Recent U.S. vital statistics data revealed that nulliparity is significantly associated with PAH among Asian American women. Future studies should identify specific factors that are associated with PAH and factors contributing to disparities in PAH risk among Asian American women.
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DOBA, EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, IZUM, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UILJ, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Background A critical gap in The Society of Thoracic Surgeons (STS) Database is the absence of patient-reported outcomes (PRO), which are of increasing importance in outcomes and performance ...measurement. Our aim was to demonstrate the feasibility of integrating PRO into the STS Database for patients undergoing lung cancer operations. Methods The National Institutes of Health Patient Reported Outcome Measurement Information System (PROMIS) includes reliable, precise measures of PRO. We used validated item banks within PROMIS to develop a survey for patients undergoing lung cancer resection. PRO data were prospectively collected electronically on tablet devices and merged with our institutional STS data. Patients were enrolled over 18 months (November 2014 to May 2016). The survey was administered preoperatively and at 1 and 6 months after lung cancer resection. Results The study included 127 patients. All patients completed the initial postoperative survey, and 108 reached the 6-month follow-up. The most common procedure was video-assisted thoracic lobectomy (55%). At the first postoperative visit, there was a significant increase in pain, fatigue, and sleep impairment and a decrease in physical function. By 6 months, these PRO measures had generally improved toward baseline. Conclusions Collecting PRO data from lung cancer surgical patients and integrating the results into an institutional database is feasible. This pilot serves as a model for widespread incorporation of PRO data into the STS Database. Future integration of such data will continue to position the STS National Database as the gold standard for clinical registries. This will be necessary for assessing overall patient responses to different surgical therapies.
Background Unilateral pulmonary edema (UPE) has been reported after mitral operations performed through the right side of the chest. The clinical presentation is compatible with an ...ischemia-reperfusion injury. This report describes modifications to robotic mitral valve operations that were designed to reduce UPE. Methods We reviewed 15 patients with UPE after robotic mitral valve operations from 2006 through 2012. Technique modifications to reduce right lung ischemia were used from 2013 through June 2015. Modifications included alterations in patient position, ventilation, and perfusion factors. The incidence of UPE before and after modifications was determined, as was perfusion factors and outcomes in a higher-risk patient subgroup with pulmonary hypertension and prolonged bypass procedures. Results The incidence of UPE was 1.4% (n = 15) in 1,059 consecutive robotic mitral valve procedures using the standard technique and 0.0% in 435 consecutive procedures using the modified technique ( p < 0.02). All patients with UPE had pulmonary hypertension and bypass times of greater than 120 minutes. Patients in the higher-risk subgroup had significantly lower systemic temperature (31°C range, 30°–32°C versus 34°C range, 33°–34°C; p < 0.01) and higher mean perfusion pressure (67mm Hg range 62-72 mm Hg versus 54 mm Hg range, 52–57 mm Hg; p < 0.01) on bypass using the modified technique. The incidence of UPE in higher-risk patients was significantly reduced using the modified technique (0% versus 5.6%; p < 0.01) without any increase in overall morbidity or mortality. Conclusions The incidence of UPE in patients undergoing robotic mitral valve operations has been significantly reduced using a modified technique, without increasing the perioperative complication rate. Further work is necessary to validate this protocol and understand the pathophysiology of postoperative UPE.
Readmission within 30 days of discharge after coronary artery bypass grafting is a measure of quality and a driver of cost in health care. Traditional predictive models use time-independent ...variables. We developed a new model to predict time to readmission after coronary artery bypass grafting using both time-independent and time-dependent preoperative and perioperative data.
Adults surviving to discharge after isolated coronary artery bypass grafting at a multi-hospital academic health system from January 2017 to September 2018 were included in this study. Two distinct data sources were used: the institutional cardiac surgical database and the clinical data warehouse, which provided more granular data points for each patient. Patients were divided into training and validation sets in an 80:20 ratio. We evaluated 82 potential risk factors using Cox survival regression and machine learning techniques. The area under the receiver operating characteristic curve was used to estimate model predictive accuracy.
We trained the model with 21 variables that scored a P value of less than .05 in the univariable analysis. The multivariable model determined 16 significant risk factors, and 6 of them were time-dependent. These included preoperative hemoglobin a1c level, preoperative creatinine, preoperative hematocrit, intraoperative hemoglobin, postoperative creatinine, and postoperative hemoglobin. Area under the receiver operating characteristic values were 0.906 and 0.868 for training and validation sets, respectively.
Time-dependent perioperative variables in an isolated coronary artery bypass grafting cohort provided better predictive ability to a readmission model. This study was unique in the inclusion of time-dependent covariates in the predictive model for readmission after discharge after coronary artery bypass grafting.
Machine learning prediction model: unraveling the impact of time-dependent perioperative variables on 30-day readmission after CABG. Display omitted
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background Vertebral subluxation (VS) is a clinical entity defined as a misalignment of the spine affecting biomechanical and neurological function. The identification and correction of VS is the ...primary focus of the chiropractic profession. The purpose of this study is to estimate VS prevalence using a sample of individuals presenting for chiropractic care and explore the preventative public health implications of VS through the promotion of overall health and function. Methodology A brief review of the literature was conducted to support an operational definition for VS that incorporated neurologic and kinesiologic exam components. A retrospective, quantitative analysis of a multi-clinic dataset was then performed using this operational definition. Descriptive statistics on patient demographic data included age, gender, and past health history characteristics. In addition to calculating estimates of the overall prevalence of VS, age- and gender-stratified estimates in the different clinics were calculated to allow for potential variations. Results A total of 1,851 patient records from seven chiropractic clinics in four states were obtained. The mean age of patients was 43.48 (SD = 16.8, range = 18-91 years). There were more females (n = 927, 64.6%) than males who presented for chiropractic care. Patients reported various reasons for seeking chiropractic care, including, spinal or extremity pain, numbness, or tingling; headaches; ear, nose, and throat-related issues; or visceral issues. Mental health concerns, neurocognitive issues, and concerns about general health were also noted as reasons for care. The overall prevalence of VS was 78.55% (95% CI = 76.68-80.42). Female and male prevalence of VS was 77.17% and 80.15%, respectively; notably, all per-clinic, age, or gender-stratified prevalences were ≥50%. Conclusions To date, this is the first study of its magnitude and application of an operational definition to estimate the prevalence of VS. Albeit nonrandom, the sample had a broad geographic distribution. The results of this study suggest a high rate of prevalence of VS in a sample of individuals who sought chiropractic care. Concerns about general health and wellness were represented in the sample and suggest chiropractic may serve a primary prevention function in the absence of disease or injury. Further investigation into the epidemiology of VS and its role in health promotion and prevention is recommended.
Background Unilateral selective antegrade cerebral perfusion with moderate hypothermic circulatory arrest has been shown to be a safe and effective method of cerebral protection during surgery for ...acute type A dissection. This study evaluates the impact of this cerebral protection strategy on clinical outcomes after extended aortic arch reconstruction in patients undergoing emergent repair of acute type A dissection. Methods A retrospective review from 2004 to 2016 at a US academic center of patients undergoing surgery for acute type A dissections using moderate hypothermic circulatory arrest and selective antegrade cerebral perfusion was performed. Patient data were abstracted from The Society of Thoracic Surgeons (STS) institutional database and patient charts. Cohorts were established based on extent of arch replacement: a hemiarch group and a transverse arch group were created. Owing to a dearth of events, a risk score was estimated using a logistic regression model with 30-day mortality as outcome and preoperative variables as predictors, including non-STS variables such as malperfusion. Postoperative outcomes were then adjusted in subsequent regression analyses for the estimated risk score. Results In all, 342 patients met inclusion criteria and were included for analysis (299 hemiarch, 43 transverse arch). The mean age was 55.4 years and not different between groups ( p = 0.79). Preoperative comorbidities, including prior stroke, diabetes mellitus, and renal failure, were also similar between groups ( p > 0.2). Inhospital mortality was 11.7% for the entire cohort (11.7% hemiarch, 9.3% transverse arch; p = 0.60), and the permanent stroke rate was 7.3% (7.7% hemiarch, 4.3% transverse arch; p = 0.47). Median circulatory arrest time was 38.9 ± 19.2 minutes (35.0 ± 13.2 hemiarch, 65.1 ± 30.1 transverse arch; p < 0.0001). Lowest median circulatory arrest temperature was 25.9° ± 3.1C° and not different between groups (25.9° ± 3.2°C hemiarch, 26.2° ± 2.6°C transverse arch; p = 0.50). In unadjusted analysis, no increase in operative mortality, temporary neurologic dysfunction, stroke, or renal failure was observed in the transverse arch group when compared with the hemiarch group. These results persisted when adjusted analysis was performed. Conclusions Unilateral selective antegrade cerebral perfusion with moderate hypothermic circulatory arrest remains a safe strategy for cerebral protection during emergent surgical repair of acute type A dissection and provides equivalent outcomes for both limited and extensive aortic arch reconstruction. Based on these data, unilateral selective antegrade cerebral perfusion and moderate hypothermic circulatory arrest may represent an optimal strategy for cerebral protection in this acute setting.
Repair of aortic root aneurysms with nonstenotic bicuspid valves (NS-BAVs) is achieved either with valve-sparing root replacement (VSRR) or conventional Bentall procedure (ROOT). Procedural and ...long-term outcomes comparing these 2 techniques are sparse and need investigation.
From March 2004 to January 2019, 158 patients with an aortic root aneurysm and NS-BAV underwent VSRR (n = 78, 49.3%) or ROOT (n = 80, 50.6%). VSRR involved optional aortic valve repair (n = 47, 60%), and ROOT was performed with bioprosthetic (81.3%) or mechanical valve replacement (18.7%). Procedural and postoperative outcomes were obtained, and univariate and Kaplan-Meier analyses were performed.
VSRR patients were younger (42.7 ± 12.0 years of age) than ROOT (54.8 ± 13.6 years of age) (P < .001). Cardiopulmonary bypass (CPB) and cross-clamp duration were longer in VSRR (CPB: 228.0 ± 39.1 minutes; cross-clamp: 200.1 ± 36.2 minutes) compared with ROOT (CPB: 199.5 ± 55 minutes; cross-clamp: 170.3 ± 39.5 minutes) (P < .001). Postoperative stroke, renal failure, pneumonia, and reoperation for bleeding were similar, but postoperative atrial and ventricular arrhythmias was lower in VSRR (15% vs 42%; P < .001). Length of stay and 30-day mortality were similar. At discharge, none had greater than trivial aortic insufficiency. Long-term 10-year survival and incidence of moderate-severe aortic insufficiency, aortic stenosis, and reoperation were equivalent between groups.
Surgery for aortopathy associated with NS-BAV is safe and effective with either VSRR or ROOT. Despite its complexity, VSRR should be considered in the surgical treatment of this population.
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