The performance of concomitant tricuspid valve repair (TVr) at the time of mitral valve repair or replacement (MVRR) has previously been associated with elevated short-term risk. Outcomes were ...assessed at incremental grades of tricuspid regurgitation (TR) to quantify the contemporary risk of concomitant TVr.
Between July 2011 and June 2014, 88,473 patients undergoing MVRR were examined using The Society of Thoracic Surgeons database. Outcomes with or without TVr, after isolated MVRR (n = 62,118) and MVRR with coronary artery bypass graft surgery (CABG n = 26,355), were independently analyzed at three levels of TR: none-mild, moderate, and severe. Risk-adjusted morbidity and mortality associated with the performance of concomitant TVr were evaluated using multivariable logistic regression.
The TR was graded as none-mild in 74.3% of patients (65,769 of 88,473), moderate in 17.2% (15,222 of 88,473), and severe in 8.5% (7,482 of 88,473). The rate of TVr by TR grade was 3.5% (2,308 of 65,769) for none-mild, 30.6% (4,661 of 15,222) for moderate, and 75.6% (5,654 of 7,482) for severe. Overall risk-adjusted occurrence of any morbidity associated with performance of TVr was increased in both groups (MVRR odds ratio OR 1.36, 95% confidence interval CI: 1.24 to 1.48; and MVRR plus CABG OR 1.33, 95% CI: 1.19 to 1.49). However, at all grades of TR, TVr was not associated with increased risk-adjusted mortality (MVRR OR 0.99, 95% CI: 0.84 to 1.17; and MVRR plus CABG OR 1.04, 95% CI: 0.85 to 1.27).
In contemporary patients, concomitant TVr is not associated with a risk-adjusted increase in mortality, regardless of TR severity. A more liberal approach to TVr at the time of MVRR may be justified when long-term benefits are thought to outweigh incremental short-term morbidity risk. Further investigation of longitudinal TVr outcomes is warranted.
...the American Taxpayer Relief Act of 2012 (12) gave providers the option of satisfying the requirements of the Physician Quality Reporting System (PQRS) (13) by participating in qualifying ...registries.\n Physio-Control Inc., ZOLL Inc.), 2012-2015; PIlow * Hypothermia Duration After Resuscitation Trial (HART) Pilot Study (Submitted to NHLBI, CR Bard Medical Division Inc., Cincinnati Sub-Zero Inc., EMCOOLS AG, Gaymar/Stryker Inc. ZOLL Circulation Inc.; 2013-2015low * Mild hypothermia for resuscitated out-of-hospital cardiac arrest patients (R01-HL089554-01), 2007-2013; Co-I Randomized Trial of Hemofiltration After Resuscitation from Cardiac Arrest (NHLBI R21 HL093641-01A1), 2009-2011; PI Resuscitation Outcomes Consortium (National Institutes of Health U01 HL077863-05), 2004-2010; Co-PIdagger Sotera Wireless, San Diego, California Velocity Pilot Study of Ultrafast Hypothermia in Patients with ST-elevation Myocardial Infarction (Velomedix Inc.), 2012-2014; PI (waived personal compensation) Washington Study of Ultrasound in Resuscitation (Philips Healthcare Inc.), 2013-2014; PIlow * Medic One Foundationlow * Novel method of tracking location of monitor/defibrillators in time and spacelow * None Randal J. Thomas Content AHA GWTG Steering Committee None None None None None None Martha Radford Content NCDR Management Board None None None None None None Debra Ness Content: National Partnership for Women and Families None None None None None None Frederic Resnic Content: NCDR Science and Quality Oversight Committee St. Jude Medical None None None FDAdagger National Institutes of Healthdagger None * This table represents the relationships of reviewers with industry and other entities that were disclosed at the time of peer review and determined to be relevant.
The Society of Thoracic Surgeons (STS) Quality Measurement Task Force is developing a portfolio of composite performance measures for the most commonly performed procedures in adult cardiac surgery. ...We now describe the fourth in this series, the STS composite measure for mitral valve repair/replacement (MVRR).
We examined all patients undergoing isolated MVRR, with or without concomitant performance of tricuspid valve repair, surgical arrhythmia ablation, or repair of atrial septal defect, between July 1, 2011, and June 30, 2014. In this two-domain model, risk-adjusted mortality and any-or-none major morbidity were combined into a composite score using 3 years of STS data and 95% Bayesian credible intervals to estimate composite scores and star ratings.
There were 61,201 MVRR patients studied at 867 participant sites. Mitral valve repair was performed in 57.4% (35,114 of 61,201) and mitral valve replacement in 42.6% (26,087 of 61,201). Mortality was 2.9% (1,773 of 61,201), and occurrence of any major morbidity was 17.0% (10,381 of 61,201). The median composite score was 93.2% (interquartile range, 92.3% to 94.2%). Star rating classifications included 23 of 867 (2.6%) 1-star programs (lower-than-expected performance), 795 of 867 (91.7%) 2-star programs (as-expected or average performance), and 49 of 867 (5.7%) 3-star programs (higher-than-expected performance).
STS has developed an MVRR composite performance measure that will be used for participant feedback, quality performance assessment and improvement, and voluntary public reporting.
Delayed sternal closure (DSC) is commonly used to optimize hemodynamic stability after neonatal and infant heart surgery. We hypothesized that duration of sternum left open (SLO) was associated with ...rate of infection complications, and that location of sternal closure may mitigate infection risk.
Infants (age ≤365 days) undergoing index operations with cardiopulmonary bypass and DSC at STS Congenital Heart Surgery Database centers (from 2007 to 2013) with adequate data quality were included. Primary outcome was occurrence of infection complication, defined as one or more of the following: endocarditis, pneumonia, wound infection, wound dehiscence, sepsis, or mediastinitis. Multivariable regression models were fit to assess association of infection complication with: duration of SLO (days), location of DSC procedure (operating room versus elsewhere), and patient and procedural factors.
Of 6,127 index operations with SLO at 100 centers, median age and weight were 8 days (IQR, 5-24) and 3.3 kg (IQR, 2.9-3.8); 66% of operations were STAT morbidity category 4 or 5. At least one infection complication occurred in 18.7%, compared with 6.6% among potentially eligible neonates and infants without SLO. Duration of SLO (median, 3 days; IQR, 2-5) was associated with an increased rate of infection complications (p < 0.001). Location of DSC procedure was operating room (16%), intensive care unit (67%), or other (17%). Location of DSC was not associated with rate of infection complications (p = 0.45).
Rate of occurrence of infectious complications is high among infants with sternum left open following cardiac surgery. Longer duration of SLO is associated with increased infection complications.
Failure to rescue (FTR) is increasingly recognized as an important quality indicator in surgery. The Society of Thoracic Surgeons National Database was used to develop FTR metrics and a predictive ...FTR model for coronary artery bypass grafting (CABG).
The study included 604,154 patients undergoing isolated CABG at 1,105 centers from January 2010 to January 2014. FTR was defined as death after four complications: stroke, renal failure, reoperation, and prolonged ventilation. FTR was determined for each complication and a composite of the four complications. A statistical model to predict FTR was developed.
FTR rates were 22.3% for renal failure, 16.4% for stroke, 12.4% for reoperation, 12.1% for prolonged ventilation, and 10.5% for the composite. Mortality increased with multiple complications and with specific combinations of complications. The multivariate risk model for prediction of FTR demonstrated a C index of 0.792 and was well calibrated, with a 1.0% average difference between observed/expected (O/E) FTR rates. With centers grouped into mortality terciles, complication rates increased modestly (11.4% to 15.7%), but FTR rates more than doubled (6.8% to 13.9%) from the lowest to highest terciles. Centers in the lowest complication rate tercile had an FTR O/E of 1.14, whereas centers in the highest complication rate tercile had an FTR O/E of 0.91.
CABG mortality rates vary directly with FTR, but complication rates have little relation to death. FTR rates derived from The Society of Thoracic Surgeons data can serve as national benchmarks. Predicted FTR rates may facilitate patient counseling, and FTR O/E ratios have promise as valuable quality metrics.
Previous studies suggest center volume is associated with outcome after the Norwood operation; however, the impact of surgeon volume is less clear. We evaluated the relative impact of surgeon and ...center volume on mortality in a large Norwood cohort.
Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database undergoing the Norwood operation (2000 to 2009) were included. Using multivariable logistic regression, we evaluated the relationship between in-hospital mortality and annual center and surgeon volume, adjusting for patient factors.
A total of 2,555 patients were operated on at 53 centers by 111 surgeons. Overall unadjusted mortality was 22.1%. When analyzed individually, both lower center and surgeon volume were associated with higher mortality (odds ratio for centers with 0 to 10 vs >20 cases per year 1.56 95% confidence interval 1.05 to 2.31; odds ratio for surgeons with 0 to 5 vs >10 cases per year 1.60 95% confidence interval 1.12 to 2.27). When analyzed together, the addition of surgeon volume to the center volume models attenuated but did not completely mitigate the association of center volume with outcome (relative attenuation of odds ratio=34%). Adjusted mortality rates in low, medium, and high volume centers were 25.6%, 22.3%, and 17.7%, respectively. Across all center volume strata, lower volume surgeons had higher adjusted mortality rates.
Both center and surgeon volumes appear to influence Norwood outcomes. These data suggest outcomes may potentially be improved through strategies that take advantage of the positive influence of both of these variables. This could include further investigation into the feasibility of regional collaborations, and the development of quality improvement initiatives within and across centers.
Abstract Objective Patients with Williams syndrome (WS) undergoing cardiac surgery are at risk for major adverse cardiac events (MACE). Prevalence and risk factors for such events have not been well ...described. We sought to define frequency and risk of MACE in patients with WS using a multicenter clinical registry. Methods We identified cardiac operations performed in patients with WS using the Society of Thoracic Surgeons Congenital Heart Surgery Database (2000-2012). Operations were divided into 4 groups: isolated supravalvular aortic stenosis, complex left ventricular outflow tract (LVOT), isolated right ventricular outflow tract (RVOT), and combined LVOT/RVOT procedures. The proportion of patients with MACE (in-hospital mortality, cardiac arrest, or postoperative mechanical circulatory support) was described and the association with preoperative factors was examined. Results Of 447 index operations (87 centers), median (interquartile range) age and weight at surgery were 2.4 years (0.6-7.4 years) and 10.6 kg (6.5-21.5 kg), respectively. Mortality occurred in 20 patients (5%). MACE occurred in 41 patients (9%), most commonly after combined LVOT/RVOT (18 out of 87; 21%) and complex LVOT (12 out of 131; 9%) procedures, but not after isolated RVOT procedures. Odds of MACE decreased with age (odds ratio OR, 0.99; 95% confidence interval CI, 0.98-0.99), weight (OR, 0.97; 95% CI, 0.93-0.99), but increased in the presence of any preoperative risk factor (OR, 2.08; 95% CI, 1.06-4.00), and in procedures involving coronary artery repair (OR, 5.37; 95% CI, 2.05-14.06). Conclusions In this multicenter analysis, MACE occurred in 9% of patients with WS undergoing cardiac surgery. Demographic and operative characteristics were associated with risk. Further study is needed to elucidate mechanisms of MACE in this high-risk population.
The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed a composite performance measure for mitral repair/replacement (MVRR) with concomitant coronary artery bypass ...grafting (CABG).
Data were acquired from the STS Adult Cardiac Surgery Database for 26,463 patients undergoing MVRR + CABG operations between July 1, 2011, and June 30, 2014. Established STS risk models were applied, along with modifications enabling the inclusion of patients with concomitant closures of atrial septal defects and patent foramen ovale, surgical ablation for atrial fibrillation, and tricuspid valve repair (TVR). Participants with fewer than 10 eligible cases over 3 years were excluded. The MVRR + CABG composite consisted of two domains: risk-adjusted mortality and the any-or-none occurrence of major morbidity (prolonged ventilation, deep sternal infection, permanent stroke, renal failure, and reoperation). Composite performance scores were calculated with the use of hierarchic regression models, and high-performing and low-performing outliers were determined with the use of 95% Bayesian credible intervals.
There were 24,740 patients at 703 participant sites after exclusions. Two percent (14/703) of programs were classified as 1-star (lower than expected performance), 95% (666/703) were classified as 2-star (as-expected performance), and 3% (23/703) were classified as 3-star (higher than expected performance). The average unadjusted operative mortality was 6.2% (1,532/24,740), and a monotonic decline in both mortality and morbidity was observed as star rating scores increased.
An STS composite performance measure was developed for MVRR + CABG operations. This measure may be useful for outcome assessment, quality improvement, patient counseling, clinical research, and public reporting.
The role of surgical resection in patients with clinical stage IIIA-N2 positive (cIIIA-N2) lung cancer is controversial, partly because of the variability in short- and long-term outcomes. The ...objective of this study was to characterize the management of cIIIA-N2 lung cancer in The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD).
The STS-GTSD was queried for patients who underwent operations for cIIIA-N2 lung cancer between 2002 and 2012. A subset of patients aged older than 65 years was linked to Medicare data.
Identified were 3,319 surgically managed, cIIIA-N2 patients, including 1,784 (54%) treated with upfront resection (treatment naïve upfront surgery group, and 1,535 (46%) with induction therapy. A positron emission tomography scan was documented in 93% of patients, and 51% of patients were coded in STS-GTSD as having undergone invasive mediastinal staging. Nodal overstaging (cN2→pN0/N1) was observed in 43% of upfront surgery patients. Lobectomy was performed in 69% of patients and pneumonectomy in 11%. Operative mortality was similar between patients treated with upfront surgery (1.9%) and induction therapy (2.5%, p = .2583). The unadjusted Kaplan-Meier estimate of 5-year survival of cIII-N2 patients treated with induction therapy then resection was 35%.
STS surgeons achieve excellent short- and long-term results treating predominantly lobectomy-amenable cIIIA-N2 lung cancer. However, prevalent overstaging and abstention from induction therapy suggest "overcoding" of false positives on imaging or variable compliance with current guidelines for cIIIA-N2 lung cancer. Efforts are needed to improve clinical stage determination and guideline compliance in the GTSD for this cohort.
The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) has been successfully linked to the Centers for Medicare and Medicaid (CMS) Medicare database, thereby facilitating ...comparative effectiveness research and providing information about long-term follow-up and cost. The present study uses this link to determine contemporary completeness, penetration, and representativeness of the STS ACSD.
Using variables common to both STS and CMS databases, STS operations were linked to CMS data for all CMS coronary artery bypass graft (CABG) surgery hospitalizations discharged between 2000 and 2012, inclusive. For each CMS CABG hospitalization, it was determined whether a matching STS record existed.
Center-level penetration (number of CMS sites with at least one matched STS participant divided by the total number of CMS CABG sites) increased from 45% in 2000 to 90% in 2012. In 2012, 973 of 1,081 CMS CABG sites (90%) were linked to an STS site. Patient-level penetration (number of CMS CABG hospitalizations done at STS sites divided by the total number of CMS CABG hospitalizations) increased from 51% in 2000 to 94% in 2012. In 2012, 71,634 of 76,072 CMS CABG hospitalizations (94%) occurred at an STS site. Completeness of case inclusion at STS sites (number of CMS CABG cases at STS sites linked to STS records divided by the total number of CMS CABG cases at STS sites) increased from 88% in 2000 to 98% in 2012. In 2012, 69,213 of 70,932 CMS CABG hospitalizations at STS sites (98%) were linked to an STS record.
Linkage of STS and CMS databases demonstrates high and increasing penetration and completeness of the STS database. Linking STS and CMS data facilitates studying long-term outcomes and costs of cardiothoracic surgery.
PDF
