Postoperative 1-year Mortality Research Articles

Impact of preoperative nutritional scores on 1-year postoperative mortality in patients undergoing valvular heart surgery

ObjectiveMalnutrition is a well-recognized risk factor for poor prognosis and mortality. We investigated whether preoperative malnutrition diagnosed with objective nutritional scores affects 1-year mortality in patients undergoing valvular heart surgery. MethodsIn this retrospective cohort observational study, we evaluated the association among the Controlling Nutritional Status score, Prognostic Nutritional Index, and Geriatric Nutritional Risk Index with 1-year mortality in 1927 patients undergoing valvular heart surgery. We identified factors for mortality using multivariable Cox proportional hazard analysis and investigated the utility of nutritional scores for risk stratification. ResultsMalnutrition, as identified by a high Controlling Nutritional Status score and low Prognostic Nutritional Index and Geriatric Nutritional Risk Index, was significantly associated with higher 1-year mortality. Kaplan–Meier survival curve showed that mortality significantly increased as the severity of malnutrition increased (log-rank test, P < .001). The predicted discrimination (C-index) was 0.79 with the Controlling Nutritional Status score, 0.77 with the Prognostic Nutritional Index, and 0.73 with the Geriatric Nutritional Risk Index. Each nutritional index (Controlling Nutritional Status; hazard ratio, 1.31, 95% confidence interval, 1.21-1.42, P < .001), the European System for Cardiac Operative Risk Evaluation II (hazard ratio, 1.07, 95% confidence interval, 1.04-1.09, P < .001), and chronic kidney disease (hazard ratio, 2.26, 95% confidence interval, 1.31-3.90, P = .003) were independent risk factors for mortality. The Controlling Nutritional Status score added to the European System for Cardiac Operative Risk Evaluation II significantly increased the predictive discrimination ability for mortality (C-index 0.82, 95% confidence interval, 0.78-0.87, P = .014) compared with the Controlling Nutritional Status or European System for Cardiac Operative Risk Evaluation II alone. ConclusionsPreoperative malnutrition as assessed by objective nutritional scores was associated with 1-year mortality after valvular heart surgery. The Controlling Nutritional Status score had the highest predictive ability and, when added to the European System for Cardiac Operative Risk Evaluation II, provided more accurate risk stratification.

Relationship between admission neutrophil/lymphocyte, thrombocyte/lymphocyte, and monocyte/lymphocyte ratios and 1-year mortality in geriatric hip fractures: Triple comparison.

Elderly patients with hip fractures have a high post-operative 1-year mortality rate. The aim of this study was to investigate the relationship of the neutrophil/lymphocyte ratio (NLR), thrombocyte/lymphocyte ratio (TLR), and monocyte/lymphocyte ratio (MLR) with mortality. The data of 350 patients who suffered femoral intertrochanteric fractures between January 2015 and January 2020 were examined, and the demographic data of 124 patients who met the study criteria were evaluated. During the 1-year follow-up, 92 patients (74%) who continued their lives and 32 patients (25%) who died were divided into two groups: Group 1 (survivors) and Group 2 (non-survivors). NLR, TLO, MLO, presence of comorbidities, age, sex, American Society of Anesthesiologists Physical Status Classification, length of hospital stay, fracture type, and fracture pattern values were statistically compared between the two groups. NLR, TLR, and MLR are the laboratory parameters assessed within the scope of the study. Preoperatively, the mean NLR was 6.59 (1.61-26.29), mean TLR was 197.94 (86-516), and mean MLR was 0.73 (0.19-15.68). In this study, a significant relationship was found between NLR, TLR, and MLR values and the occurrence of post-operative 1-year mortality (p=0.01). In addition, the result was significant in the correlation between these parameters. Cutoff values were found to be 7.53 for NLR, 192 for TLR, and 0.54 for MLR in receiver operator characteristic curve analysis (p<0.01). NLR, TLR, and PLR are significant predictors of 1-year mortality in patients aged over 60 years with hip fractures.

Effect of Dementia on Postoperative Mortality in Elderly Patients with Hip Fracture.

BackgroundThe aim of this study was to assess the prevalence of dementia as an underlying disease in elderly patients with hip fracture, to investigate the effect of dementia on postoperative mortality after surgery of hip fracture, and to analyze the differences in postoperative mortalities according to the severity of dementia through subgroup analysis.MethodsThis study selected 2,346 elderly patients who were diagnosed with unilateral intertrochanteric or femoral neck fractures who underwent surgery between January 2004 and December 2018. The patients were classified into the non-dementia group (2,196 patients) and dementia group (150 patients; no-medication [66 patients] and medication [84 patients] subgroups). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the groups. A univariate regression test was performed using age, sex, diagnosis, surgery type, and Charlson's comorbidity index (CCI), as these variables had P values of < 0.10. Multivariate regression analysis was performed to identify independent risk factors associated with mortality.ResultsThe 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.8%, 3.8%, 5.6%, 8.9%, and 13.6%, respectively, in the non-dementia group, and 2%, 7.3%, 14%, 19.3%, and 24%, respectively, in the dementia group (P = 0.748, P = 0.048, P < 0.001, P < 0.001, and P = 0.001). The factors that affected the 1-year mortality were age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02–1.08; P < 0.001), sex (OR, 2.68; 95% CI, 2.07–3.47; P < 0.001), CCI (OR, 1.34; 95% CI, 1.23–1.47; P < 0.001), and dementia (OR, 1.70; 95% CI, 1.46–1.08; P = 0.016). In subgroup analysis, severity of dementia influenced the 6-month mortality (OR, 1.41; 95% CI, 1.70–2.01; P = 0.018), and 1-year mortality (OR, 1.30; 95% CI, 1.17–1.90; P = 0.027).ConclusionIn elderly hip fracture patients, the comparison between patients with and without dementia revealed that dementia was an independent risk factor for mortality at a minimum of 1 year of follow-up, and the severity of dementia in hip fracture patients was a risk factor for mortality within 6 months and 1 year, postoperatively.

Low surgical Apgar score in older patients with gynecological cancer is a risk factor for postoperative complications and 1-year mortality: A multicenter retrospective cohort study.

Little is known about preoperative and intraoperative risk factors for postoperative complications in older patients with gynecological cancer. The present retrospective multi-institutional study included 173 older patients with primary gynecological cancer between January 2015 and December 2015 at four institutions. The cancer stage, medical history, Charlson comorbidity score, body mass index (BMI), subjective global assessment, fall risk assessment, American Society of Anesthesiologists physical status classification, surgical Apgar score (SAS), type of surgery and 1-year postoperative mortality were investigated. Multivariate analysis revealed that BMI and mental illness were risk factors for postoperative complications, and low SAS increased the risk for both postoperative complications and mortality within 1 year. Receiver operating characteristic curve analysis of postoperative complications in terms of SAS revealed that low SAS predicted high risk with a sensitivity of 85.7% and a specificity of 46.5%, and high SAS predicted low risk with a sensitivity of 21.4% and a specificity of 95%. The present results suggest that SAS, which is an intraoperative assessment, may be useful for assessing the risks of postoperative complications and mortality within 1 year. It is important to develop a preoperative assessment tool that can predict a low SAS score and reflect the postoperative prognosis of older patients with gynecological cancer.

Outcomes of total hip arthroplasty using dual-mobility cups for femoral neck fractures: a systematic review and meta-analysis.

Femoral neck fractures (FNFs), with up to 15% mortality, are prominent orthopaedic emergencies. After treating FNFs, dislocation is another challenge increasing morbidity, mortality and treatment costs substantially. The emerging dual-mobility cup (DMC) may decrease dislocation rates following total hip arthroplasty (THA) for FNFs. We performed a systematic review of literature reporting dislocation and mortality rates with DMC-THA for the treatment of FNFs. 2 authors independently searched PubMed (MEDLINE), Google Scholar and Cochrane library for studies reporting dislocation and mortality rates for FNFs treated with DMC-THA since inception up to January 2019. Data on outcomes of interest was extracted from all studies and assessed for eligibility for a meta-analysis. Out of 522 search results, 18 studies were included in the systematic review and 4 in the meta-analysis. The mean rate of dislocation following DMC-THA for FNFs was found to be 1.87% ± 2.11, with a 1-year mortality rate of 14.0% ± 10.55. Results of meta-analysis showed that dislocation and 1-year postoperative mortality rates were significantly lower for DMC-THA with a risk ratio 0.31 (95% CI, 0.16-0.59; I2 = 0%, p = 0.0003) and 0.55 (0.40, 0.77; I2 = 0%, p = 0.003) respectively when compared to biploar hemiathroplasty (BHA). The mean dislocation and mortality rates in DMC-THA are lower than previously reported rates for THA with single cup and comparable to unipolar and bipolar hemiarthroplasty. Further research involving randomised control trials to assess differences in outcomes, longevity and cost-effectiveness needs to be conducted to make recommendations for the use of DMC in treating FNFs.

The role of bone cement for the development of intraoperative hypotension and hypoxia and its impact on mortality in hemiarthroplasty for femoral neck fractures

Background and purpose — The bone cement implantation syndrome characterized by hypotension and/or hypoxia is a well-known complication in cemented arthroplasty. We studied the incidence of hypotension and/or hypoxia in patients undergoing cemented or uncemented hemiarthroplasty for femoral neck fractures and evaluated whether bone cement was an independent risk factor for postoperative mortality.Patients and methods — In this retrospective cohort study, 1,095 patients from 2 hospitals undergoing hemiarthroplasty with (n = 986) and without (n = 109) bone cementation were included. Pre-, intra-, and postoperative data were obtained from electronic medical records. Each patient was classified for grade of hypotension and hypoxia during and after prosthesis insertion according to Donaldson’s criteria (Grade 1, 2, 3). After adjustments for confounders, the hazard ratio (HR) for the use of bone cement on 1-year mortality was assessed.Results — The incidence of hypoxia and/or hypotension was higher in the cemented (28%) compared with the uncemented group (17%) (p = 0.003). The incidence of severe hypotension/hypoxia (grade 2 or 3) was 6.9% in the cemented, but not observed in the uncemented group. The use of bone cement was an independent risk factor for 1-year mortality (HR 1.9, 95% CI 1.3–2.7), when adjusted for confounders.Interpretation — The use of bone cement in hemiarthroplasty for femoral neck fractures increases the incidence of intraoperative hypoxia and/or hypotension and is an independent risk factor for postoperative 1-year mortality. Efforts should be made to identify patients at risk for BCIS and alternative strategies for the management of these patients should be considered.

Effect of heart failure on postoperative short and long-term mortality in elderly patients with hip fracture

IntroductionWe designed a comparative study using elderly hip fracture patients with and without heart failure (HF). The purpose of this study was to assess 1) prevalence of HF, compare 2) early and late mortality after elderly hip fracture between HF and non-HF patients and to assess 3) risk factors of mortality after hip fractures in elderly patients with HF. In addition, we also investigated 4) whether there is a difference in mortality according to the severity of left ventricular (LV) systolic dysfunction classified by LV ejection fraction (EF) in HF patients through subgroup analysis. MethodsThis study included 1992 patients (1992 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between January 2004 and June 2018. The patients were categorized into a non-HF group (1782 patients) and a HF group (210 patients; mild [119 patients] and moderate-to- severe HF subgroups [91 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-HF and HF. Logistic regression analysis was conducted to identify independent factors associated with mortality. ResultsOf 1992 patients, 210 (10.5%) patients were diagnosed with HF. The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were respectively 1.6%, 3.6%, 5.1%, 8.4%, and 12.9% in the non-HF group, and 5.7%, 9.5%, 12.4%, 17.1%, and 25.2% in the HF group (p ≤ 0.001). The factors that affected 1-year mortality were sex (OR, 2.10; 95% CI, 1.62–2.72; p < 0.001) and age (OR, 1.04; 95% CI, 1.02–1.06; p < 0.001) and presence of HF (OR, 1.62; 95% CI, 1.45–1.86; p = 0.005). In subgroup analysis, the factors that affected 30-day mortality were only moderate-to-severe HF (OR, 4.01; 95% CI, 1.10–8.78; p = 0.009). ConclusionsIn elderly patients with hip fracture, the comparison between the HF and non-HF patients revealed that HF was an independent factor of mortality at a minimum of 1-year follow-up, and severity of LV systolic dysfunction classified by LVEF in patients with hip fracture was also a risk factor of 30-day mortality.

Predicting Factors for Return to Prefracture Ambulatory Level in High Surgical Risk Elderly Patients Sustained Intertrochanteric Fracture and Treated With Proximal Femoral Nail Antirotation (PFNA) With and Without Cement Augmentation.

Introduction:Postoperative outcomes in the elderly patients with intertrochanteric fracture were generally poor with a low rate of return to prefracture ambulatory level (RPAL). Recent studies showed that proximal femoral nail antirotation (PFNA) with cement augmentation might be useful for postoperative functional recovery. This study aimed to compare the outcomes in elderly patients with high surgical risk, American Society of Anesthesiologist (ASA) grade 3 or 4, who sustained intertrochanteric fractures and were treated with PFNA with and without cement augmentation, and to correlate perioperative surgical factors with the RPAL.Methods:A retrospective consecutive series was conducted based on 135 patients with prefracture ambulation classified as independent in community with or without a single cane (68 in augmented group and 67 in control group). Perioperative data and data on the complications within 1-year postsurgery were collected and compared. Predictive factors for RPAL were analyzed via logistic regression analysis.Results:The overall 1-year postoperative mortality rate was 10% (n = 14) with no significant difference between groups (P = .273). The proportion of elderly patients with RPAL in the augmented group was significantly higher than for those in the control group (48% vs 29%, P = .043). Via univariate analysis, ASA grade 4 (P = .077), history of stroke (P = .035), and use of cement augmentation (P = .041) were correlated with RPAL. However, multivariate regression analysis showed that ASA grade 4 (odds ratio [OR] = 0.40, 95% confidence interval [CI]: 0.18-0.90, P = .026) and use of cement augmentation (OR = 2.72, 95% CI: 1.22-6.05, P = .014) were the significant predictors for RPAL.Discussion and Conclusions:The results of the present study showed that PFNA with cement augmentation is safe and effectiveness in the intertrochanteric fracture treatment of elderly. Postoperative functional recovery, like RPAL, in elderly patients who sustained intertrochanteric fractures is relatively low, especially in those with ASA grade 4. However, cement augmentation with PFNA might be helpful for increasing the RPAL in high-surgical-risk geriatric patients.

Hypoxemia Within the First 3 Postoperative Days Is Associated With Increased 1-Year Postoperative Mortality After Adjusting for Perioperative Opioids and Other Confounders.

Postoperative hypoxemia (POH) is common and primarily treated with temporary oxygen supplementation. Because the clinical impact of POH is sometimes presumed as minor, efforts to better understand and minimize it have been limited. Here, we hypothesized that, after adjusting for opioids received perioperatively and other confounders, the frequency of POH events (POH%) reported within the first 3 postoperative days (PODs) is associated with increased postoperative 1-year mortality. With prior institutional review board (IRB) approval, the Epic Clarity database was queried for all adult inpatient anesthesia encounters performed at our health system (1 academic and 2 community hospitals) from January 1, 2012 to March 31, 2016. Patients with multiple hospitalizations or subsequent surgeries within the same hospitalization were excluded. We classified patients based on the presence (POH) or not (No-POH) of ≥1 documented peripheral saturation of oxyhemoglobin (SpO2) ≤85% event of any duration occurring between the discharge from the postanesthesia care unit (PACU) until POD 3. Demographics, comorbidities, surgery duration, morphine milligram equivalents (OMME) administered perioperatively, respiratory therapies, intensive care unit (ICU) admission, and hospital length of stay (LOS) were also collected. Logistic regression was used to characterize the association between POH and 1-year postoperative mortality after adjusting for perioperatively administered opioids and other confounding factors. A total of 43,011 patients met study criteria. At least 1 POH event was reported in 10,727 (24.9%) patients. Of these, 7179 (66.9%) had ≥1 hypoxemic event on POD 1, 5340 (49.8%) on POD 2, and 3455 (32.3%) on POD 3. Patients with ≥1 POH event, compared to No-POH patients, were older, had more respiratory and other comorbidities, underwent longer surgeries, received greater opioid doses on the day of surgery and POD 1, and received more continuous pulse oximetry monitoring. POH patients required more frequent postoperative oxygen therapy, noninvasive ventilation (NIV), intubation, and ICU admission. One-year postoperative mortality occurred in 4.4% of patients with ≥1 POH and 3.0% of No-POH patients (P < .001). After adjusting for confounding factors, for every 10% increase in the frequency of SpO2 ≤85% readings, the odds of postoperative 1-year mortality were 1.20 (95% confidence interval [CI], 1.11-1.29; P < .001). Perioperative opioids were not independently associated with increased 1-year mortality. After adjusting for perioperative opioids and other confounders, moderate/severe POH within the first 3 PODs was independently associated with increased 1-year postoperative mortality. Increased efforts should be directed to understand if efforts to detect and reduce POH lead to improved patient outcomes.

Postoperative mortality after a hip fracture over a 15-year period in Denmark: a national register study

Background and purpose — In Denmark, 44 per 10,000 persons over the age of 50 years suffered a hip fracture (HF) in 2011. We characterized the patients and identified risk factors associated with 30-day, 90-day, and 1-year postoperative mortality in Denmark from 2000 to 2014.Patients and methods — The study builds upon data from the Danish National Patients Register and the National Causes of Death Register including all acute hospitalized HF patients aged 18 years and above. Outcomes were 30-day, 90-day, and 1-year postoperative mortality. Mortality risk was analyzed with a univariable and multivariable Cox regression including predefined variables.Results — 113,721 acute hospitalized HF patients were admitted to Danish hospitals between 2000 and 2014. The 30-day mortality risk was 9.6%, 16% at 90 days, and 27% at 1 year after HF surgery. Mortality risk was similar from 2000 to 2014 while the median lengths of stay declined from 14 (IQR 8–25) to 8 (IQR 5–11) days. Male sex, increasing age, higher Charlson Comorbidity Index, per- and subtrochanteric fracture, and operation type other than total hip arthroplasty were independently associated with postoperative mortality.Interpretation — Short- and long-term mortality was high after hip fracture surgery and did not decline in Denmark from 2000 to 2014.

Relationship between preoperative left ventricular longitudinal strain and survival after cardiovascular surgery in patients with preserved ejection fraction: a preliminary result

Introduction Left ventricular longitudinal strain is reportedly able to detect early ventricular dysfunction in patients with preserved ejection fraction.¹ However, it remains unclear whether this concept can be applied to predict postoperative outcomes. The aim of this study is to investigate the relationship between preoperative left ventricular longitudinal strain and survival after cardiovascular surgery in patients with preserved ejection fraction. Methods This observational study included 823 adult patients with preserved ejection fraction (ejection fraction >50%) who underwent cardiovascular surgery between January 2015 and December 2016 at a tertiary academic hospital. The patients were divided into the normal strain group ( = −18.0%). The primary outcome was postoperative 1-year all-cause mortality. Propensity matching was performed to minimize differences in baseline characteristics between patients with normal and abnormal left ventricular longitudinal strain. Kaplan-Meier survival analysis and Cox proportional hazard regression were used to evaluate the association between preoperative left ventricular longitudinal strain and primary outcome. Results Of the 823 patients (40.3 % women; median age, 64 years), 30 patients (3.6 %) died within one year. Cumulative 1-year mortality rate was 3.4% (95% confidence interval; 1.5–5.2%) in the normal strain group and 3.9% (95% confidence interval; 2.1–5.6%) in the abnormal strain group. After propensity score matching (a total of 606 patients in matched cohort), there was no statistically significant difference in 1-year mortality between strain groups; 3.3% (95% confidence interval; 1.3–5.3%) in the normal strain group, 3.6% (95% confidence interval; 1.5–5.7%) in the abnormal group, hazard ratio of 1.11 (95% confidence interval; 0.47–2.61, P-value = 0.81). Discussion Preoperative left ventricular longitudinal strain does not have statistically significant association with postoperative 1-year mortality in patients undergoing cardiovascular surgery with preserved ejection fraction in this preliminary analysis.

Relationship of chronic obstructive pulmonary disease severity with early and late mortality in elderly patients with hip fracture

IntroductionWe conducted a comparative study to compare patients with and without chronic obstructive pulmonary disease (COPD) and to analyze the effect of COPD severity on mortality in elderly patients with hip fractures who were diagnosed by pulmonologists. The purposes of this study were to compare early and late mortality after hip fracture between COPD and non-COPD patients and to assess risk factors of mortality after hip fractures in elderly patients with COPD. MethodsThis study included 1294 patients (1294 hips) who were diagnosed as having unilateral femoral neck or intertrochanteric fractures and who underwent surgery at two hospitals between 2004 and 2017. The patients were categorized into a non-COPD group (853 patients) and a COPD group (441 patients; mild-to-moderate [354 patients] and severe-to-very severe COPD subgroups [87 patients]). The cumulative crude mortality rate was calculated, and 30-day, 60-day, 3-month, 6-month, and 1-year mortality rates were compared between the non-COPD and COPD groups. Logistic regression analysis was conducted to identify independent factors associated with mortality. ResultsThe 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates were 1.3%, 2.5%, 3.5%, 6.6%, and 10.7%, respectively, in the non-COPD group, and 2.9%, 5.7%, 7.7%, 11.8%, and 16.6%, respectively, in the COPD group (p = 0.049, p = 0.004, p = 0.002, p = 0.002, and p = 0.004, respectively). The 30-day, 60-day, 3-month, 6-month, and 1-year postoperative cumulative mortality rates in the severe-to-very severe COPD group were 4.6%, 6.9%, 11.5%, 20.7%, and 26.4%, respectively. In elderly patients with hip fracture, COPD increased the risk of mortality for 1.6 times and 1.7 times at 3 months and 1 year postoperative, respectively. In subgroup analysis, severe-to-very severe COPD was associated with 1.55-fold and 1.65-fold increased postoperative mortality risk at 6 months and 1 year respectively, as compared with mild-moderate COPD. ConclusionsIn elderly patients with hip fracture, the comparison between the COPD and non-COPD patients revealed that COPD was an independent factor of mortality at a minimum of 1-year follow-up, and COPD severity in patients with hip fracture was also a risk factor of 6-month and 1-year mortality.

The Houston Methodist Lung Transplant Risk Model: A Validated Tool for Pretransplant Risk Assessment

Lung transplantation is the gold standard for a carefully selected patient population with end-stage lung disease. This study sought to create a risk stratification model using only preoperative recipient data to predict 1-year postoperative mortality during the pretransplant assessment. Data of lung transplant recipients at Houston Methodist Hospital in Houston, Texas from January 2009 to December 2014 were extracted from the United Network for Organ Sharing (UNOS) database. Patients were randomly divided into development andvalidation cohorts. Cox proportional-hazards models were conducted. Variables associated with 1-year mortality after transplantation were assigned weights on the basis of the beta coefficients, and riskscores were derived. Patients were stratified into low-, medium- and high-risk categories. The model was validated using the validation data set and data from other US transplant centers in the UNOS database. The study randomized 633 lung recipients from Houston Methodist Hospital into development (n=317 patients) and validation cohorts (n= 316). The 1-year survival after transplantation was significantly different among risk groups: 95% (low risk), 84% (mediumrisk), and 72% (high risk) (P < .001), with a C-statistic of 0.74. Patient survival in the validation cohortwas also significantly different among risk groups (85%, 77%, and 65%, respectively; P < .001). Validation of the model with the UNOS data set included 9920 patients and found 1-year survival to be 91%, 86%, and 82%, respectively (P < .001). Using only recipient data collected at the time of the prelisting evaluation, this simple scoring system was found to have good discrimination power and could be a practical tool in the assessment and selection of potential lung transplant recipients.

Nutrition and Inflammation Influence 1-Year Mortality of Surgically Treated Elderly Intertrochanteric Fractures: A Prospective International Multicenter Case Series.

Introduction:Hip fracture is a common and devastating event in older adults causing increased dependence, comorbidity, and mortality. Since new surgical techniques have not significantly improved the mortality rate, a better understanding of patient risk factors could improve the treatment algorithm and outcomes. This prospective study aimed to document the 1-year survival rate of patients with intertrochanteric fracture treated surgically in Latin America and to investigate risk factors associated with 1-year mortality.Patients and Methods:Between January 2013 and March 2015, 199 patients were prospectively enrolled. Inclusion criteria were aged 60 years or older, isolated intertrochanteric fracture (AO/OTA 31-A), and time to surgery within 10 days after injury. The follow-up period was 1 year. The association between mortality and patient demographics, comorbidity, surgical details, and preoperative laboratory parameters was assessed using log-rank tests.Results:Twenty patients died by 365 days after surgery (including 5 that died within 30 days of surgery) resulting in a 1-year survival rate of 89.8% (95% confidence interval = 84.6-93.3). The 1-year mortality was significantly associated with age (≥85 years old, P = .032), existing comorbidity (P = .002), preinjury mobility level (P = .026), mental state (Mini-Mental State Examination > 23, P = .040), low preoperative plasma albumin level (P = .007), and high preoperative blood C-reactive protein level (CRP; P = .012). At the 1-year follow-up, patients on average did not regain their preinjury hip function and mobility, although the self-assessed quality of life was equal or better than before the injury.Discussion:As a prospective study, the current patient population had clear inclusion and exclusion criteria and was relatively homogeneous. The resulting associations between 1-year postoperative mortality and preoperative hypoalbuminemia and preoperative elevated CRP level are therefore especially notable. Previously identified risk factors such as male gender and time to surgery showed no significant association with 1-year mortality—the overall favorable condition of the current population or the lack of statistical power maybe responsible for this observation.Conclusion:The current results showed that under the condition of optimal surgical treatment and low surgery-related complication, preinjury health status as indicated by the blood level of albumin and CRP has a direct and significant impact on 1-year mortality rate.

Joint effects of uric acid and lymphocyte count on adverse outcomes in elderly patients with rheumatic heart disease undergoing valve replacement surgery

ObjectivesIncreased uric acid and decreased lymphocyte count are common in elderly patients or those with heart failure, which were prognostic markers. We aimed to investigate the joint effect of uric acid and lymphocyte count for risk stratification in elderly patients with rheumatic heart disease undergoing valve replacement surgery. MethodsUric acid to lymphocyte ratio was calculated as serum uric acid (mg/dL)/lymphocyte count (×109/L). Univariate and multivariate analyses were performed to investigate the association of uric acid to lymphocyte ratio, with adverse events in 949 elderly patients with rheumatic heart disease undergoing valve replacement surgery. For clinical use, the uric acid to lymphocyte ratio was classified into 3 groups by the tertile, and a cutoff was also selected according to the receiver operator characteristic curve. ResultsUric acid to lymphocyte ratio produced relatively higher predictive value (area under the curve, 0.703; 95% confidence interval [CI], 0.630-0.776; P < .001) than uric acid or lymphocyte count for in-hospital mortality, and the optimal cutoff was 3.7 (sensitivity, 82.1%; specificity, 52.4%). Uric acid to lymphocyte ratio was an independent predictor for in-hospital (adjusted odds ratio, 1.17; 95% CI, 1.07-1.29; P = .001) and 1-year mortality (adjusted hazard ratio, 1.13; 95% CI, 1.03-1.25; P = .010). The in-hospital mortality increased from the lowest to the highest uric acid to lymphocyte ratio tertile (P < .001) and significantly higher in patients with uric acid to lymphocyte ratio greater than 3.7 (P < .001). The cumulative 1-year postoperative mortality risk was significantly higher in patients with uric acid to lymphocyte ratio greater than 3.7 (P < .001) or upper uric acid to lymphocyte ratio tertile (P < .001). ConclusionsUric acid to lymphocyte ratio, combining the effect of uric acid and lymphocyte count, produced more prognostic value in elderly patients with rheumatic heart disease undergoing valve replacement surgery, which could be considered as a preoperative risk-stratified method.

Ensemble-based Classification Models for Predicting Post-Operative Mortality Risk in Coronary Artery Disease

IntroductionThere has been an increased demand for more accurate prediction tools to aid clinical decision-making regarding disease diagnosis prognosis for coronary artery disease(CAD) patients. Patients undergoing CABG surgery are older and a larger number have had previous heart surgery. Consequently, mortality after CABG is expected to increase despite procedural advances.&#x0D; Objectives and ApproachThis study aims to compare the predictive performance of random forest(RF) and logistic regression(LR) classifiers for predicting 30-day and 1-year post-operative mortality risk in CAD patients who underwent CABG. Data was obtained by linking the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease(APPROACH) registry, a prospective longitudinal data of patients undergoing cardiac catheterization in Alberta, Canada, to vital statistics database. All patients who underwent first-time isolated CABG between January 1, 2007 and December 31, 2012 were included in the analysis. Area under the receiver operating curve(AUC) was used to compare the predictive performance of LR and RF regression.&#x0D; ResultsOf the 4,908 eligible subjects who underwent isolated CABG during the study period, mortality estimates of 30-day and 1-year post CABG surgery were 1.59% and 3.85%, respectively. Descriptive analysis revealed that age, sex, hypertension, dialysis, cerebrovascular disease, chronic obstructive pulmonary disease, and chronic heart failure were associated with 30-day and 1-year mortality. The accuracy of the LR and RF regression classifiers in predicting 30-day mortality were 74.1, and 99.7%, respectively. While the accuracy of the former and latter classifiers in predicting 1-year post CABG mortality were 74% and 97.4%, respectively.&#x0D; Conclusion/ImplicationsThis study shows that RF classifier results in better predictive accuracy than LR in predicting post-operating mortality risk in CAD patients. Machine learning models are potentially usefully for developing clinical prediction models that can be used to aid the monitoring of post-discharge outcomes in the management of cardiovascular diseases.

90-day and 1-year predictive mortality of cadaveric liver transplant recipients: a new scoring system using patient characteristics at the time of listing

Introduction: Primary aim of this study was to assess the predictive value of a scoring system designed to estimate the risk of 90-day and 1-year mortality based on recipient characteristics at the time of listing for liver transplantation (LT). Methods: Using the UNOS database, all adult recipients of first time LT in the USA between 2002 and 2013 were included (n.30,458). Partial and live donor, redo, multi-visceral and recipients with primary or secondary malignancies were excluded. Classification tree and neural network were used to identify predictors and validate the risk score. Results: The scoring system had a minimum of 0 and a maximum of 6 points. The included predictors were: female gender (1 point), presence of type I or II diabetes (1 point), need for renal replacement therapy (1 point), body mass index < 18.5 (1 point), body mass index >40 (1 point), age 65–69 (1 point), age 70–74 (2 points), age >75 (3 points) and MELD 25-29 (1 point), MELD 30-34 (2 points) MELD >35 (3 points). 90-day mortality was 5.9%, 7.6%, 9.7%, 12.2%, 13.8%, 17.2% and 19.9% for recipients with 0, 1, 2, 3, 4, 5, 6 points respectively (P< 0.05). 1-year mortality was 16.3%, 19.5%, 23.3%, 27.4%, 31.2%, 35.5% and 37.7% for recipients with 0, 1, 2, 3, 4, 5, 6 points respectively (P< 0.05). The percentage of incorrect predictions was 9.1–9.3%. Conclusions: The risk level for 90-day and 1-year postoperative mortality can be predicted using patient characteristics at the time of listing.

Clinical outcomes with transcatheter aortic valve implantation at a single cardiac center in Saudi Arabia.

BACKGROUNDTranscatheter aortic valve implantation (TAVI) has been recognized as a valid alternative to surgery for severe aortic valve stenosis (AS) in high-risk surgical patients.OBJECTIVEDetermine first-year clinical outcomes for TAVI at Madinah Cardiac Center (MMC) in Saudi Arabia.DESIGNRetrospective, analytical cross-sectional.SETTINGTertiary cardiac care center.PATIENTS AND METHODSAll patients who underwent TAVI for severe AS between February 2013 and December 2016 were included. Clinical, imaging, and laboratory information at baseline and at one year follow-up were analyzed.MAIN OUTCOME MEASURESClinical and echocardiography outcomes at discharge, at 1-month, and at end of follow-up; one-year mortality, complications and clinical response to TAVI procedure.SAMPLE SIZE AND CHARACTERISTICSN=80, mean (SD) age 79.5 (10.6) years, with severe AS and high-surgical risk.RESULTSFifty-five (69.2%) patients received Core valves, and 25 (30.8%) received Edward valves. Peri-procedure mortality was 3.8% and 1-year post-operative mortality was 13.8%. Ten patients (12.5%) had life-threatening or major bleeding. Nineteen (23.8%) patients had vascular complications, which were mostly minor. Fourteen patients (17.5%) developed acute kidney injury and 86% of these patients recovered. Five patients (6.25%) had pericardial effusion. Two patients (2.5%) developed endocarditis and another 2 patients (2.5%) had cerebrovascular accidents. Five patients (6.25%) received pacemakers. Mean aortic valve gradient significantly reduced from a mean (SD) 47.6 (19) mm Hg to 10.7 (6.0) mm Hg (P<.001). New York Heart Association functional class was significantly reduced (P<.001).CONCLUSIONThe TAVI experience at MCC is encouraging and comparable to international outcomes in terms of success, morbidity, and mortality rate.LIMITATIONSRetrospective, relatively small sample size. Rate of minor bleeding was overestimated.

Value of Preoperative Modified Body Mass Index in Predicting Postoperative 1-Year Mortality

Serum albumin and conventional BMI (cBMI) are commonly used indices of malnutrition status. Because cBMI does not reflect fluid accumulation, modified body mass index (mBMI, serum albumin × cBMI) is a more accurate measure of malnutrition status. This study investigated the association between preoperative mBMI and postoperative 1-year mortality, in comparison with serum albumin and cBMI. Medical records of 80,969 adult patients who underwent surgical procedures in a tertiary care hospital between 1 January, 2011 and 31 December, 2015 were retrospectively reviewed. Postoperative 1-year mortality increased with reduction in cBMI, mBMI, and albumin separately (P < 0.001). When considering interaction between cBMI and albumin, albumin was the only significant factor of postoperative 1-year mortality [odds ratio: 0.377, 95% confidence interval (0.245–0.579), P < 0.001], while cBMI or interaction (cBMI * albumin) was not significant (P > 0.05). Adjusted area under the curve (AUC) was highest (0.885) in the overall model (cBMI + albumin + cBMI * albumin); adjusted AUC between mBMI and albumin did not differ significantly (P = 0.558). Low albumin is the strongest independent predictor of postoperative 1-year mortality among the three variables (albumin, cBMI, mBMI). Adding cBMI to albumin does not increase the validity of the AUC of albumin.

Hypertrophic Cardiomyopathy in Liver Transplantation Patients

BackgroundHypertrophic cardiomyopathy (HCM) is an autosomal dominant disorder that presents with a hypertrophied nondilated left ventricle. In the absence of other known causes of cardiomyopathy, it is often associated with left ventricular outflow tract obstruction during systole, systolic anterior motion of the mitral valve, mitral regurgitation, and increased risk of sudden cardiac death. When HCM coexists with end-stage liver disease, it can be further complicated by cirrhosis-associated cardiovascular abnormalities, including hyperdynamic circulation, systolic and diastolic dysfunction, and electrophysiologic abnormalities. MethodsWe retrospectively examined patient characteristics, comorbidities, preoperative echocardiogram results, sudden cardiac death risk prediction model score, and 1-year postoperative mortality of patients with HCM who underwent liver transplantation at our institution from January 1, 2000, through January 1, 2015. ResultsOf the 2,812 liver transplantations performed during the study period, we identified 15 patients with a preoperative diagnosis of HCM. When comparing the patients who did vs did not survive the first year after orthotopic liver transplantation, we identified significant differences in maximal left ventricular wall thickness (P = .004) and resting left ventricular outflow tract gradient (P = .004). Preoperative left atrium size (measured by echocardiography; P = .66) and the sudden cardiac death risk prediction model score (P = .32) were not significantly associated with 1-year survival. ConclusionsPreoperative left ventricular outflow tract gradient exceeding 60 mm Hg was strongly associated with death during the first year after transplant. These results suggest that the severity of HCM influences patient outcomes.