Outcomes of Early Mitral Valve Reoperation in the Medicare Population.

BACKGROUND: Surgical series on mitral valve reoperation are limited by small numbers and lack of national representation. Large-scale outcomes of reoperation for mitral valve surgery remain uncertain. METHODS: This is a descriptive analysis of 1,627 Medicare beneficiaries who underwent mitral valve reoperation within a 3-year follow-up period after an initial mitral operation (repair or replacement) that took place between 2000 and 2006. The primary outcomes were hospital mortality and long-term survival. RESULTS: The 1,627 patients included in the study comprise 1.6% of patients who underwent operation between 2000 and 2006. The initial surgery was repair in 49.9%, bioprosthetic replacement in 22.0%, and mechanical replacement in 28.1%. Re-repair was performed in 15.4%. Hospital mortality was 12.0% and was similar for repair and bioprosthetic or mechanical replacement. Reoperative mortality was similar for men and women and for patients aged 75 years or less versus more than 75 years; and was significantly higher for nonelective than for elective operations (15.6% versus 5.5%, p = 0.0001), for patients with endocarditis than without endocarditis (21.4% versus 11.0%, p = 0.0001), and for patients with heart failure than without heart failure (14.2% versus 9.9%, p = 0.0080). Cumulative long-term survival rates were 58.6% at 5 years. CONCLUSIONS: The incidence of mitral valve reoperation within 3 years after initial repair or replacement is low but carries high surgical risk, which is significantly increased by certain preoperative characteristics, such as urgent status, endocarditis, and heart failure.

A surgical simulation curriculum for senior medical students based on TeamSTEPPS.

OBJECTIVE: To investigate whether the existing Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum can effectively teach senior medical students team skills. DESIGN Single-group preintervention and postintervention study. SETTING AND INTERVENTION: We integrated a TeamSTEPPS module into our existing resident readiness elective. The curriculum included interactive didactic sessions, discussion groups, role-plays, and videotaped immersive simulation scenarios. MAIN OUTCOME MEASURES: Improvement of self-assessment scores, multiple-choice examination scores, and performance ratings of videotaped simulation scenarios before and after intervention. The videos were rated by masked reviewers on the basis of a global rating instrument (TeamSTEPPS) and a more detailed nontechnical skills evaluation tool(NOTECHS). PARTICIPANTS: Seventeen students participated and completed the study. RESULTS: The self-evaluation scores improved from 12.76 to 16.06 (P < .001). The increase was significant for all of the TeamSTEPPS competencies and highest for leadership skills (from 2.2 to 3.2; P < .001). The multiple-choice score rose from 84.9% to 94.1% (P < .01). The postintervention video ratings were significantly higher for both instruments (TeamSTEPPS, from 2.99 to 3.56; P < .01; and NOTECHS, from 4.07 to 4.59; P < .001). CONCLUSIONS: The curriculum led to improved self-evaluation and multiple-choice scores as well as improved team skills during simulated immersive patient encounters. The TeamSTEPPS framework may be suitable for teaching medical students teamwork concepts and improving their competencies. Larger studies using this framework should be considered to further evaluate the generalizability of our results and the effectiveness of TeamSTEPPS for medical students.

Sex differences in procedure selection and outcomes of patients undergoing mitral valve surgery.

BACKGROUND: There is a paucity of data on sex differences in procedure selection and outcomes of patients undergoing mitral valve surgery. METHODS AND RESULTS: The National Inpatient Sample database from 2005 to 2008 was searched to identify patients ≥30 years of age who underwent mitral valve repair or replacement (ICD-9-CM codes 35.12, 35.23, and 35.24). Women constituted 51.6% of the patients, and they were older, were less affluent, had higher values for the Charlson comorbidity index, and more often presented on an urgent/emergent basis. Women underwent repair less often than men (37.9% versus 55.9%, P < .001) and more often underwent concomitant tricuspid surgery or a Maze procedure. After adjustment for propensity scores, women were more likely to undergo replacement (odds ratio, 1.78; 95% confidence interval, 1.64-1.93; P = .0001), they had longer lengths of stay, and less favorable disposition. Among the patients who underwent mitral valve repair, women had a higher hospital mortality (2.06% versus 1.36%, P = .0328). After adjustment for propensity scores and concomitant procedures, this relationship was no longer statistically significant. CONCLUSIONS: Women are less likely than men to receive mitral valve repair. Although the higher hospital mortality of women presenting for mitral valve surgery was accounted for by their worse preoperative profiles, this sex disparity reflects the current reality in surgical practice and identifies an important area for future improvement in the care of patients with valvular heart disease.

Impact of race on mitral procedure selection and short-term outcomes of patients undergoing mitral valve surgery.

BACKGROUND: Racial disparity with respect to mitral valve (MV) surgery has been documented; however, previous reports have been limited by small numbers, focus on patients undergoing MV replacement only, or comparison of African-American patients to white patients. Using more recent data from the largest all-payer database in the United States, we examined whether type of mitral procedure performed was influenced by race and whether racial differences exist in baseline characteristics and short-term outcomes of patients undergoing mitral repair or replacement for MV disease. METHODS: Using the 2005-2007 National Inpatient Sample (NIS) Database, we identified patients ≥ 30 years of age who underwent MV repair or replacement, excluding ischemic and congenital MV disease. Patients were stratified into 4 racial groups: whites, African-Americans, Hispanics, and others. The 4 groups were compared with respect to baseline characteristics, type of MV procedure (repair versus replacement), and short-term outcomes. RESULTS: Non-whites comprised 22.3% (7818 out of 35,074) of the patients and were generally younger, more often on Medicaid and from urban locations, and more often presented on an urgent/emergent basis. African-Americans and Hispanics tended to be less affluent and have a higher Charlson comorbidity index. MV repair was performed in 45.8% of the patients overall. The racial groups differed significantly with respect to the proportion of patients receiving repair. Hispanics were 2 times more likely to have MV replacement compared to whites (odds ratio [OR] = 2.06, 95% confidence interval [CI] = 1.52-2.80, P = .0001), and African-Americans were more than 1.5 times more likely to have replacement compared to whites (OR = 1.69, 95% CI = 1.35-2.11). Following adjustment for baseline characteristics, there was no difference with respect to race for in-hospital mortality or likelihood of repair, but differences between groups persisted for length of stay and discharge location. African-Americans and Hispanics were more likely than whites to have a prolonged hospitalization. CONCLUSIONS: African-Americans and Hispanics present for MV surgery with worse preoperative profiles and undergo mitral repair less often compared to whites. Although in-hospital mortality was not influenced by race, African-Americans and Hispanics had a more protracted hospital course even following adjustment. The disparity in mitral procedure selection among racial groups was present only prior to adjustment for important baseline characteristics. Nevertheless, this racial difference reflects current reality in surgical practice and identifies an important area for future improvement in the care of patients with valvular heart disease.

Correlates of late and very late thrombosis of drug eluting stents.

BACKGROUND: Late and very late thrombosis of coronary drug-eluting stents (DES) has received much attention but essentially remains unpredictable. We sought to identify correlates of stent thrombosis (ST) developing >30 days after DES implantation. METHODS: We analyzed data from our single-center registry on 5,342 consecutive patients, who underwent a first DES implant between May 2003 and December 2006. The Academic Research Consortium definitions were applied to classify definite, probable, and possible ST. Cox regression analysis was performed to identify predictors of ST. RESULTS: Follow-up information was obtained at 6 months and at 1, 2, and 3 years after DES implantation in 97.2%, 95.2%, 92.4%, and 89.8% of patients, respectively. We identified 34 patients who developed definite and 5 with probable ST >30 days after the index stent procedure. The 3-year cumulative incidence of definite and definite + probable ST >30 days was 1.33% and 1.50%, respectively. By Cox multiple variable regression, predictors of definite + probable ST were age (hazard ratio [HR] 0.95, 95% CI 0.92-0.98, P < .001), current smoking (HR 2.55, 95% CI 1.29-5.07, P = .007), prior percutaneous coronary intervention (HR 2.68, 95% CI 1.42-5.05, P = .002), "off-label" DES indication (HR 3.10, 95% CI 1.10-8.75, P = .032), bifurcation stenting (HR 2.37, 95% CI 1.40-3.99, P = .001), and stenting an occluded vessel (HR 3.02, 95% CI 1.59-5.74, P < .001). CONCLUSIONS: We identified several baseline characteristics, which, when combined, may identify patients at risk for late-occurring ST, particularly after off-label DES placement.

Long-term outcomes after management of restenosis or thrombosis of drug-eluting stents.

OBJECTIVES: The purpose of this study was to examine the outcomes of patients who developed coronary in-stent restenosis (ISR) or stent thrombosis (STH) inside drug-eluting stents (DES). BACKGROUND: Drug-eluting stents have markedly reduced the incidence of restenosis. However, when restenosis occurs within a DES, its optimal management remains unclear. METHODS: We retrospectively analyzed clinical and angiographic data from 92 patients who underwent revascularization for ISR (n = 84) or STH (n = 8) within a DES at our institution. Regular follow-ups were available up to 2 years. We recorded the occurrence of major adverse cardiac events (MACE), defined as deaths from all causes, myocardial infarction (MI), or target lesion revascularization (TLR), among patients treated by the "DES sandwich" technique or by other treatment methods. RESULTS: In-hospital MACE included 1 periprocedural MI and 2 deaths. Over a mean follow-up of 15 +/- 6 months, the overall rates of death, MI, and TLR were 8.7%, 2.2%, and 30.6%, respectively. By actuarial analysis, the 12-month TLR and MACE rates were 28.2% and 42.9%, respectively. CONCLUSIONS: Current treatments of ISR or STH in DES are associated with a high long-term rate of MACE.

Exercise barrier and task self-efficacy in breast cancer patients during treatment.

Understanding exercise self-efficacy in breast cancer patients during treatment is important for enhancing physical activity adherence. Therefore, the primary study purpose was to determine, among breast cancer patients during treatment, the psychometric properties of scales to measure exercise barrier and task self-efficacy. The study also aimed to determine the following: (1) level of self-efficacy, (2) associations between barrier and task self-efficacy, and (3) associations between self-efficacy and patient age, race, and treatment type. Eighty-six female breast cancer patients recruited from a medical oncologist's office completed the scales once, and 46 repeated the scales 2 weeks later. The majority were Caucasian (95%), with 26% receiving chemotherapy, 64% hormonal therapy alone, and 5% radiation/other. The mean age was 59+/-14 years. The Cronbach's alpha for the nine-item barrier self-efficacy scale was 0.96, with a test-retest correlation of 0.89 (p<0.001). The Cronbach's alpha for the four-item task self-efficacy scale was 0.89, with a test-retest correlation of 0.83 (p<0.001). The mean barrier self-efficacy was slightly to moderately confident, with the lowest confidence reported in the ability to exercise when nauseated. The mean task self-efficacy was slightly to moderately confident, with the lowest confidence reported in the ability to jog for 10 min without stopping. Although no significant associations were found between self-efficacy and participant's race or treatment type, lower task self-efficacy was associated with older age (r=-0.36, p=0.001). Both self-efficacy scales demonstrated good internal consistency and test-retest reliability. Self-efficacy may be a useful target for physical activity interventions among breast cancer patients during treatment.

Indications and outcomes of AneuRx Phase III trial versus use of commercial AneuRx stent graft.

OBJECTIVE: Approval by the United States Food and Drug Administration of endoluminal repair of abdominal aortic aneurysm (AAA) with the AneuRx stent graft was based on the outcome of a multicenter trial in which patients met strict inclusion and exclusion criteria. Since widespread use of the commercially available graft, little information is available as to whether indications and outcomes have evolved. We examined this important issue at our institution. METHODS: Data concerning indications, repair, and follow-up for all patients undergoing endoluminal repair of AAA was prospectively entered into a patient registry. Group 1 comprised consecutive patients enrolled in the AneuRx Phase III clinical trial between November 1998 and September 2000. Group 2 consisted of consecutive patients who underwent implantation of the commercially available AneuRx graft between May 1999 and June 2001. RESULTS: Group 1 included 42 patients (mean age, 72 years), and group 2 included 54 patients (mean age, 73 years). Patient demographics and risk factors were similar between the two groups. Maximum aortic aneurysm diameter was significantly greater (P =.021) in group 1 (55 mm +/- 10.9 [SD] mm) compared with group 2 (52 +/- 15.6 mm). Maximum infrarenal aortic neck length was significantly longer (P =.022) in group 1 (30 +/- 11.7 mm) than in group 2 (23 +/- 12.0 mm). Maximum left common iliac artery diameter in group 1 (13.0 +/- 3.2 mm) was significantly smaller (P =.032) than that in group 2 (14 +/- 6.5 mm). During follow-up, no differences were observed for number of endoleaks, subsequent interventions, or graft explantation between the two groups. CONCLUSIONS: In group 2 patients AAAs were significantly smaller, infrarenal aortic neck length was shorter, and left common iliac arteries were larger. Common iliac artery ectasia and aneurysmal disease has become another indication for use of the AneuRx commercial graft at our institution, with no significant differences in intermediate outcome. Given the possibility for evolving indications compared with trial inclusion and exclusion criteria, institutions that use the AneuRx commercial graft should prospectively monitor outcomes for quality assurance.