Objective Coronary artery bypass grafting (CABG) is the operation most commonly performed by cardiac surgeons. There are few contemporary data examining evolving patient characteristics and surgical ...outcomes of isolated CABG. We used the Society of Thoracic Surgeons adult cardiac surgery database to characterize trends in patient characteristics and outcomes after CABG over the past decade. Methods From 2000 to 2009, 1,497,254 patients underwent isolated primary CABG at Society of Thoracic Surgeons participating institutions. Demographics, operative characteristics, and postoperative outcomes were assessed, and risk-adjusted outcomes were calculated. Results Compared with the year 2000, patients undergoing isolated primary CABG in 2009 were more likely to have diabetes mellitus (33% vs 40%) and hypertension (71% vs 85%). There were clinically insignificant differences in age, gender, and body surface area. Between 2000 and 2009, there has been a 6.3% and 19.5% increase in the preoperative use of aspirin and beta-blockers, respectively. Between 2004 and 2009, there was a 7.8% increase in the use of angiotension-converting enzyme inhibitors preoperatively. Furthermore, between 2005 and 2009 there was a 3.8% increase in the use of statins preoperatively. The median number of distal anastomoses performed was unchanged between 2000 and 2009 (3; interquartile range, 2–4). There was a significant increase in the use of the internal thoracic artery (88% in 2000 vs 95% in 2009). The predicted mortality rates of 2.3% were consistent between 2000 and 2009. The observed mortality rate over this period declined from 2.4% in 2000 to 1.9% in 2009 representing a relative risk reduction of 24.4%. The incidence of postoperative stroke decreased significantly from 1.6% to 1.2%, representing a risk reduction of 26.4%. There was also a 9.2% relative reduction in the risk of reoperation for bleeding and a 32.9% relative risk reduction in the incidence of sternal wound infection. Conclusions Over the past decade, the risk profile of patients undergoing CABG has changed, with fewer smokers, more diabetic patients, and better medical therapy characterizing patients referred for surgical coronary revascularization. The left internal thoracic artery is nearly universally used and outcomes have improved substantially, with a significant decline in postoperative mortality and morbidity.
Background The introduction of transcatheter aortic valve replacement mandates attention to outcomes after surgical aortic valve replacement (SAVR) in low-risk, intermediate-risk, and very high-risk ...patients. Methods The study population included 141,905 patients who underwent isolated primary SAVR from 2002 to 2010. Patients were risk-stratified by Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) <4% (group 1, n = 113,377), 4% to 8% (group 2, n = 19,769), and >8% (group 3, n = 8,759). The majority of patients were considered at low risk (80%), and only 6.2% were categorized as being at high risk. Outcomes were analyzed based on two time periods: 2002 to 2006 (n = 63,754) and 2007 to 2010 (n = 78,151). Results The mean age was 65 years in group 1, 77 in group 2, and 77 in group 3 ( p < 0.0001). The median STS PROM for the entire population was 1.84: 1.46% in group 1, 5.24% in group 2, and 11.2% in group 3 ( p < 0.0001). Compared with PROM, in-hospital mean mortality was lower than expected in all patients (2.5% vs 2.95%) and when analyzed within risk groups was as follows: group 1 (1.4% vs 1.7%), group 2 (5.1% vs 5.5%), and group 3 (11.8% vs 13.7%) ( p < 0.0001). In the most recent surgical era, operative mortality was significantly reduced in group 2 (5.4% vs 6.4%, p = 0.002) and group 3 (11.9% vs 14.4%, p = 0.0004) but not in group 1. Conclusions Nearly 80% of patients undergoing SAVR have outcomes that are superior to those by the predicted risk models. In the most recent era, early results have further improved in medium-risk and high-risk patients. This large real-world assessment serves as a benchmark for patients with aortic valve stenosis as therapeutic options are further evaluated.
Surgical ablation of atrial fibrillation trends and outcomes in North America Ad, Niv, MD; Suri, Rakesh M., MD, DPhil; Gammie, James S., MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
11/2012, Letnik:
144, Številka:
5
Journal Article
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Objective Despite growing awareness of the clinical significance of atrial fibrillation (AF) and observational data demonstrating the safety and efficacy of surgical therapy, AF ablation is variably ...performed among patients with AF undergoing cardiac surgery. We examined the national trends of surgical ablation and perioperative outcomes for stand-alone surgical ablation of AF. Methods Using the Society of Thoracic Surgeons Adult Cardiac Surgery Database, 91,801 (2005-2010) surgical AF ablations were performed of which 4893 (5.3%) were stand-alone procedures. The outcomes of 854 propensity-matched pairs having “on” versus “off” cardiopulmonary bypass stand-alone ablation were compared. Results The percentage of patients with preoperative AF increased from 2005 to 2010 (from 10.0% to 12.2%). Overall, 40.6% of patients with AF underwent concomitant surgical ablation—a significant decline of 1.6% from 2005 to 2010. The number of stand-alone surgical ablations increased significantly from 552 to 1041 cases (2005-2010). Overall, the stand-alone group had a mean age of 60 years, 71% were men, and 80% were treated “off” cardiopulmonary bypass. The “on” cardiopulmonary bypass group had significantly more pulmonary disease, diabetes, and congestive heart failure. Overall, the operative mortality and stroke rate was 0.7% for each. After propensity matching, the “off” cardiopulmonary bypass group underwent significantly fewer reoperations for bleeding and had a lower incidence of prolonged ventilation and shorter hospitalization. New pacemaker implantation was low, without group differences. Conclusions The prevalence of AF in patients undergoing cardiac surgery has increased, as has the number of stand-alone surgical ablations. The treatment of concomitant disease declined slightly. Isolated surgical ablation is safe, performed “on” or “off” cardiopulmonary bypass. These results support consideration of surgical AF ablation as an alternative to percutaneous ablation for patients with lone AF.
Background The purpose of this study is to examine trends in mitral valve (MV) repair and replacement surgery using The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD). Methods ...The study population included isolated mitral valve operations performed between January 2000 and December 2007 at 910 hospitals participating in the STS ACSD. Patients with endocarditis, prior cardiac operation, shock, emergency operation, and concomitant coronary artery bypass graft or aortic valve surgery were excluded. Results During the 8-year study period, 58,370 patients underwent isolated primary MV operations. For patients with isolated mitral regurgitation (n = 47,126), the rate of MV repair (versus replacement) increased from 51% to 69% ( p < 0.0001). Among patients having replacement (n = 24,404), there has been a pronounced decline in the use of mechanical valves: 68% to 37% ( p < 0.0001). The operative mortality for MV replacement was consistently higher than that for repair (3.8% versus 1.4%), a finding that persisted after risk-adjustment (adjusted odds ratio 0.52, 95% confidence interval: 0.45 to 0.59; p < 0.0001). Among patients having elective isolated MV repair (n = 28,140), the operative mortality was 1.2%. For asymptomatic (class I) patients, operative mortality was 0.6%. Conclusions This study documents several important trends in MV surgery, including the progressive adoption of mitral valve repair and increasing use of bioprosthetic replacement valves. Operative risks of MV repair are significantly lower than those for MV replacement. Operative mortality for isolated elective mitral valve repair is 1% in contemporary clinical practice.
Background The aim of this study is to create models for perioperative risk of lung cancer resection using the STS GTDB (Society of Thoracic Surgeons General Thoracic Database). Methods The STS GTDB ...was queried for all patients treated with resection for primary lung cancer between January 1, 2002 and June 30, 2008. Three separate multivariable risk models were constructed (mortality, major morbidity, and composite mortality or major morbidity). Results There were 18,800 lung cancer resections performed at 111 participating centers. Perioperative mortality was 413 of 18,800 (2.2%). Composite major morbidity or mortality occurred in 1,612 patients (8.6%). Predictors of mortality include the following: pneumonectomy ( p < 0.001), bilobectomy ( p < 0.001), American Society of Anesthesiology rating ( p < 0.018), Zubrod performance status ( p < 0.001), renal dysfunction ( p = 0.001), induction chemoradiation therapy ( p = 0.01), steroids ( p = 0.002), age ( p < 0.001), urgent procedures ( p = 0.015), male gender ( p = 0.013), forced expiratory volume in one second ( p < 0.001), and body mass index ( p = 0.015). Conclusions Thoracic surgeons participating in the STS GTDB perform lung cancer resections with a low mortality and morbidity. The risk-adjustment models created have excellent performance characteristics and identify important predictors of mortality and major morbidity for lung cancer resections. These models may be used to inform clinical decisions and to compare risk-adjusted outcomes for quality improvement purposes.
Background Several single-institution series have demonstrated that compared with open thoracotomy, video-assisted thoracoscopic lobectomy may be associated with fewer postoperative complications. In ...the absence of randomized trials, we queried the Society of Thoracic Surgeons database to compare postoperative mortality and morbidity following open and video-assisted thoracoscopic lobectomy. A propensity-matched analysis using a large national database may enable a more comprehensive comparison of postoperative outcomes. Methods All patients having lobectomy as the primary procedure via thoracoscopy or thoracotomy were identified in the Society of Thoracic Surgeons database from 2002 to 2007. After exclusions, 6323 patients were identified: 5042 having thoracotomy, 1281 having thoracoscopy. A propensity analysis was performed, incorporating preoperative variables, and the incidence of postoperative complications was compared. Results Matching based on propensity scores produced 1281 patients in each group for analysis of postoperative outcomes. After video-assisted thoracoscopic lobectomy, 945 patients (73.8%) had no complications, compared with 847 patients (65.3%) who had lobectomy via thoracotomy ( P < .0001). Compared with open lobectomy, video-assisted thoracoscopic lobectomy was associated with a lower incidence of arrhythmias n = 93 (7.3%) vs 147 (11.5%); P = .0004, reintubation n = 18 (1.4%) vs 40 (3.1%); P = .0046, and blood transfusion n = 31 (2.4%) vs n = 60 (4.7%); P = .0028, as well as a shorter length of stay (4.0 vs 6.0 days; P < .0001) and chest tube duration (3.0 vs 4.0 days; P < .0001). There was no difference in operative mortality between the 2 groups. Conclusions Video-assisted thoracoscopic lobectomy is associated with a lower incidence of complications compared with lobectomy via thoracotomy. For appropriate candidates, video-assisted thoracoscopic lobectomy may be the preferred strategy for appropriately selected patients with lung cancer.
Background Pneumonectomy is associated with a significant incidence of perioperative morbidity and mortality. The purpose of this study is to identify the risk factors responsible for adverse ...outcomes in patients after pneumonectomy utilizing The Society of Thoracic Surgeons General Thoracic Surgery Database (STS GTDB). Methods All patients who had undergone pneumonectomy between January 2002 and December 2007 were identified in the STS GTDB. Among 80 participating centers, 1,267 patients were selected. Logistic regression analysis was performed on preoperative variables for major adverse outcomes. Results The rate of major adverse perioperative events was 30.4%, including 71 patients who died (5.6%). Major morbidity was defined as pneumonia, adult respiratory distress syndrome, empyema, sepsis, bronchopleural fistula, pulmonary embolism, ventilatory support beyond 48 hours, reintubation, tracheostomy, atrial or ventricular arrhythmias requiring treatment, myocardial infarct, reoperation for bleeding, and central neurologic event. Patients with major morbidity had a longer mean length of stay compared with patients without major morbidity (13.3 versus 6.1 days, p < 0.001). Independent predictors of major adverse outcomes were age 65 years or older ( p < 0.001), male sex ( p = 0.026), congestive heart failure ( p = 0.04), forced expiratory volume in 1 second less than 60% of predicted ( p = 0.01), benign lung disease ( p = 0.006), and requiring extrapleural pneumonectomy ( p = 0.018). Among patients with lung carcinoma, those receiving neoadjuvant chemoradiotherapy were more at risk for major morbidity than patients without induction therapy ( p = 0.049). Conclusions The mortality rate after pneumonectomy by thoracic surgeons participating in the STS database compares favorably to that in previously published studies. We identified risk factors for major adverse outcomes in patients undergoing pneumonectomy.
Outcomes for endocarditis surgery in North America: A simplified risk scoring system Gaca, Jeffrey G., MD; Sheng, Shubin, PhD; Daneshmand, Mani A., MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
2011, 2011-Jan, 2011-01-00, 20110101, Letnik:
141, Številka:
1
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Objective Operation for infective endocarditis is associated with the highest mortality of any valve disease, with overall rates of in-hospital mortality exceeding 20%. The Society of Thoracic ...Surgeons Adult Cardiac Surgery Database was examined to develop a simple risk scoring system and identify areas for quality improvement. Methods From 2002 through 2008, 19,543 operations were performed for infective endocarditis. Logistic regression analysis related baseline characteristics to both operative mortality and a composite of mortality and major morbidity within 30 days. Points were assigned to each risk factor, and estimated risk was obtained by averaging events for all patients having the same number of points. Results Overall unadjusted mortality was 8.2%, and complications occurred in 53%. Significant preoperative risk factors for mortality (associated points) were as follows: emergency, salvage status, or cardiogenic shock (17), preoperative hemodialysis, renal failure, or creatinine level less than 2.0 (12), preoperative inotropic or balloon pump support (10), active (vs treated) endocarditis (10), multiple valve involvement (9), insulin-dependent diabetes (8), arrhythmia (8), previous cardiac surgery (7), urgent status without cardiogenic shock (6), non–insulin-dependent diabetes (6), hypertension (5), and chronic lung disease (5), with a C statistic of 0.7578 (all P < .001). Risk-adjusted mortality and major morbidity were unchanged over the course of the study. In the entire data set, mortality was better if “any valve” was repaired (odds ratio = 0.76; P = .0023). Conclusions Operative mortality for surgically treated infective endocarditis is substantially lower than reported in-hospital mortality rates for infective endocarditis. The described risk scoring system will inform clinical decision-making in these complex patients.
Background Tricuspid valve (TV) infective endocarditis (IE) accounts for 15% of IE cases and usually is treated medically. Surgical intervention is rare, and understanding of treatment options is ...based on small series of patients. The purpose of this study was to describe the population and outcomes for isolated TV IE using The Society of Thoracic Surgeons Adult Cardiac Database. Methods Between 2002 and 2009, 910 operations for TV IE were performed. Procedures included replacement, repair, and valvectomy. Healed IE was present in 31.4% (n = 286), and active IE, in 68.5% (n = 624). Baseline patient characteristics as well as operative mortality and morbidity were analyzed, and univariate statistical differences were evaluated by Kruskal-Wallis test and stratum-adjusted Mantel-Haenszel χ2 tests. Results The median age was 40 years, with 50.6% male. Replacement of the TV was the most common procedure (n = 490; 53.8%), followed by TV repair (n = 354; 38.9%) and valvectomy (n = 66; 7.2%). Overall operative mortality was 7.3%, with no significant difference in mortality among valvectomy 12%, repair 7.6%, and replacement 6.3% ( p = 0.34). Compared with the active group, healed patients experienced a trend toward lower operative mortality (4.2% versus 8.6%; p = 0.06), lower complication rates (35.6% versus 51.4%; p = 0.0004), and shorter overall length of stay (12 versus 22 days; p < 0.0001). Conclusions Isolated TV operation for IE is a rare clinical entity with a similar operative mortality to left-sided IE operations. Repair and replacement of the TV had similar perioperative mortality. Patients in the healed TV IE group demonstrated lower complication rates, length of stay, and a trend toward decreased mortality.
Background Wedge resection is often used instead of anatomic resection in an attempt to mitigate perioperative risk. In propensity-matched populations, we sought to compare the perioperative outcomes ...of patients undergoing wedge resection with those undergoing anatomic resection. Methods The Society of Thoracic Surgery database was reviewed for stage I and II non-small cell lung cancer patients undergoing wedge resection and anatomic resection to analyze postoperative morbidity and mortality. Propensity scores were estimated using a logistic model adjusted for a variety of risk factors. Patients were then matched by propensity score using a greedy 5- to 1-digit matching algorithm, and compared using McNemar’s test. Results Between 2009 and 2011, 3,733 wedge resection and 3,733 anatomic resection patients were matched. The operative mortality was 1.21% for wedge resection versus 1.93% for anatomic resection ( p = 0.0118). Major morbidity occurred in 4.53% of wedge resection patients versus 8.97% of anatomic resection patients ( p < 0.0001). A reduction was noted in the incidence of pulmonary complications, but not cardiovascular or neurologic complications. There was a consistent reduction in major morbidity regardless of age, lung function, or type of incision. Mortality was reduced in patients with preoperative forced expiratory volume in 1 second less than 85% predicted. Conclusions Wedge resection has a 37% lower mortality and 50% lower major morbidity rate than anatomic resection in these propensity-matched populations. The mortality benefit is most apparent in patients with forced expiratory volume in 1 second less than 85% predicted. These perioperative benefits must be carefully weighed against the increase in locoregional recurrence and possible decrease in long-term survival associated with the use of wedge resection for primary lung cancers.
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