Contemporary national outcomes of hyperbaric oxygen therapy in necrotizing soft tissue infections.

BACKGROUND: The role of hyperbaric oxygen therapy (HBOT) in necrotizing soft tissue infections (NSTI) is mainly based on small retrospective studies. A previous study using the 1998-2009 National Inpatient Sample (NIS) found HBOT to be associated with decreased mortality in NSTI. Given the argument of advancements in critical care, we aimed to investigate the continued role of HBOT in NSTI. METHODS: The 2012-2020 National Inpatient Sample (NIS) was queried for NSTI admissions who received surgery. 60,481 patients between 2012-2020 were included, 600 (<1%) underwent HBOT. Primary outcome was in-hospital mortality. Secondary outcomes included amputation, hospital length of stay, and costs. A multivariate model was constructed to account for baseline differences in groups. RESULTS: Age, gender, and comorbidities were similar between the two groups. On bivariate comparison, the HBOT group had lower mortality rate (<2% vs 5.9%, p<0.001) and lower amputation rate (11.8% vs 18.3%, p<0.001) however, longer lengths of stay (16.9 days vs 14.6 days, p<0.001) and higher costs ($54,000 vs $46,000, p<0.001). After multivariate analysis, HBOT was associated with decreased mortality (Adjusted Odds Ratio (AOR) 0.22, 95% CI 0.09-0.53, P<0.001) and lower risk of amputation (AOR 0.73, 95% CI 0.55-0.96, P = 0.03). HBO was associated with longer stays by 1.6 days (95% CI 0.4-2.7 days) and increased costs by $7,800 (95% CI $2,200-$13,300), they also had significantly lower risks of non-home discharges (AOR 0.79, 95%CI 0.65-0.96). CONCLUSIONS: After correction for differences, HBOT was associated with decreased mortality, amputations, and non-home discharges in NSTI with the tradeoff of increase to costs and length of stay.

Outcomes and Prognostic Factors of Pulmonary Hypertension Patients Undergoing Emergent Endotracheal Intubation.

Background: Emergent endotracheal intubations (ETI) in pulmonary hypertension (PH) patients are associated with increased mortality. Post-intubation interventions that could increase survivability in this population have not been explored. We evaluate early clinical characteristics and complications following emergent endotracheal intubation and seek predictors of adverse outcomes during this post-intubation period. Methods: Retrospective cohort analysis of adult patients with groups 1 and 3 PH who underwent emergent intubation between 2005-2021 in medical and liver transplant ICUs at a tertiary medical center. PH patients were compared to non-PH patients, matched by Charlson Comorbidity Index. Primary outcomes were 24-h post-intubation and inpatient mortalities. Various 24-h post-intubation secondary outcomes were compared between PH and control cohorts. Results: We identified 48 PH and 110 non-PH patients. Pulmonary hypertension was not associated with increased 24-h mortality (OR 1.32, 95%CI 0.35-4.94, P = .18), but was associated with inpatient mortality (OR 4.03, 95%CI 1.29-12.5, P = .016) after intubation. Within 24 h post-intubation, PH patients experienced more frequent acute kidney injury (43.5% vs. 19.8%, P = .006) and required higher norepinephrine dosing equivalents (6.90 [0.13-10.6] mcg/kg/min, vs. 0.20 [0.10-2.03] mcg/kg/min, P = .037). Additionally, the median P/F ratio (PaO2/FiO2) was lower in PH patients (96.3 [58.9-201] vs. 233 [146-346] in non-PH, P = .001). Finally, a post-intubation increase in PaCO2 was associated with mortality in the PH cohort (post-intubation change in PaCO2 +5.14 ± 16.1 in non-survivors vs. -18.7 ± 28.0 in survivors, P = .007). Conclusions: Pulmonary hypertension was associated with worse outcomes after emergent endotracheal intubation than similar patients without PH. More importantly, our data suggest that the first 24 hours following intubation in the PH group represent a particularly vulnerable period that may determine long-term outcomes. Early post-intubation interventions may be key to improving survival in this population.

Chronic Obstructive Pulmonary Disease is Not Associated with In-Hospital Mortality in COVID-19: An Observational Cohort Analysis.

Background: Chronic obstructive pulmonary disease (COPD) is associated with worsened outcomes in COVID-19 (coronavirus disease 2019). However, data remain fraught with heterogeneity and bias from comorbid conditions. Additionally, data on the impact of COPD-specific factors, such as pre-hospital medications and pulmonologist involvement, remain sparse. Objective: We report a single-center analysis of COPD patients hospitalized with COVID-19 compared to those without COPD. Primary outcomes include ICU admission, mechanical ventilation, and in-hospital mortality. Methods: We evaluated all patients ≥40 years admitted with PCR-confirmed COVID-19 between February 2020 and February 2021. COPD was defined by documented ICD-10 diagnosis of COPD, confirmed smoking history, and active bronchodilator use. We compared outcomes between COPD patients and the remainder of the COVID-19 cohort. Multivariable analyses were adjusted for age, sex, smoking status, and comorbid conditions. Results: Of 1537 hospitalized COVID-19 patients, 122 (7.9%) carried a diagnosis of COPD. The COPD cohort was older (74 ± 13 vs 66 ± 15 years, P < 0.001) and more often former smokers (P < 0.001). Comorbid conditions including diabetes, cardiovascular disease, and kidney disease were more prevalent in the COPD group (P < 0.001). After adjusting for comorbid conditions, the COPD cohort had higher severity scores and trended towards fewer hospital-free days. Among patients with COPD, pre-hospital use of aspirin was associated with decreased ICU admissions (aHR 0.56, P = 0.049) and mechanical ventilation (aHR 0.25, P = 0.008), while LAMAs (long-acting muscarinic antagonists) were associated with decreased in-hospital mortality (aHR 0.34, P = 0.047). Involvement of pulmonology in pre-hospital management of COPD was not found to significantly affect outcomes. Conclusion: When corrected for comorbid illnesses, COPD was associated with more severe disease but not with increased ICU admission, mechanical ventilation, or in-hospital mortality rates. Among COPD patients, prehospital treatment with aspirin and COPD-directed therapies were associated with improved outcomes.

Shock Management Without Formal Fluid Responsiveness Assessment: A Retrospective Analysis of Fluid Responsiveness and Its Outcomes.

BACKGROUND: In order to quantify fluid administration and evaluate the clinical consequences of conservative fluid management without hemodynamic monitoring in undifferentiated shock, we analyzed previously collected data from a study of carotid Doppler monitoring as a predictor of fluid responsiveness (FR). METHODS: This study was a retrospective analysis of data collected from a single tertiary academic center from a previous study. Seventy-four patients were included for post-hoc analysis, and 52 of them were identified as fluid responsive (cardiac output increase > 10% with passive leg raise) according to NICOMTM bioreactance monitoring (Cheetah Medical, Newton Center, MA, USA). Treating teams provided standard of care conservative fluid resuscitation but were blinded to independently performed FR testing results. Outcomes were compared between fluid responsive and fluid non-responsive patients. Primary outcome measures were volume fluids administered and net fluid balance 24- and 72-hour post-FR assessment. Secondary outcome measures included change in vasopressor requirements, mean peak lactate levels, length of hospital/intensive care unit stay, acute respiratory failure, hemodialysis requirement, and durations of vasopressors and mechanical ventilation. RESULTS: Mean fluids administered within 72 hours were similar between fluid non-responsive and fluid responsive patients (139 mL/kg [95% confidence interval [CI]: 102.00-175.00] vs. 136 mL/kg [95% CI: 113.00-158.00], p = 0.92, respectively). We observed an insignificant trend toward higher 28-day mortality among fluid non-responsive patients (36% vs. 19%, p = 0.14). Volume of fluids administered significantly correlated with adverse outcomes such as increased hemodialysis requirements (32 patients, 43%), (odds ratio [OR] = 1.7200, p = 0.0018). Subgroup analysis suggested administering ≥ 30 mL/kg fluids to fluid responsive patients had a trend toward increased mortality (25% vs. 0%, p = 0.09) and a significant increase in hemodialysis (55% vs. 17%, p = 0.024). CONCLUSIONS: Without formal FR assessment, similar amounts of total fluids were administered in both fluid responsive and non-responsive patients. As greater volumes of intravenous fluids administered were associated with adverse outcomes, we suggest that dedicated FR assessment may be a beneficial utility in early shock resuscitation.

Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis.

BACKGROUND: Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes. METHODS: We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes. RESULTS: An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P < .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P = .40). CONCLUSIONS: In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.

Passive Leg Raise: Feasibility and Safety of the Maneuver in Patients With Undifferentiated Shock.

PURPOSE: Passive leg raise (PLR), in combination with technologies capable of capturing stroke volume changes, has been widely adopted in the management of shock. However, dedicated evaluation of safety, feasibility, and receptiveness of patients and nursing staff to PLR maneuver is missing. METHODS: A noninterventional, prospective trial recruited adult patients with onset of undifferentiated shock within 24 hours with persistent vasopressor requirements despite fluid resuscitation. A standardized PLR maneuver was used to compare two noninvasive hemodynamic monitoring systems, each without significant impact on the performance of the maneuver. Safety and efficacy of the PLR were evaluated via subjective and objective measures. Objective measures of patient comfort and tolerance were evaluated through changes in vital signs, sedation, and analgesia requirements. Nurses and awake patients completed surveys on their experience. RESULTS: Seventy-nine patients were enrolled. Testing was aborted in 2 cases for medical reasons (one patient developed rapid atrial fibrillation, second had profound desaturation). Of all, 5.4% of patients required additional vasopressor support after completion of the PLR maneuver due to persistent hypotension and 4.1% of patients required additional sedation. Among awake patients (N = 35), 6% reported pain and 29% reported discomfort. A total of 11% of nurses reported minor technical difficulties with the maneuver. CONCLUSION: Passive leg raise maneuver leads to a few serious but reversible complications in a selected population of hemodynamically unstable patients. Although it provides relevant diagnostic information, it may impact patient care. Treating physician should be aware of infrequent but possible complications and appreciate the impact of the maneuver on patients' comfort and nursing workload.

A Targeted Swallow Screen for the Detection of Postoperative Dysphagia in Liver Transplant Patients.

INTRODUCTION: Postoperative dysphagia leads to aspiration pneumonia, prolonged hospital stay, and is associated with increased mortality. We have demonstrated the validity of a bedside targeted swallow evaluation following cardiac surgery. Since dysphagia following liver transplantation is not well examined, we evaluated the efficacy of this swallow screen method in postoperative liver transplant patients. METHODS: This was a prospective trial involving adult patients who underwent liver transplant surgery at our institution over a 5-month period. Within 24 hours of extubation and prior to the initiation of oral intake, all patients were evaluated using the targeted swallow screen, which is a direct assessment of mental status and laryngeal sensation/elevation upon swallowing of progressively larger amounts of water. A fiberoptic endoscopic evaluation of swallowing was requested for failed screenings. RESULTS: During the study, 50 patients were screened. Twenty (40%) failed the targeted swallow screen, while 18 (90%)/20 failed the subsequent fiberoptic endoscopic examination (overall dysphagia incidence = 40%). Patients with dysphagia were older and had significantly longer intensive care unit and hospital stays. The screening test had a 90% sensitivity and a specificity of 83% for detecting dysphagia. CONCLUSION: The true incidence of dysphagia following liver transplantation appears to be significantly higher than previously recognized. A simple bedside swallow screen can efficiently screen these patients for dysphagia. Our findings require further validation and may support programs for reduction and early detection of dysphagia.

Comparison of Frequency of Late Gastrointestinal Bleeding With Transcatheter Versus Surgical Aortic Valve Replacement.

Improvements in technology and operator experience have led to exponential growth of transcatheter aortic valve implantation (TAVI) programs. Late bleeding complications were recently highlighted after TAVI with a high impact on morbidity. The purpose of the present study was to assess the incidence and financial impact of late Gastrointestinal (GI) bleeding after TAVI, and compare with the surgical cohort. Retrospective analysis of the National Readmissions Database was performed from January 2011 to December 2014, and patients who underwent TAVI or surgical aortic valve replacement (SAVR) were identified. Incidence of readmission with a diagnosis of GI bleeding was utilized as the primary end point. Overall, 43,357 patients were identified who underwent TAVI, whereas 310,013 patients underwent SAVR. Compared with SAVR, TAVI patients were older (81 vs 68y, p < 0.001), more women (48% vs 36%, p < 0.001), and had higher Elixhauser Comorbidity Index (6 vs 5, p < 0.001). Hospital stay was shorter with TAVI (5 vs 8 days, p < 0.001), but raw in-hospital mortality rates were similar (4.2% vs 3.8%, p = 0.022). In the TAVI cohort, 3.3% of patients were rehospitalized for GI bleeding compared with 1.5% of the SAVR cohort (p < 0.001). Average time to bleeding readmission was similar between cohorts (92 vs 84 days, p = 0.049). After multivariable adjustment, TAVI remained significantly associated with readmissions for GI bleeding compared with SAVR Adjusted Odds Ratio (AOR 1.54 [1.38 to 1.71], p < 0.001). In this national cohort study, TAVI was associated with more frequent readmissions for late GI bleeding compared with SAVR. In conclusion, strategies to reduce late GI bleeding may serve as important targets for improvement in overall quality of care.

Incidence of Cerebral Microemboli in Single-Dose vs. Multidose Cardioplegia in Adult Cardiac Surgery.

Cerebral microemboli have been associated with neurocognitive deficits after cardiac operations using cardiopulmonary bypass (CPB). Interventions by the perfusionist and alterations in blood flow account for a large proportion of previously unexplained microemboli. This study compared the incidence of microemboli during cardiac operations using conventional (multidose) and del Nido (single-dose) cardioplegia delivery. Transcranial Doppler ultrasonography was used to detect microemboli in bilateral middle cerebral arteries of 30 adult patients undergoing cardiac operations using CPB and aortic clamping. Multidose conventional blood cardioplegia (CBC) was used in 15 patients and single-dose del Nido cardioplegia (DNC) in 15. Manual count of microemboli during cross-clamp and during administration of cardioplegia was performed. Baseline preoperative characteristics were similar between groups. There were no differences in the ascending aortic atheroma grade (1.4 ± .4 CBC vs. 1.6 ± .7 DNC, p = .44), bypass times (141 ± 36 minutes CBC vs. 151 ± 33 minutes DNC, p = .64), and cross-clamp times (118 ± 32 minutes CBC vs. 119 ± 45 minutes DNC, p = .95). The use of multidose CBC was associated with a seven-fold increase in the number of microemboli per minute of bypass (1.65 ± 1 vs. .24 ± .18 emboli/min DNC, p = .0004). In this prospective pilot study, we found that the use of single-dose cardioplegia strategy led to fewer cerebral microemboli when compared with the traditional multidose approach. Our findings warrant further investigation of various cardioplegia strategies and neurologic outcomes in larger cohorts.

Ultrasound Assessment of the Change in Carotid Corrected Flow Time in Fluid Responsiveness in Undifferentiated Shock.

OBJECTIVES: Adequate assessment of fluid responsiveness in shock necessitates correct interpretation of hemodynamic changes induced by preload challenge. This study evaluates the accuracy of point-of-care Doppler ultrasound assessment of the change in carotid corrected flow time induced by a passive leg raise maneuver as a predictor of fluid responsiveness. Noninvasive cardiac output monitoring (NICOM, Cheetah Medical, Newton Center, MA) system based on a bioreactance method was used. DESIGN: Prospective, noninterventional study. SETTING: ICU at a large academic center. PATIENTS: Patients with new, undifferentiated shock, and vasopressor requirements despite fluid resuscitation were included. Patients with significant cardiac disease and conditions that precluded adequate passive leg raising were excluded. INTERVENTIONS: Carotid corrected flow time was measured via ultrasound before and after a passive leg raise maneuver. Predicted fluid responsiveness was defined as greater than 10% increase in stroke volume on noninvasive cardiac output monitoring following passive leg raise. Images and measurements were reanalyzed by a second, blinded physician. The accuracy of change in carotid corrected flow time to predict fluid responsiveness was evaluated using receiver operating characteristic analysis. MEASUREMENTS AND MAIN RESULTS: Seventy-seven subjects were enrolled with 54 (70.1%) classified as fluid responders by noninvasive cardiac output monitoring. The average change in carotid corrected flow time after passive leg raise for fluid responders was 14.1 ± 18.7 ms versus -4.0 ± 8 ms for nonresponders (p < 0.001). Receiver operating characteristic analysis demonstrated that change in carotid corrected flow time is an accurate predictor of fluid responsiveness status (area under the curve, 0.88; 95% CI, 0.80-0.96) and a 7 ms increase in carotid corrected flow time post passive leg raise was shown to have a 97% positive predictive value and 82% accuracy in detecting fluid responsiveness using noninvasive cardiac output monitoring as a reference standard. Mechanical ventilation, respiratory rate, and high positive end-expiratory pressure had no significant impact on test performance. Post hoc blinded evaluation of bedside acquired measurements demonstrated agreement between evaluators. CONCLUSIONS: Change in carotid corrected flow time can predict fluid responsiveness status after a passive leg raise maneuver. Using point-of-care ultrasound to assess change in carotid corrected flow time is an acceptable and reproducible method for noninvasive identification of fluid responsiveness in critically ill patients with undifferentiated shock.

Vascular Complications in the Sapien 3 Era: Continued Role of Transapical Approach to Transcatheter Aortic Valve Replacement.

With the introduction of the latest generation Sapien 3 (S3) transcatheter aortic valve, there has been a reduction in the usage of transapical (TA) approach for transcatheter aortic valve replacements in many centers. However, despite the smaller sheath size and the more streamlined delivery system, vascular complications continue to occur, especially in patients with peripheral vascular disease. Thus, our institution has maintained a stringent TA protocol aiming to prevent these complications. We hypothesize that this protocol has helped to reduce vascular complications and improve outcomes at our institution even in the S3 era. All transcatheter aortic valve replacement procedures done at our institution were considered for analysis. Patients were grouped according to whether their procedure was done before (Pre-S3 era) or after (S3 era) the introduction of the S3 valve, as well as whether they underwent a TA or a transfemoral (TF) approach. A femoral artery intraluminal diameter of <7.5 mm in the Pre-S3 era and <5.5 mm in the S3 era with circumferential calcifications triggered TA approach consideration. Vascular complications included vascular perforation, dissection, flow-limiting stenosis, unplanned vascular surgery, significant postprocedural bleeding, hematoma at the access site, and retroperitoneal bleed. The Welch t test of unequal variance and chi-squared test were used as appropriate. An alpha of <0.05 was considered significant. A total of 275 patients were included in the analysis (121 Pre-S3 era and 154 S3 era). The TA approach was utilized in 45% in the Pre-S3 era vs 15% in the S3 era (P < 0.001). Within the S3 era, 131 underwent the TF approach compared with 23 who underwent the TA approach. TA and TF patients were similar in all preoperative characteristics except hypertension. Mortality was significantly lower in the S3 era (0% vs 4% in the pre-S3 era, P = 0.02). Overall rates of vascular complications were similar between the Pre-S3 and the S3 eras (16% vs 14%, P = 0.63). Overall adverse outcomes were similar between the TA and the TF groups. TA patients saw significantly longer intensive care unit stay and total hospital stay. Our results show that despite a smaller sheath size, vascular complications continue at a similar rate into the S3 era. This occurred in the setting of an ongoing aggressive TA utilization in select patients, specifically those with peripheral vascular disease. Maintaining this approach is likely a large contributor to both our current success and reduced mortality.

Improved costs and outcomes with conscious sedation vs general anesthesia in TAVR patients: Time to wake up?

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has become a commonplace procedure for the treatment of aortic stenosis in higher risk surgical patients. With the high cost and steadily increasing number of patients receiving TAVR, emphasis has been placed on optimizing outcomes as well as resource utilization. Recently, studies have demonstrated the feasibility of conscious sedation in lieu of general anesthesia for TAVR. This study aimed to investigate the clinical as well as cost outcomes associated with conscious sedation in comparison to general anesthesia in TAVR. METHODS: Records for all adult patients undergoing TAVR at our institution between August 2012 and June 2016 were included using our institutional Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) registries. Cost data was gathered using the BIOME database. Patients were stratified into two groups according to whether they received general anesthesia (GA) or conscious sedation (CS) during the procedure. No-replacement propensity score matching was done using the validated STS predicted risk of mortality (PROM) as a propensity score. Primary outcome measure with survival to discharge and several secondary outcome measures were also included in analysis. According to our institution's data reporting guidelines, all cost data is presented as a percentage of the general anesthesia control group cost. RESULTS: Of the 231 patients initially identified, 225 (157 GA, 68 CS) were included for analysis. After no-replacement propensity score matching, 196 patients (147 GA, 49 CS) remained. Overall mortality was 1.5% in the matched population with a trend towards lower mortality in the CS group. Conscious sedation was associated with significantly fewer ICU hours (30 vs 96 hours, p = <0.001) and total hospital days (4.9 vs 10.4, p<0.001). Additionally, there was a 28% decrease in direct cost (p<0.001) as well as significant decreases in all individual all cost categories associated with the use of conscious sedation. There was no difference in composite major adverse events between groups. These trends remained on all subsequent subgroup analyses. CONCLUSION: Conscious sedation is emerging as a safe and viable option for anesthesia in patients undergoing transcatheter aortic valve replacement. The use of conscious sedation was not only associated with similar rates of adverse events, but also shortened ICU and overall hospital stays. Finally, there were significant decreases in all cost categories when compared to a propensity matched cohort receiving general anesthesia.

Dysphagia after Cardiac Operations Is Associated with Increased Length of Stay and Costs.

Although the true incidence of postoperative dysphagia after cardiac surgery is unknown, it has been reported to occur in 3 to 21.6 per cent of patients. Historically, dysphagia has been associated with increased surgical complications and prolonged hospital stay. This study aimed to evaluate the costs and outcomes associated with dysphagia after cardiac surgery. Patients undergoing nonemergent, nontransplant cardiac operations between June 2013 and June 2014 were eligible for inclusion. Independent predictors of cost were identified through a multivariate linear regression model. Of the 354 patients (35% female) included for analysis, 56 (16%) were diagnosed with postoperative dysphagia. On univariate analysis, patients with dysphagia had increased intensive care unit and total hospital lengths of stay (11.8 vs 5.2 days, P < 0.001 and 18.2 vs 9.7 days, P < 0.001, respectively), and a 57 ± 15 per cent increase in cost of care (P < 0.001). Dysphagia was not associated with higher rates of in-hospital mortality (3.6% vs 3.0%, P = 0.83). On multivariate linear regression, the development of dysphagia was independently associated with a 45.1 per cent increase in total hospital costs [95% confidence interval (31% and 59%), P < 0.001]. Dysphagia is an independent and major contributor to health care costs after cardiac operations, suggesting that postoperative dysphagia represents a highly suitable target for quality improvement and cost containment efforts.

Use of preoperative aspirin in combined coronary and valve operations.

BACKGROUND: The aim of this study was to determine the relationship between preoperative aspirin use and postoperative outcomes in patients undergoing combined coronary artery bypass grafting and valve operations. METHODS: All combined coronary artery bypass grafting and valve procedures from 2008 to 2015 at our institution were identified. After exclusions, patients were stratified according to those that received preoperative aspirin and those who did not. Propensity score methodology was used to match the 2 groups using baseline and operative characteristics. Logistic regression models were then developed to assess differences in postoperative outcomes between groups. RESULTS: Of the 563 patients identified, 534 met inclusion criteria: preoperative aspirin = 327 (61.2%), no preoperative aspirin = 207 (38.8%). After propensity matching, 194 patient pairs were analyzed, with no significant differences in preoperative characteristics. No significant differences were observed between the preoperative aspirin and no preoperative aspirin groups in rates of 30-day mortality (3.6% vs 4.1%, P = 1.00), major adverse cardiovascular events (23.2% vs 24.2%, P = .91), or 30-day readmission (12.4% vs 11.9%, P = 1.00), among others. CONCLUSION: Preoperative aspirin use in patients undergoing combined coronary artery bypass grafting and valve operations was not associated with significant differences in major postoperative outcomes. Large-scale, randomized trials are needed to better establish the role of preoperative aspirin in this population.

Do preoperative ß-blockers improve postoperative outcomes in patients undergoing cardiac surgery? Challenging societal guidelines.

Preoperative ß-blockers (BBs) are widely administered to reduce morbidity and mortality among surgical patients. In fact, the Society of Thoracic Surgeons uses the administration of preoperative BBs as a quality metric. Recent reports, however, have questioned the benefit and safety of preoperative BB administration. The aim of our study was to investigate whether preoperative BBs lead to improved surgical outcomes in patients undergoing cardiac surgery. A review of our prospectively maintained institutional database was done to identify adults undergoing cardiac operations at our institution from 2008 to 2013. Survival to discharge was the primary outcome with several additional secondary measures of morbidity included. A total of 2120 patients were included in the analysis and a multivariate logistic regression model was developed to adjust for differences between patient groups. After adjustment, BB administration was associated with lower odds of both prolonged ventilation (odds ratio [OR], 0.73; P = 0.032) and prolonged length of stay (OR, 0.79; P = 0.044). BB use was not associated with significant differences in other outcomes such as mortality or postoperative atrial fibrillation. Our study found that preoperative BBs may not be associated with sufficiently improved outcomes to justify their use as a quality metric in this population. Thus, prospective studies are warranted.

CHADS2 score predicts atrial fibrillation following cardiac surgery.

BACKGROUND: Atrial fibrillation (AF) following cardiac surgery portends higher morbidity and increased health expenditure. Although many anatomic and patient risk factors have been identified, a simple clinical scoring system to identify high-risk patients is lacking. The CHADS2 score is widely used to predict the risk of stroke in patients with AF. We assessed the utility of this scoring algorithm in predicting the development of de novo postoperative atrial fibrillation (POAF) in cardiac surgery patients. MATERIAL AND METHODS: A total of 2120 patients from 2008 to 2013 were identified for inclusion in our analysis. CHADS2 scores were calculated, and patients grouped into low- (0), intermediate- (1) and high-risk (≥2) categories. A multivariate regression model was developed to account for known risk factors of AF. RESULTS: Of the 2120 patients, 344 (16.2%) patients developed de novo POAF during their primary hospitalization. Mean CHADS2 scores for POAF patients and no POAF patients were 2.1 ± 1.2 and 1.7 ± 1.3 (P < 0.0001), respectively. CHADS2 score was a significant predictor of AF on multivariate regression analysis (adjusted odds ratio, 1.26; 95% confidence interval, 1.14-1.40). As CHADS2 score increased from 0 to 6, the probability of POAF increased from 11.1% to 32.7% (P < 0.0001). Compared with the low-risk group, the intermediate-risk and high-risk groups had a 1.73- and 2.58-fold increase in odds of developing POAF, respectively (P < 0.02 and P < 0.0001). CONCLUSIONS: CHADS2 score is a powerful and convenient predictor of developing POAF. We recommend its utilization in identifying high-risk patients that may benefit from pharmacologic prophylaxis.