Outcomes of patients with advanced liver disease undergoing cardiac surgery.

Objective: Liver disease (LD) is considered a risk factor for inferior outcomes in general and cardiac surgery, yet current cardiac surgery risk estimators exclude LD, and literature on the topic remains scant. We sought to evaluate whether the presence of advanced LD is associated with inferior outcomes following cardiac surgery. Methods: This single-center, retrospective, observational study included 285 patients diagnosed with LD who underwent cardiac surgery in 2010 to 2020. The cohort contained 3 groups, Child-Turcotte-Pugh (CTP) class A (n = 219), CTP early-class B (n = 34), and CTP advanced-class B (n = 32). A model for end-stage liver disease score of 12.7 points (determined using a receiver-operating characteristic curve analysis on 30-day mortality) dichotomized class B into early- and advanced-groups. Univariate and multivariate logistic regression analyses were performed to identify predictors of 30-day mortality. Results: Patients in CTP advanced-class B had the longest length of stay (14 days), highest incidence of prolonged ventilation (46.9%), renal failure (21.9%), 30-day mortality (18.8%), and in-hospital mortality (18.8%). Incidence of ≥1 postoperative complication was higher in CTP advanced-class B (59.4%), compared with CTP class A (37.9%) and CTP early-class B (38.2%). Multivariate logistic regression analysis demonstrated that female sex (odds ratio, 3.01; 95% CI, 1.07-8.77; P = .037) and peripheral vascular disease (odds ratio, 4.01; 95% CI, 1.33-12.2; P = .013) were independent predictors of 30-day mortality in patients with advanced LD. Conclusions: Severity of LD influences perioperative outcomes following cardiac surgery. Our data suggest that patients in CTP class A and selected patients in CTP class B (model for end-stage liver disease score <12.7) can undergo surgery with acceptable risk.

Two hundred robotic mitral valve repair procedures for degenerative mitral regurgitation: the Yale experience.

Background: Robotic surgery has gained popularity over the past two decades due to the benefits related to smaller surgical incisions, enhanced technical dexterity and better intraoperative visualization. We present the Yale experience of the first two hundred totally endoscopic, robotic-assisted mitral valve repair procedures for the treatment of degenerative mitral regurgitation. Methods: We performed a retrospective cohort study of patients undergoing totally endoscopic, robotic-assisted isolated or concomitant mitral valve repair for degenerative mitral regurgitation at Yale-New Haven Hospital from October 2018 to April 2022. Mitral valve repair procedures for rheumatic or secondary functional mitral regurgitation and planned robotic-assisted mitral valve replacement cases were excluded. Results: Two hundred consecutive procedures were performed. The median age was 65 years (interquartile range, 58-73 years). Six patients (3.0%) had a history of mediastinal radiation, four patients (2.0%) had previous cardiac surgery, and one patient (0.5%) had cardiac dextroversion. Median cardiopulmonary bypass and aortic cross-clamp times were 122 and 79 minutes, respectively. Femoral vessel cannulation was performed percutaneously in 57 (28.5%) patients with no major access-site related complication. Aortic cross-clamping was performed with the endoaortic balloon occlusion device in 151 (75.5%) patients. No conversions to sternotomy occurred. Satisfactory repair was achieved in 100% of cases, with 184 (92.0%) and 16 (8.0%) of patients having trace/none or mild residual mitral regurgitation, respectively. Forty-two patients (21.0%) underwent concomitant Cox-maze procedure and 25 patients (12.5%) underwent concomitant tricuspid valve repair. Thirty-day mortality rate was 0.5%, with an observed-to-expected ratio of 0.53. Two patients (1.0%) underwent re-exploration for bleeding, one had early postoperative stroke (0.5%), five developed pneumothorax (2.5%) and two required dialysis for acute renal failure (1.0%). The median length of hospital stay was four days. Conclusions: Excellent short-term outcomes can be achieved in experienced centers for the treatment of degenerative mitral regurgitation with a totally endoscopic, robotic-assisted approach.

Risk factors and mortality associated with permanent pacemaker after surgical or transcatheter aortic valve replacement: Early versus late implantation.

INTRODUCTION: Inflation of transcatheter aortic valve replacement (TAVR) procedures compared to surgical aortic valve replacement (SAVR) has increased the number of patients requiring a postprocedure permanent pacemaker (PPM). We investigate the impact of PPM on mid-term mortality comparing SAVR versus TAVR procedures and risk factors for early and late (>14 days) need of PPM. METHODS: We conducted a retrospective, single-center evaluation of 903 patients that underwent either SAVR or TAVR procedures at the Yale New Haven Hospital from 2012 to 2017. Patients were stratified into PPM and non-PPM groups. We performed Kaplan-Meier and Cox proportional hazard analysis to characterize mid-term mortality. Further subgroup analysis was performed to identify risk factors for early and late PPM implantation in the TAVR cohort. RESULTS: There was no correlation between PPM implantation and mid-term mortality in both SAVR (hazard ratio [HR] = 0.69; confidence interval [CI] = 0.21-2.30; p = .56) and TAVR (HR = 0.70; CI = 0.42-1.17; p = .18) patients. The presence of the right bundle branch block (Odds ratio = 24.07; 95% CI = 2.34-247.64, p = .007) was associated with higher odds of early PPM requirement after TAVR procedures. CONCLUSION: PPM placement after SAVR or TAVR procedures is not associated with increased mid-term mortality. In-depth characterization of risk factors for early and late PPM implantation will require further analysis in the growing TAVR patient population.

Cardiac surgeons' practices and attitudes toward addiction care for patients with substance use disorders.

INTRODUCTION: Rates of injection-drug use associated infective endocarditis (IDU-IE) are rising, and most patients with IDU-IE do not receive addiction care during hospitalization. We sought to characterize cardiac surgeons' practices and attitudes toward patients with IDU-IE due to their integral role treating them. METHODS: This is a survey of 201 cardiac surgeons in the U.S who were asked about the addiction care they engage for patients with IDU-IE along with questions pertaining to stigma against people who use drugs (PWUD). Descriptive statistics and multivariable logistic regression were used to identify patterns in surgeons' practices and determine associations between attitudes toward substance use disorder (SUD) and beliefs about medications for opioid use disorder (MOUD). RESULTS: A minority of surgeons have access to specialty addiction services (35%) in their hospital, but when available 93% consult them for patients with IDU-IE. A quarter of surgeons reported thinking that SUD is a choice and do not believe MOUD have a role in reducing IDU-IE recurrence. Conversely, 69% of surgeons agreed with the disease model of addiction and were four times more likely to believe that MOUD has a role in reducing IDU-IE recurrence (aOR 4.09, 95% CI 1.8-9.27, p = 0.001). CONCLUSION: Access to addiction specialists is limited in most hospital settings, but when available, most surgeons report consulting them and supporting MOUD. However, a significant proportion of surgeons hold non-evidence-based attitudes toward SUD and PWUD. This suggests that lack of education and stigma may affect the care of patients with IDU-IE, highlighting the need for education about, and destigmatization of addiction within health systems.

Relationship of surgeon experience and outcomes of surgery for degenerative mitral valve disease.

OBJECTIVE: To assess the impact of surgeon experience on the outcomes of degenerative mitral valve disease. METHODS: We reviewed all patients who had surgery for degenerative mitral valve disease between 2011 and 2016. Experienced surgeon was defined as performing ≥ 25 mitral valve operations/year. Patient characteristics and outcomes were compared. Competing risk analysis was performed to identify factors associated with mitral regurgitation (MR) recurrence. Survival analysis for mortality was done using Kaplan Meier curve and Cox proportional hazard method. RESULTS: There were 575 patients treated by 9 surgeons for severe MR caused by degenerative mitral valve disease between 2011 and 2016. Three experienced surgeons performed 77.2% of the operations. Patients treated by less experienced surgeons had worse comorbidity profile and were more likely to have an urgent or emergent operation (p = .001). Experienced surgeons were more likely to attempt repair (p = .024), to succeed in repair (94.7% vs. 87%; p = .001), had shorter cross-clamp times (p = .001), and achieved higher repair rate (81.3% vs. 69.7%; p = .005). Experienced surgeons were more likely to use neochordae (p = .001) and less likely to use chordae transfer (p = .001). Surgeon experience was not associated with recurrence of moderate or higher degree of MR after repair but was an independent risk factor for mortality (HR = 2.64; p = .002). CONCLUSIONS: Techniques of degenerative mitral valve surgery differ with surgeon experience, with higher rates of repair and better outcomes associated with more experienced surgeons.

STratification risk analysis in OPerative management (STOP score) for drug-induced endocarditis.

BACKGROUND: The opioid epidemic has seen a drastic increase in the incidence of drug-associated infective endocarditis (IE). No clinical tool exists to predict operative morbidity and mortality in patients undergoing surgery. METHODS: A multi-institutional database was reviewed between 2011 and 2018. Multivariate logistic regression was fitted in an automated stepwise fashion. The STratification risk analysis in OPerative management of drug-associated IE (STOP) score was constructed. Morbidity was defined as reintubation, prolonged ventilation, pneumonia, renal failure, dialysis, stroke, reoperation for bleeding, and a permanent pacemaker. Cross-validation provided an unbiased estimate of out-of-sample performance. RESULTS: A total of 1181 patients underwent surgery for drug-associated IE (median age, 39; interquartile range [IQR], 30-54, 386 women [32.7%], 341 reoperations for prosthetic valve endocarditis [28.9%], 316 patients with multivalve disease [26.8%]). Operative morbidity and mortality were 41.1% and 5.9%, respectively. Predictors of morbidity were dialysis (95% confidence interval [CI], 1.16-2.82), emergent intervention (1.83-4.73), multivalve procedure (1.01-1.98), causative organisms other than Streptococcus (1.09-2.02), and type of valve procedure performed [aortic valve procedure (1.07-2.15), mitral valve replacement (1.03-2.05), tricuspid valve replacement (1.21-2.60)]. Predictors of mortality were dialysis (1.29-5.74), active endocarditis (1.32-83), lung disease (1.25-5.43), emergent intervention (1.69-6.60), prosthetic valve endocarditis (1.24-3.69), aortic valve procedure (1.49-5.92) and multivalve disease (1.00-2.95). Variables maximizing explanatory power were translated into a scoring system. Each point increased odds of morbidity and mortality by 22.0% and 22.4% with an accuracy of 94.0% and 94.1%, respectively. CONCLUSION: Drug-related IE is associated with significant morbidity and mortality. An easily-applied risk stratification score may aid in clinical decision-making.

Inconsistent Addiction Treatment for Patients Undergoing Cardiac Surgery for Injection Drug Use-associated Infective Endocarditis.

INTRODUCTION: Cases of surgical injection drug use-associated infective endocarditis (IDU-IE) are on the rise, amid the US opioid epidemic. We aimed to describe nature of perioperative addiction treatment for these patients. METHODS: This is a retrospective review of 56 surgical IDU-IE from 2011 to 2016 at a tertiary care center. Data collected included substances used, documented psychosocial consultations (social work or psychiatry), medications for addiction and evidence of enrollment in a drug rehabilitation program after discharge.Among patients with active drug use (ADU), we compared the 24-month survival of those who received comprehensive addiction treatment, defined as both psychosocial consultation and medications for opioid use disorder to that of those who received partial or no treatment. RESULTS: Out of 56 patients, 42 (75%, n = 56) received a psychosocial consultation, 23 (41.1%, n = 56) received medications for opioid use disorder and 15 (26.8% n = 56) attended a drug rehabilitation program.Forty-two patients had ADU. Among those, 20 (47.6%, n = 42) received comprehensive addiction treatment, while 28 (52.4%, n = 42) received partial or no treatment, and 10 (23.8%, n = 42) attended drug rehabilitation. Most patients with ADU who attended drug rehabilitation (9, 90%) had received comprehensive addiction treatment. All patients with ADU who received comprehensive addiction treatment were alive after 24-months, while 7 patients (25%, n = 28) who received partial or no treatment were not. CONCLUSION: Addiction treatment was inconsistent for surgical IDU-IE patients. Comprehensive addiction treatment predicted drug rehabilitation attendance, and was protective against 24-month mortality. Implementing protocols for comprehensive perioperative addiction treatment in IDU-IE patients is of the utmost importance.

Trends in Infective Endocarditis Hospitalizations, Characteristics, and Valve Operations in Patients With Opioid Use Disorders in the United States: 2005-2014.

Background To evaluate changes in patient characteristics and outcomes for infective endocarditis (IE) related to opioid use disorder (OUD), we used the National (Nationwide) Inpatient Sample (NIS) to characterize the trend in hospitalizations for patients with IE with and without OUD and those treated medically and surgically. Methods and Results Temporal trends in hospitalization characteristics for patients with IE with and without OUD and those treated medically and surgically were estimated via the NIS data in 2005-2014. Hospitalizations for OUD and IE increased from 119 to 202 and from 12 to 15 cases per 100 000 between 2005 and 2014, respectively. Hospitalizations with OUD among all IE hospitalizations increased from 6.3% in 2005 to 11.6% in 2014. Among all IE hospitalizations, patients being admitted for IE in the setting of OUD were younger compared with the cohort of IE without OUD (aged 37.6±0.21 years versus 60.9±0.16 years). Myocardial infarction, diabetes mellitus, chronic kidney disease, peripheral vascular disease, and heart failure were more common in patients without OUD. The OUD cohort more frequently had liver disease (46.0% versus 10.8%) and immunosuppressed status (4.3% versus 2.1%). Valve operations for IE accounted for 10.2% of all valve operations in 2005, and this increased to 12.7% in 2014. These proportions were similar between OUD (11.4%) and non-OUD (11.1%) cohorts. Operative mortality was lower in patients with OUD (4.3% versus 9.4%, P<0.001). Conclusions IE associated with OUD has a distinct phenotype and has become more prevalent. Surgical outcomes are favorable and operations were performed in similar proportions of patients who had IE with OUD compared with patients who had IE without OUD.

Incidence and characteristics of hospitalization for proximal aortic surgery for acute syndromes and for aneurysms in the USA from 2005 to 2014.

OBJECTIVES: The effectiveness of proximal thoracic aortic aneurysm (TAA) surgery in preventing acute aortic syndromes, such as dissection and rupture, is unknown at the populational level. This study evaluated trends in acute aortic syndrome operation incidence relative to proximal aortic surgical volume in the USA. METHODS: A retrospective analysis of the National Inpatient Sample in 2005-2014 was performed. Acute aortic syndrome and TAA were identified with International Classification of Diseases, 9th edition diagnosis codes. Proximal aortic surgery was defined as the diagnosis of acute aortic syndrome or TAA with an aortic procedure and either cardioplegia, cardiopulmonary bypass or other cardiac operation. Annual rates of acute aortic syndrome surgery and proximal thoracic aneurysm surgery were adjusted for US population. Trends were evaluated using linear regression. RESULTS: We identified 38 442 operations for acute aortic diagnoses and 74 953 operations for TAAs. Case volume for acute aortic syndromes increased from 0.93 to 1.63 per 100 000 (P = 0.001), and aneurysm surgery increased from 1.75 to 3.19 per 100 000 (P < 0.001). Patient and hospital characteristics differed between acute aortic and aneurysm operations, with black patients being most notably underrepresented in the aneurysm population (4.9% vs 17.0%, P < 0.001). CONCLUSIONS: Acute aortic syndrome operative volume increased from 2005 to 2014 despite increasing rates of proximal aortic aneurysm surgery. Patient characteristic discrepancies were observed between the 2 groups of hospitalizations, highlighting the need for continued efforts to minimize sociodemographic disparities.

Persistence of risk of death after hospital discharge to locations other than home after cardiac surgery.

OBJECTIVE: Temporal changes in the risk of postoperative death following cardiac surgery are uncharacterized. We aimed to quantify the duration of postoperative phase with elevated risk of death in patients who underwent cardiac surgery and were discharged to home and destinations other than home. METHOD: We conducted a retrospective cohort study of 6894 patients who underwent cardiac surgery between 2008 and 2016 at a tertiary care center in the United States. Logistic regression models with restricted cubic splining along the days since hospital discharge were fitted for risk of death in patients who were discharged to home and those discharged to destinations other than home. The splining curves were analyzed to quantify the duration of postoperative high-risk phase in each cohort. RESULTS: Mortality rate was significantly higher in the nonhome cohort compared with those discharged to home at 365 days following hospital discharge (9.3% vs 2.1%; P < .001). Discharge to destinations other than home was an independent predictor of late death (hazard ratio, 1.36; 95% confidence interval, 1.15-1.61; P < .001). Analysis of restricted cubic splining curves demonstrated that the postoperative phase with elevated risk of death persisted for 80.3 days in nonhome discharge cohorts, whereas a comparable phase was nonexistent in patients who went home. Predictors of nonhome discharge were identified, with combination of preoperative and postoperative variables yielding C statistics of 0.83. CONCLUSIONS: Hospital discharges to locations other than home following cardiac surgery were associated with an increased risk of late mortality. The postoperative high-risk phase persisted for 80 days in patients who were discharged to locations other than home, supporting the use of 90-day outcome measures as quality metrics. Predictors of discharge to locations other than home were identified, and this may aid in selective intervention to reduce the risk of death in this vulnerable patient population.

Risk of reoperative valve surgery for endocarditis associated with drug use.

BACKGROUND: We aimed to quantify incidence and operative risks associated with reoperative valve surgeries (RVS) in patients with drug-associated infective endocarditis in a multi-center setting. METHODS: We formed a registry of patients with drug-associated infective endocarditis who underwent valve surgeries at 8 US centers between 2011 and 2017. Outcomes of first-time valve surgery (FVS) and RVS were compared. Multivariable logistic regression models related RVS to 30-day mortality. Poisson regression models were fitted to evaluate temporal trends in overall case volume and proportions of patients undergoing RVS. RESULTS: The cohort consisted of 925 patients with drug-associated infective endocarditis who underwent a valve surgery, of which 652 were FVS and 273 were RVS. Patients undergoing FVS had fewer comorbidities than those undergoing RVS. Overall case volume increased from 108 in 2012 to 229 cases in 2017 (P < .001). The proportion of redo valve cases increased from 19% in 2012 to 28% in 2017 (P < .001). The 30-day mortality in RVS was higher compared with FVS (8.1% vs 4.8%; P = .049). An increase in unadjusted mortality rates were observed as the number of prior cardiac surgeries increased, from 4.8% in FVS to 11.8% in ≥3 RVS. Multivariable model demonstrated that RVS was associated with an increased risk of 30-day mortality (odds ratio, 2.22; 95% confidence interval, 1.22-4.06; P = .010). CONCLUSIONS: An increasing proportion of valve surgery for drug-associated infective endocarditis is for RVS. Despite being young and harboring few comorbidities, the RVS cohort is still susceptible to increased risk of 30-day mortality compared with those undergoing FVS.

Mulibrey Nanism Syndrome: A Case for Heart Transplantation.

Mulibrey nanism syndrome is a rare genetic disorder affecting multiple organ systems. The cardiovascular system is one of the most significantly affected, with simultaneous myocardial and pericardial disease. These patients are usually managed by pericardiectomy to resolve the milieu of hemodynamic problems ensuing due to concurrent constrictive and restrictive pathologies. We highlight the use of cardiac transplantation as a definitive management for a hemodynamically decompensated patient with Mulibrey nanism syndrome.

Clinical significance of presenting syndromes on outcome after coronary artery bypass grafting.

OBJECTIVES: Evidence of an association between postoperative survival and the presenting syndrome following coronary artery bypass grafting (CABG) is limited. Our goal was to evaluate whether the presenting symptoms of acute coronary syndrome (ACS) or stable ischaemic heart disease were associated with mid-term survival in patients undergoing CABG. METHODS: We performed a single-centre retrospective study involving consecutive CABG operations from 2011 to 2016. Post-discharge survival was ascertained via patient-level data linkage with the State of Connecticut vital statistics. Baseline and postoperative variables were compared between the two groups. The multivariate Cox proportional hazard model, adjusted for demographics and comorbidity, was used to show whether the presenting syndrome category was independently associated with mid-term survival. RESULTS: A total of 1631 patients were included: 794 with stable ischaemic heart disease and 837 with ACS. Patients with ACS who underwent CABG showed more comorbidities. The overall 30-day mortality rate was 1.8% (ACS 2.3% vs stable ischaemic heart disease 1.3%; P = 0.12). In-hospital, postoperative outcomes revealed higher rates of prolonged ventilation (11.7% vs 4.8%; P < 0.001), pneumonia (6.6% vs 3.9%; P = 0.016) and stay in the intensive care unit (3.7 ± 4.0 vs 3.2 ± 2.7 days; P = 0.014) in patients with ACS. The overall mean duration of the long-term follow-up period was 27.9 ± 16.5 months, during which 117 deaths occurred. The multivariable Cox proportional hazard model adjusted for demographics and comorbidity showed that ACS was not a predictor of mid-term mortality [hazard ratio (HR) 1.26, 95% confidence interval (CI) 0.84-1.90; P = 0.26]. Other significant predictors were cardiogenic shock (HR 2.12, 95% CI 1.04-4.33; P = 0.039) and history of congestive heart failure (HR 1.78, 95% CI 1.18-2.69; P = 0.0062). CONCLUSIONS: The presenting syndrome was not an independent predictor of the mid-term mortality rate. The results indicate that the classification of the presenting syndrome may be fluid and that clinical decision-making for postoperative care of patients who have CABG directed by category of presenting syndrome needs careful consideration. These data should be interpreted in the context of the limitations of this study.

Rapid Diagnosis and Treatment of Patients with Acute Type A Aortic Dissection and Malperfusion Syndrome May Normalize Survival to that of Patients with Uncomplicated Type A Aortic Dissection.

OBJECTIVES: Malperfusion syndrome in the setting of acute Type A dissection (ATAD) is typically associated with poor prognosis. We evaluated the contemporary outcomes of patients with ATAD presenting with and without malperfusion syndrome who underwent aortic surgery. METHODS: We performed a single-center, retrospective review of 103 consecutive patients that underwent surgery for ATAD. The cohort was dichotomized by patients with and without malperfusion syndromes. Multivariate and bivariate analyses were performed to evaluate association between the presence of malperfusion syndrome and operative outcomes. RESULTS: A total of 29 (28.1%) patients presented with malperfusion syndrome. The 30-day mortality for patients presenting with and without malperfusion was 13.7 and 9.4%, respectively (p = 0.49). Patients with malperfusion syndrome had a shorter mean admission-to-incision interval of 4.3 ± 2.5 hours compared with 6.3 ± 4.6 hours for those without malperfusion (p = 0.02). Difference in 30-day mortality for patients with and without malperfusion syndrome was found to be nonsignificant on multivariate regression analysis (odds ratio: 1.53; 95% confidence interval: 0.40-5.82, p = 0.49). CONCLUSIONS: This series demonstrated that there was nonsignificant difference in early- or midterm outcomes for patients with and without malperfusion syndrome. Patients with malperfusion were taken to the operating room more rapidly than those without, which offers a potential explanation for the comparable outcome of the malperfusion cohort.