Hospital readmission after pulmonary resection: prevalence, patterns, and predisposing characteristics.

BACKGROUND: Our objective was to define the prevalence, patterns, and predisposing characteristics for hospital readmission after pulmonary resection. METHODS: Five years of pulmonary resections, excluding lung biopsies, were analyzed from a prospective, computerized database. Readmission was defined as inpatient or emergency department admission within 90 days of operation. Search of 1,173,912 admissions to the Providence Health System in Oregon identified readmissions. Readmission analysis excluded operative deaths. RESULTS: A total of 374 patients underwent pulmonary resections, of whom 8 died (2.1%). Of 366 patients discharged, 69 (18.9%) were readmitted a total of 113 times: 42 had only one readmission, 16 had two readmissions, 7 had three readmissions, 2 had four readmissions, and 2 had five readmissions. Slightly more than half (51%) were readmitted as inpatients. Causes of the 113 readmissions included pulmonary (27%), postoperative infection (14%), cardiac (7%), and other (16%). Mean time to readmission was 32.5 +/- 24.6 days. Inpatient readmission mean length of stay was 4.9 +/- 3.4 days. Readmission to hospitals other than the hospital of the operation was as follows: first readmission, 15.9%; second readmission, 14.8%; third readmission, 36.3%; fourth readmission, 25%; fifth readmission, 0%. Analysis revealed only pneumonectomy as a risk for readmission. Twelve of 33 (36%) pneumonectomies were readmitted (p = 0.005). Of the 297 patients discharged after pulmonary resection and not requiring readmission, 12 (4%) died over the study interval, whereas 8 of 69 patients (11.6%) requiring readmission died. CONCLUSIONS: Readmission after pulmonary resection is frequent and multiple readmissions are common. Causes are predominately pulmonary diagnoses and infections related to the operation. Pneumonectomy is a risk for readmission. An important portion of readmissions occurs outside the hospital of operation. The population requiring readmission after successfully undergoing pulmonary resection is at increased risk of subsequent mortality.

Surgery for second lung cancers.

PURPOSE: To evaluate the outcomes of patients surgically treated for their second primary lung cancer. METHOD: In a computerized surgical registry of > 800 consecutive patients treated for primary pulmonary carcinoma since 1980, 37 patients presented with a second lung cancer. These patients were analyzed regarding their original treatment, preoperative evaluation, operative procedures, and long-term follow-up. RESULTS: Three fifths of the patients were female, and 57% were > or = 65 years old at the time of their second operation. One patient originally had two synchronous tumors; another patient had three metachronous neoplasms. The interval between surgeries ranged from 5 to 239 months. In 31 patients, treatment for their original tumor was surgical resection alone. Lobectomy was the most common operation for the original tumor, and 78% were stage I. When the second tumor was diagnosed, 25 patients (68%) were asymptomatic. Eight patients (22%) were current smokers, and 29 patients (78%) were former smokers. The most common operation for the second tumor was a lobectomy. Surgical mortality was 5.4%. Nineteen patients (51%) survived 2 years, and 9 patients (24%) survived > or = 5 years. Eleven patients (30%) were still alive at last follow-up, 3 to 198 months postoperatively, and only 13 patients (34%) had died of their cancer. CONCLUSION: Surgical treatment of second primary pulmonary neoplasms can be performed in selected patients with acceptable long-term survival.

MIDCAB: impact of epicardial stabilization upon outcomes.

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) has been criticized as compromising anastomotic patency. Epicardial mechanical stabilization devices purportedly facilitate left internal mammary artery (LIMA) anastomosis, thereby enhancing patency and outcome. METHODS: From June 1996 through January 1999, 39 patients underwent MIDCAB via a small left anterior thoracotomy for revascularization of the left anterior descending coronary artery (LAD) without cardiopulmonary bypass (CPB). Immediate postoperative coronary angiography was performed on 38 of the patients. RESULTS: Group 1 consisted of 11 patients who were operated upon without epicardial stabilization. Mean age was 64 years. Two had undergone previous coronary artery bypass (CAB). Predicted mortality was 4.3%. Angiographic anastomotic patency was 60%. Revisions on CPB in three cases increased LIMA patency to 90%. There was one intra-operative death. Average length of stay (LOS) was 5.4 days. Group 2 consisted of 28 patients operated on with mechanical epicardial stabilization. Predicted risk of mortality was 4.4%. Mean age was 66 years. Twelve had undergone previous CAB. Anastomotic patency at angiography was 97.4%. There were no intra-operative deaths and mean LOS was 3.0 days. CONCLUSIONS: We conclude that mechanical epicardial stabilization has transformed the MIDCAB operation into one that offers excellent early patency and clinical outcomes. This operation is of particular value for revascularization of the anterior coronary circulation in patients with previous CAB; clinical results are significantly better than predicted for standard redo-CAB.

Sweet's syndrome and associated sarcoidosis--a rare clinical case.

Sweet's syndrome is frequently idiopathic; however, it has been associated with malignancy in up to 20% of reported cases. We report a case of concurrent presentation of Sweet's syndrome with sarcoidosis. Although this association has been infrequently described we feel that this could be an alternative diagnosis in patients with Sweet's syndrome who present with mediastinal lymphadenopathy with or without erythema nodosum. The relevant literature on this subject is reviewed.

Optimal electrode position for transvenous defibrillation: a prospective randomized study.

OBJECTIVES: This study was performed to determine the optimal position for the proximal electrode in a two-electrode transvenous defibrillation system. BACKGROUND: Minimizing the energy required to defibrillate the heart has several potential advantages. Despite the increased use of two-electrode transvenous defibrillation systems, the optimal position for the proximal electrode has not been systematically evaluated. METHODS: Defibrillation thresholds were determined twice in random sequence in 16 patients undergoing implantation of a two-lead transvenous defibrillation system; once with the proximal electrode at the right atrial-superior vena cava junction (superior vena cava position) and once with the proximal electrode in the left subclavian-innominate vein (innominate vein position). RESULTS: The mean (+/- SD) defibrillation threshold with the proximal electrode in the innominate vein position was significantly lower than with the electrode in the superior vena cava position (13.4 +/- 5.7 J vs. 16.3 +/- 6.6 J, p = 0.04). Defibrillation threshold with the proximal electrode in the innominate vein position was lower or equal to that achieved in the superior vena cava position in 75% of patients. In patients with normal heart size (cardiothoracic ratio < or = 0.55), the improvement in defibrillation threshold with the proximal electrode in the innominate vein position was more significant than in patients with an enlarged heart (innominate vein 13.0 +/- 6.5 J vs. superior vena cava 17.9 +/- 5.1 J, p < 0.01). In patients with an enlarged heart, no difference between the two sites was observed (innominate vein 13.9 +/- 4.5 J vs. superior vena cava 13.6 +/- 8.3 J, p = NS). CONCLUSIONS: During implantation of a two-lead transvenous defibrillation system, positioning the proximal defibrillation electrode in the subclavian-innominate vein will lower defibrillation energy requirements in the majority of patients.

Cleft in the anterior and posterior leaflet of the mitral valve: a rare anomaly.

A rare entity that causes congenital mitral regurgitation is an isolated cleft mitral valve. The cleft in the mitral valve can be seen in either the anterior or posterior leaflet of the valve. We present a unique case of an individual with a history of congenital mitral regurgitation caused by a cleft in both the anterior and posterior leaflets of the mitral valve.

The specificity of normal qualitative angiography in excluding cardiac allograft vasculopathy.

It has been frequently stated that qualitative coronary angiography is insensitive in the diagnosis of cardiac allograft vasculopathy because the disease can be diffuse without observable luminal irregularities. However, the specificity of otherwise normal qualitative coronary angiography for excluding cardiac allograft vasculopathy has not been prospectively studied. Accordingly, 28 patients who underwent transplantation from June 23, 1989 to July 9, 1990 underwent coronary angiography within 3 weeks (predischarge) after transplantation and at 1 year. Twenty-one of these patients who had both normal 1-year qualitative coronary angiography and predischarge angiograms adequate for analysis served as the study cohort. Cross-section luminal diameters (average, 14.3 per angiogram) were measured at the same branch points on each pair of angiograms in the right anterior oblique view. Seventeen of the 21 patients had no change in average luminal diameters, while the remaining four patients had consistent narrowing in all vessels and in all segments. In these four patients, the mean fall in luminal diameter was 20% +/- 2%. The specificity of normal qualitative angiography in predicting absence of cardiac allograft vasculopathy is 81%. In conclusion, qualitative angiography usually predicts the absence of cardiac allograft vasculopathy. However, 15% to 20% of patients will have diffuse disease not detected by a normal study.

Cardiac allografts from high-risk donors: excellent clinical results.

Rising waiting list mortality and increasing demand for donor organs have led to extension of traditionally accepted criteria for evaluation of cardiac grafts. From December 1985 to June 1992, 188 cardiac grafts were orthotopically transplanted into 178 recipients. Of these grafts, 38.3% (72/188) were defined as high-risk donors. Risk criteria included prolonged cardiopulmonary resuscitation, age greater than 40 years, high inotrope requirements, undersizing by more than 20% body weight, significant wall motion impairment by echocardiography, elevation of myocardial enzyme levels, and cold ischemia time greater than 4 hours. There were no recipient deaths attributable to primary graft failure in the perioperative period. Operative (30-day), 1-year and 5-year survival was 95.5%, 86.1%, and 77.3%, respectively, in the high-risk group compared with 93.7%, 86.0%, and 67.2%, respectively, in the low-risk donor cohort (p = 0.94). Comparison of duration of postoperative inotrope use, intensive care unit stay, total hospital stay, and in-hospital costs revealed no significant trends favoring either group in postoperative morbidity. Among long-term survivors, development of graft coronary disease was noted in 47.1% (24/51) of the high-risk donor group and only 17.4% (12/69) of the remaining group (p = 0.0005). Left ventricular ejection fractions in the high risk donor group were 0.58 +/- 0.01 at 2 years. Review of this series suggests that selective use of apparently compromised cardiac donors is compatible with excellent cardiac function and survival. Higher incidence of graft vasculopathy may cause significant morbidity during late follow-up.

Heart transplantation in patients with previous cardiac operations. Excellent clinical results.

A significant proportion of potential transplant recipients have undergone previous cardiac procedures and may be subject to an increased risk because of technical and other factors inherent in a reoperation. Between December 1985 and June 1991, 155 orthotopic heart transplantations were carried out in 146 patients. Eighty-five transplantations (54.8%) were carried out as the initial cardiac operation (group I); 61 operations (45.2%) were performed in patients who had previous nontransplant cardiac operations (group II). Preoperative variables including hemodynamic indexes, renal function, and status on the waiting list were similar between these groups; however, group II patients tended to be older than group I patients (51.9 +/- 10.7 versus 47.7 +/- 11.6 years, respectively; p < 0.05) and were more likely to have ischemic heart disease (80.3% versus 34.1%) than were those in group I. Significantly longer cardiopulmonary bypass time (127.6 +/- 44.7 minutes versus 108.2 +/- 18.8 minutes, p < 0.01) and duration of operation (448.1 +/- 120.9 minutes versus 353.2 +/- 85.1 minutes, p < 0.01) was found in group II. Operative mortality in group I was 4.7% and in group II was 6.6% (p > 0.9). Group I actuarial survival at 1 year and 5 years was 87.1% +/- 3.6% and 72.9% +/- 6.2%, respectively. Group II actuarial survival was 85.3% +/- 4.5% and 76.0% +/- 6.6%, respectively, for the same time periods. In spite of the greater technical challenge implied by previous cardiac operations, no significant survival differences occurred between these groups (p > 0.9). However, patients undergoing a second cardiac transplantation (n = 9) were identified as a high-risk subset with operative mortality of 22.8% and 1-year survival of only 33.3% +/- 15.7% (p < 0.0003). Cardiac transplantation in patients who have undergone previous nontransplant cardiac operations can be carried out without compromising immediate or long-term outcome.

ABO-incompatible heart transplantation: a special case for the A2 donor.

Limited clinical experience concerning heart transplantation across ABO blood group barriers suggests a high incidence of hyperacute rejection and poor patient outcome. Reported is a case of the short-term survival of an ABO-mismatched cardiac graft without evident adverse immunologic effects. A 41-year-old man with blood type O underwent heart transplantation receiving a blood type A2 donor organ. Cyclosporine-based immunosuppression was augmented with daily plasmapheresis and OKT3 therapy. Circulating anti-A antibodies were reduced quickly and held to a very low level with this regimen. The patient remained hemodynamically stable until retransplantation 4 days later. The explanted heart showed no evidence of cellular infiltrate or antibody deposition. Long-term success with the use of type A2 organs in type O recipients has been shown in select series with other types of solid organ transplants. Although this patient underwent retransplantation early, the lack of rejection phenomena gives evidence that the relatively low antigenicity of the A2 subtype may allow planned heart transplantation across this blood group barrier, either as a bridge or on a permanent basis.

Prolonged cytomegalovirus infection with viremia is associated with development of cardiac allograft vasculopathy.

Several reports have suggested an association between cytomegalovirus infection and the subsequent development of cardiac allograft vasculopathy. The difficulties in interpreting these studies include the variety of methods used for the diagnosis of cytomegalovirus infection and variable criteria for the diagnosis of cardiac allograft vasculopathy. To determine whether specific aspects of cytomegalovirus infection are risk factors for cardiac allograft vasculopathy, the patient population of the Oregon Cardiac Transplant Program was analyzed for the following variables: cytomegalovirus infection, primary cytomegalovirus infection, and persistent cytomegalovirus infection for 4 or 6 months documented by either blood or urine cultures and persistent cytomegalovirus viremia for 4 months. In the 129 patients available for analysis, there was no higher incidence of cardiac allograft vasculopathy in patients with or without cytomegalovirus infection, nor was there a higher incidence of cardiac allograft vasculopathy in primary cytomegalovirus infection. There was a nonstatistically significant trend toward an increased incidence of cardiac allograft vasculopathy in patients with persistent cytomegalovirus infection as assessed by cultures positive for infection in either blood or urine. There was, however, a significant increase in the incidence of cardiac allograft vasculopathy in patients who had persistent viremia for at least 4 months compared with those without this finding (47% vs 18%, respectively; p = 0.012). In our population persistent cytomegalovirus viremia and presumably long-term exposure of the allograft coronary tree to cytomegalovirus is associated with cardiac allograft vasculopathy.

Methods of implantable cardioverter-defibrillator-pacemaker insertion to avoid interactions.

Experience with combined transvenous pacemaker and implantable cardioverter-defibrillator insertion in 21 patients is described. Special techniques are needed to avoid potentially lethal pacemaker-implantable cardioverter-defibrillator interaction. Separation between leads for the two devices should be maximized. The electrophysiologic criteria for successful device function can be met, even when some leads for both devices must be placed by a transvenous approach.

University of Wisconsin solution for human donor heart preservation: initial clinical experience.

Although in vitro and primate orthotopic transplant experiments have suggested the superiority of University of Wisconsin solution (UWS) compared with crystalloid cardioplegia and saline solution storage for hypothermic heart preservation, concerns about the viscosity and the high potassium concentration of UWS have precluded its use in human cardiac transplantation. To test the safety and efficacy of UWS, 16 patients received hearts arrested with, flushed with, and stored in UWS at 4 degrees C for a mean ischemic time of 153.3 +/- 30.7 minutes. After reperfusion, the hearts contracted vigorously and attained a stable sinus rhythm within 4.0 +/- 2.4 minutes, and the patients were weaned from bypass in 24.5 +/- 8.0 minutes. There was no evidence of acute or chronic ischemic myocardial injury by enzymatic analysis, electrocardiography, or biopsy specimen histology. The results suggest UWS can be safely used, within currently accepted limits of donor ischemic time, to arrest and preserve human hearts for transplantation. Further studies of preservation are required to compare UWS with crystalloid cardioplegia and saline solution storage and to test the ability of UWS to prolong the period of safe donor hypothermic ischemia in clinical heart transplantation.

Improved heart preservation with University of Wisconsin solution: experimental and preliminary human experience.

We tested the ability of University of Wisconsin solution (UWS) to extend hypothermic nonperfused heart preservation in baboons and then proceeded to human transplantation. Orthotopic transplantation was performed in five baboons (UWS cardioplegia and storage [4 degrees C]; preservation time 10.3 +/- 0.6 hours). Four survivors were immunosuppressed for 45 days and killed. One animal died from disruption of the aortic anastomosis due to technical error. Preservation did not alter histology under light and electron microscopy or heart weight (at harvest, 51.4 +/- 11.6 g; before implant, 52.5 +/- 11.1 g). Animals were weaned from bypass (mean, 23 +/- 12 minutes) and returned to their cages without intravenous support within 3.6 +/- 0.6 hours. Weekly biopsy, electrocardiogram, enzyme analysis, echocardiogram, and right heart catheterization demonstrated excellent cardiac function. Following success in baboons, UWS was applied to human transplantation (n = 2, UWS cardioplegia and storage [4 degrees C]; preservation time 4.2 and 2.1 hours). The hearts returned to sinus rhythm within 4 minutes of reperfusion without defibrillation, and enzymatic and hemodynamic data reveal excellent heart preservation. Preliminary data suggest the ability of UWS to prolong heart preservation in baboons and be used safely in humans. Further studies are required to compare UWS with crystalloid cardioplegia and saline storage and to prolong donor heart preservation in humans.