Bypass Graft Surgery Research Articles

Coronary Revascularization in High-Risk Stable Patients With Significant Comorbidities: Challenges in Decision-Making.

There is a growing cohort of complex high-risk patients with stable ischemic heart disease (SIHD) who present for coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI). These patients are older, have complex coronary disease, and a substantial comorbidity burden including frailty. The procedural risks and outcomes of CABG and PCI in these patients are more difficult to assess based on the available literature, which has generally studied a younger population with a lower comorbidity burden. There have been initiatives to recalibrate and expand risk models derived from procedural registries to inform the care of complex higher-risk patients, including patients "turned down" for CABG. There is greater recognition of the need for improved assessment of risk, quality, and benefits of coronary revascularization in higher-risk SIHD patients with a substantial comorbidity burden. Clinicians and patients should be aware that there are significant evidence gaps regarding revascularization in complex high-risk patients. The limitations of procedural-derived risk scores should be understood when presenting treatment options. Future randomized controlled trials and expanded registries are greatly desired and should be achievable. Meanwhile, a multidisciplinary heart team approach should be employed for proper decision-making.

Relationship between plaque composition by virtual histology intravascular ultrasound and clinical outcomes after percutaneous coronary intervention in saphenous vein graft disease patients: study protocol of a prospective cohort study

BackgroundPlaque composition and morphologic characteristics identified by virtual histology intravascular ultrasound (VH-IVUS) can determine plaques at increased risk of clinical events following percutaneous coronary intervention (PCI) among coronary artery disease (CAD) patients. However, there have been few studies to investigate the relationship between plaque composition of saphenous vein graft (SVG) by VH-IVUS and clinical outcomes in patients with saphenous vein graft disease (SVGD) undergoing PCI. The purpose of this study is to determine whether plaque components and characteristics by VH-IVUS can predict major adverse cardiac events (MACEs) among SVGD patients undergoing PCI.Methods/designThis is a prospective cohort study conducted in Tianjin Chest Hospital, China. Participants with SVGD referred for PCI will be invited to participate in this study, and will be followed up at 1, 6, 12, 24 and 36 months post-PCI to assess clinical outcomes.The planned sample size is 175 subjects. We will recruit subjects with SVGD scheduled to receive PCI, aged 18–80 years, with a history of previous coronary artery bypass graft (CABG) surgery more than 1 year ago, and willing to participate in the study and sign informed consent.The composite primary study endpoint is the incidence of MACEs after PCI for SVGD, including death from cardiac causes, non-fatal myocardial infarction, unplanned target lesion revascularization (TLR) and target vessel revascularization (TVR). The primary outcome analysis will be presented as Kaplan-Meier estimates and the primary outcome analysis will be carried out using a Cox proportional hazards regression model.DiscussionOnce the predictive values of plaque components and characteristics by VH-IVUS on subsequent clinical outcomes are determined among SVGD patients undergoing PCI, an innovative prediction tool of clinical outcomes for SVGD patients undergoing PCI will be created, which may lead to the development of new methods of risk stratification and intervention guidance.Trial registrationThe study is registered to ClinicalTrials.gov (NCT03175952).

Predictors of Outcome for Aortic Valve Reimplantation Including the Surgeon—A Single-Center Experience

Aortic valve reimplantation is considered technically demanding. We searched for predictors of long-term outcome including the surgeon as risk factor. We selected all aortic valve reimplantations performed in our department between December 1999 and January 2017 and obtained a complete follow-up. The main indications were combined aortic aneurysm plus aortic valve regurgitation (AR), 69% and aortic dissections (15%). In 14%, valves were bicuspid. Cusp repair was performed in 27% of patients. One-third received additional procedures (coronary artery bypass grafting, mitral, or arch surgery). We performed multivariable analyses for independent risk factors of short- and long-term outcomes, including "surgeon" as variable. Twelve different surgeons operated on 193 patients. We created three groups: surgeons A and B with 84 and 64 procedures, respectively, and surgeon C (10 surgeons for 45 patients). Cardiopulmonary bypass and clamp times were 176 ± 45 and 130 ± 24 minutes, respectively. In-hospital mortality was 2%. Postoperatively, 5% had mild and 0.5% had moderate AR. Kaplan-Meier's survival estimates, freedom from reoperation, and freedom from severe AR at 12 years were 97 ± 1, 93 ± 2, and 91 ± 3%, respectively. Age and chronic obstructive pulmonary disease appeared as risk factors for perioperative complications by univariate analysis. Age, coronary artery disease, and duration of cardiopulmonary bypass, but not surgeon, presented as risk factors by multivariable analysis. The results suggest that if a David procedure is performed successfully, long-term durability may be excellent. They also suggest that good and durable results are possible even with limited experience of the operating surgeon.

Abstract 17153: Trends in Coronary Revascularization Among Cancer Patients in the United States, 2005-2014

Introduction: Although co-existing coronary artery disease (CAD) and cancers are increasing, trends of coronary revascularization in patients with cancer history is scarce. Hence, we examined trends, costs, hospital length of stay and in-hospital mortality among cancer patients who underwent percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) surgery in the United States. Methods: The current study was a retrospective analysis of the National Inpatient Sample, collected during the period 2005-2014. Coronary revascularizations were identified among patients ≥45 years by procedure codes 36.01-36.07, 36.09, or 00.66 for PCI, and 36.1x for CABG surgery. Cancer hospitalizations were identified if any of the CCS codes were 11-43. Results: A total of 8,428,811 weighted coronary revascularizations were done during the study period, and 636,819 (7.6%) were among cancer patients. Of this, 454,138 (71.3%) were PCI and 182,681 (28.7%) were CABG. About 35.0% were in the age group 65-74 years and 41.0% in the age group ≥70 years. Majority of patients had Medicare coverage (72.0%), followed by private insurance (22.15%). Among patients with history of cancer, coronary revascularizations increased significantly from 6.5% to 8.5% (relative increase, 30.8%; P trend <0.001). PCI increased significantly from 4.7% to 6.0% (relative increase, 27.7%; P trend <0.001) and CABG increased significantly from 1.8% to 2.5% (relative increase, 38.9%; P trend =0.056) during the study period. The median (interquartile range [IQR]) length of stay decreased significantly from 2.8 (0.86-6.3) to 3.2 (1.6-6.4) days (relative decrease, 14.3%; P trend =0.003) and overall in-hospital mortality rate increased significantly from 1.7% to 2.4% (relative decrease, 41.2%; P trend =0.031). Median cost of hospitalizations increased significantly from $51,206 to $87,935 (relative increase, 71.7%; P trend =0.047). Conclusion: Cancer patients had increasing number of coronary revascularization interventions and adverse hospital outcomes. Prevention and management of risk factors, early disease diagnosis, and advanced treatments should be implemented to improve CAD outcomes in this population.

Aortic valve replacement with or without myocardial revascularization in octogenarians. Can minimally invasive extracorporeal circuits improve the outcome?

The positive impact of minimally invasive extracorporeal circuits (MiECC) on patient outcome is expected to be most evident in patients with limited physiologic reserves. Nevertheless, most studies have limited their use to low-risk patients undergoing myocardial revascularization. As such, there is little evidence to their benefit outside this patient population. We, therefore, set out to explore their potential benefit in octogenarians undergoing aortic valve replacement (AVR) with or without concomitant myocardial revascularization. Based on the type of the utilized ECC, we performed a retrospective propensity score-matched comparison among all octogenarians (n = 218) who received a primary AVR with or without concomitant coronary artery bypass grafting in our institution between 2003 and 2010. A MiECC was utilized in 32% of the patients. The propensity score matching yielded 52 matched pairs. The 30-day postoperative mortality (2% vs. 10%; p=0.2), the incidence of low cardiac output (0% vs. 6%; p=0.2) and the Intensive Care Unit (ICU) stay (2.5 ± 2.6 vs. 3.8 ± 4.7 days; p=0.06) were all in favour of the MiECC group, but failed to reach statistical significance while the 90-day postoperative mortality did (2% vs. 16%; p=0.02). MiECCs have a positive influence on the outcome of octogenarians undergoing AVR with or without concomitant coronary artery bypass grafting. Their use should, therefore, be extended beyond isolated coronary artery bypass graft (CABG) surgery.

The comparative effects of esmolol and amiodarone on isolated coronary artery bypass grafts

Background/aim: Esmolol and amiodarone are two most commonly used antiarrhythmic drugs in coronary artery bypass grafting (CABG) surgery. Nevertheless, blockade of beta-2 receptors by increasing doses raise concerns about possible vasospasms. We studied the vasoactive effects of amiodarone and esmolol on left internal mammary artery (LIMA), radial artery (RA), and saphenous vein (SV) grafts. Materials and methods: After determining the presence of functional smooth muscle and endothelial layers, the responses of submaximally preconstricted graft samples were recorded in a tissue bath system. A total of 96 graft samples from 40 patients were used: 16 LIMA, 16 RA, and 16 SV grafts for each drug. Esmolol and amiodarone were added to reservoirs separately, starting from a concentration of 10-8 M until a concentration of 10-4 M. Results: Although both drugs caused vasodilatation, amiodarone exhibited a more potent vasodilatory effect than esmolol (P < 0.0001 for LIMA, P = 0.0128 for RA, and P < 0.0001 for SV). The vasodilatation rates with esmolol were 48.99 ± 2.28% in LIMA, 49.77 ± 3.03% in RA, and 41.90 ± 4.05% in SV grafts and with amiodarone they were 71.65 ± 5.18% in LIMA, 58.61 ± 5.87% in RA, and 65.07 ± 4.09% in SV grafts. Conclusion: This in vitro study revealed that even increasing doses of both drugs induce vasodilatation of CABG grafts, with amiodarone having a more potent vasodilatory effect than esmolol.

Elevated preoperative Galectin-3 is associated with acute kidney injury after cardiac surgery

BackgroundPrevious research suggests that novel biomarkers may be used to identify patients at increased risk of acute kidney injury following cardiac surgery. The purpose of this study was to evaluate the relationship between preoperative levels of circulating Galectin-3 (Gal-3) and acute kidney injury after cardiac surgery.MethodsPreoperative serum Gal-3 was measured in 1498 patients who underwent coronary artery bypass graft (CABG) surgery and/or valve surgery as part of the Northern New England Biomarker Study between 2004 and 2007. Preoperative Gal-3 levels were measured using multiplex assays and grouped into terciles. Univariate and multinomial logistic regression was used to assess the predictive ability of Gal-3 terciles and AKI occurrence and severity.ResultsBefore adjustment, patients in the highest tercile of Gal-3 had a 2.86-greater odds of developing postoperative KDIGO Stage 2 or 3 (p < 0.001) and 1.70-greater odds of developing KDIGO Stage 1 (p = < 0.001), compared to the first tercile. After adjustment, patients in the highest tercile had 2.95-greater odds of developing KDIGO Stage 2 or 3 (p < 0.001) and 1.71-increased odds of developing KDIGO Stage 1 (p = 0.001), compared to the first tercile. Compared to the base model, the addition of Gal-3 terciles improved discriminatory power compared to without Gal-3 terciles (test of equality = 0.042).ConclusionElevated preoperative Gal-3 levels significantly improves predictive ability over existing clinical models for postoperative AKI and may be used to augment risk information for patients at the highest risk of developing AKI and AKI severity after cardiac surgery.

Two Decades of Contemporary Surgery of Primary Cardiac Tumors.

Objective The decision to operate cardiac tumors is an issue of balancing surgical outcome and survival with quality of life (QOL). We report our single-center experience in managing primary cardiac tumors between 1994 and 2014. Methods and Results In this study, 269 patients were subjected to our standardized operative protocols, preoperative preparations, postoperative follow-up, and consents of participation. Demographic and preoperative/intraoperative/postoperative variables were collected with focus on long-term follow-up and survival. A total of 72,000 cardiac procedures were performed within 20 years at our institution. Two hundred sixty-nine patients were diagnosed with primary cardiac tumors (0.37%), with a male:female ratio of 1:1.68, mean age of 57.4 ± 19.5 years, and body mass index of 25.49 ± 6.5. The most presenting symptoms were dyspnea ( n = 94), arrhythmias ( n = 53), embolic event ( n = 36), and chest pain ( n = 29), and 33 patients were accidentally discovered. Isolated tumor excision and concomitant ablation were performed on 181 patients, while the rest needed additional procedures such as coronary artery bypass grafting ( n = 27) or valve surgery ( n = 61). Focus on pathology, tumor location was done reporting the commonest pathology such as myxoma ( n = 177) and fibroelastoma ( n = 56). The frequent site was the left atrium ( n = 162). Our primary results showed incidence of bleeding in 9 patients (3.3%), arrhythmias in 76 patients (28.25%), and mortality in 49 patients (18.2%). Five patients (1.8%) showed recurrence and 220 patients (81.8%) showed complaint-free survival. Conclusion Complete excision of primary cardiac tumors is the golden rule in management as it improves survival and decreases morbidity expected from the progressing tumors process. The progression of minimally invasive techniques improves QOL and should be performed whenever possible.

A Rabbit Model of Durable Transgene Expression in Jugular Vein to Common Carotid Artery Interposition Grafts.

Vein graft bypass surgery is a common treatment for occlusive arterial disease; however, long-term success is limited by graft failure due to thrombosis, intimal hyperplasia, and atherosclerosis. The goal of this article is to demonstrate a method for placing bilateral venous interposition grafts in a rabbit, then transducing the grafts with a gene transfer vector that achieves durable transgene expression. The method allows the investigation of the biological roles of genes and their protein products in normal vein graft homeostasis. It also allows the testing of transgenes for the activities that could prevent vein graft failure, e.g., whether the expression of a transgene prevents the neointimal growth, reduces the vascular inflammation, or reduces atherosclerosis in rabbits fed with a high-fat diet. During an initial survival surgery, the segments of right and left external jugular vein are excised and placed bilaterally as reversed end-to-side common carotid artery interposition grafts. During a second survival surgery, performed 28 days later, each of the grafts is isolated from the circulation with vascular clips and the lumens are filled (via an arteriotomy) with a solution containing a helper-dependent adenoviral (HDAd) vector. After a 20-min incubation, the vector solution is aspirated, the arteriotomy is repaired, and flow is restored. The veins are harvested at time points dictated by individual experimental protocols. The 28-day delay between the graft placement and the transduction is necessary to ensure the adaptation of the vein graft to the arterial circulation. This adaptation avoids rapid loss of transgene expression that occurs in vein grafts transduced before or immediately after grafting. The method is unique in its ability to achieve durable, stable transgene expression in grafted veins. Compared to other large animal vein graft models, rabbits have advantages of low cost and easy handling. Compared to rodent vein graft models, rabbits have larger and easier-to-manipulate blood vessels that provide abundant tissue for analysis.

3D numerical model of blood flow in the coronary artery bypass graft during no pulse and pulse situations: Effects of an anastomotic angle and characteristics of fluid

Coronary heart disease (CHD) is a fatal condition caused by atherosclerosis or plaque on the arterial walls resulting in its breakage. Curing this disease effectively can be conducted through bypass graft surgery, which helps to restore the blood flow. However, some patients have required repeated surgery because of frequent failures of an implanted bypass graft. In this study, the stenosed coronary artery bypass graft including an analysis of the blood flow phenomena and wall shear stress, based on a three-dimensional computer model, was analyzed and developed to approach a realistic situation, inlet pulse and non-Newtonian behavior. The effects of the anastomotic angles (45°, 60° and 90°), blood characteristics (Newtonian and non-Newtonian) and inlet situations (with and without pulse) were taken into consideration. The results demonstrated that the anastomosis of 45° was the most appropriate for resolving the CHD problem and could act as a guide for medical treatment as well.

Prognostic value of frontal QRS-T angle in patients undergoing myocardial revascularization or cardiac valve surgery

BackgroundAn abnormal frontal QRS-T angle (fQRSTa) is associated with increased risk of death in primary and secondary cardiovascular prevention. The aim of this study was to evaluate the fQRSTa prognostic role in patients undergoing myocardial revascularization and/or cardiac valve surgery. MethodsWe enrolled and prospectively followed for 48 ± 26 months 939 subjects with available QRS and T axis data; mean age was 68 ± 12 years, 449 patients (48%) underwent myocardial revascularization, 333 (35%) cardiac valve surgery, 94 (10%) valve plus bypass graft surgery and 63 (7%) cardiac surgery for other cardiovascular (CV) diseases. The ECG variables were collected at the end of the cardiac rehabilitation program and fQRSTa was considered normal if <60°, abnormal if >120°, borderline otherwise. Endpoints were overall and CV mortality. ResultsThe fQRSTa was normal in 333 patients (36%), borderline in 285 (30%) and abnormal in 321 (34%). Overall (p = 0.012) and cardiovascular (p = 0.007) mortality were significantly higher in patients with abnormal fQRSTa even after adjusting separately for gender, PR-, QTc- intervals, presence of right or left bundle branch block and left atrial volume index. The predictive value was confirmed in patients with stable coronary artery disease (SCAD), not in patients with acute coronary syndrome or valve disease. SCAD patients with abnormal both fQRSTa and QRS axis had higher risk of overall (hazard ratio = 2.9, p < 0.0001) and CV (hazard ratio = 4.4, p < 0.0001) mortality compared with SCAD patients with normal fQRSTa, even after multivariate adjustment for age, gender, ECG intervals, left-ventricle ejection fraction and mass index. ConclusionsIn SCAD patients undergoing myocardial revascularization, abnormal fQRSTa is independent predictor of overall and CV mortality.

In Vivo Performance of Decellularized Vascular Grafts: A Review Article.

Due to poor vessel quality in patients with cardiovascular diseases, there has been an increased demand for small-diameter tissue-engineered blood vessels that can be used as replacement grafts in bypass surgery. Decellularization techniques to minimize cellular inflammation have been applied in tissue engineering research for the development of small-diameter vascular grafts. The biocompatibility of allogenic or xenogenic decellularized matrices has been evaluated in vitro and in vivo. Both short-term and long-term preclinical studies are crucial for evaluation of the in vivo performance of decellularized vascular grafts. This review offers insight into the various preclinical studies that have been performed using decellularized vascular grafts. Different strategies, such as surface-modified, recellularized, or hybrid vascular grafts, used to improve neoendothelialization and vascular wall remodeling, are also highlighted. This review provides information on the current status and the future development of decellularized vascular grafts.

Unaltered Fatty Acid Uptake, Utilization, and Mitochondrial Respiration in Right Atrial Appendage of Type 2 Diabetic Human Heart

Previous studies on diabetic human heart have shown decreased utilization of fatty acid (FA)/carbohydrate substrates. We hypothesized that increased mitochondrial dysfunction with concomitant decrease in fatty acid utilization would be found in diabetic hearts of patients from the Indian subcontinent that would explain their increased propensity of cardiovascular complications. We have compared mitochondrial respiration in atrial appendage tissue from nondiabetic and diabetic human subjects undergoing elective coronary artery bypass graft (CABG) surgery using high-resolution respirometry with FA and carbohydrate substrate combinations. In the presence of FA, diabetic mitochondria showed unimpaired complex I and electron transferring flavoprotein (ETF) mediated respiration while significantly lower oxygen consumption was noted when succinate was added, indicating the possible derangement of complex II respiration. Unlike other human studies, we report no significant reduction in FA- mediated mitochondrial respiration. However, the carbohydrate protocol indicated impairment of complex I mediated respiration. There was no significant change in the expression of OXPHOS proteins. Unchanged levels of FA uptake proteins like CD36 and FABP, FA oxidation enzyme, long chain acyl CoA deydrogenase (LCAD), regulators of FA metabolism like sirtuins and nuclear receptors, PPARα and transcription coactivators, PGC1α/β were observed in diabetic heart. The acetylation status of mitochondrial specific proteins involved in fatty acid oxidation (acetylated LCAD and PGC1α/β) also showed no significant changes. Diabetic patients showed equal expression of the antioxidant enzymes and other markers of oxidative stress. The unimpaired FA uptake, oxidation and mitochondrial respiration indicates absence of overt mitochondrial dysfunction in type 2 diabetic human heart. Disclosure N. Rj: None. R. Sr: None. V.V. Pillai: None. J. K.: None. S. Gopala: None.

Alogliptin and Pioglitazone, Alone or in Combination, Prevent Palmitate-Induced Apoptosis and Autophagy in Human Cardiac Progenitor Cells

Physiological tissue turnover in the heart requires proper activation and viability of multipotent cardiac progenitor cells (CPCs). A defective CPC compartment, in terms of CPC number and maturation capacity, contributes to diabetes- and hyperglycemia-related heart failure in humans. GLP-1-based therapies, including the DPP-4 inhibitors, improve cardiac function in vivo and ameliorate myocardial and endothelial dysfunction in vitro. Pioglitazone has also demonstrated pleiotropic anti-oxidant and anti-atherogenic effects. The aim of this study was to evaluate the effects of alogliptin and pioglitazone, alone or in combination, on the viability of human CPCs exposed to 0.25 mM palmitate for 16 h. Human CPCs were obtained from patients undergoing cardiac surgery for coronary artery bypass grafting and/or valve surgery. Exposure of human CPCs to both alogliptin (10 µM) and pioglitazone (10 µM) for 16 h resulted in Akt, but not Erk, activation. Exposure to palmitate was associated with increased human CPC apoptosis and autophagy evaluated by ELISA assay and LC3-II immunoblotting, respectively (p&amp;lt;0.05). Pretreatment with alogliptin, alone or in combination with pioglitazone for 1 h before exposure to palmitate, reduced palmitate-induced apoptosis and autophagy (p&amp;lt;0.05). In conclusion, palmitate induces apoptosis and autophagy in human CPCs, and alogliptin and pioglitazone, as well as their combination, prevent the effects of palmitate, likely through enhancement of pro-survival pathways. Hence, DPP-4 inhibitors and thiazolidinediones, alone or in combination, may limit the lipotoxic damage of the human heart by preserving the viability of myocardial progenitor cells. Disclosure M. Incalza: None. R. D'Oria: None. C. Caccioppoli: None. A. Leonardini: None. R. Schipani: None. A. Cignarelli: Advisory Panel; Self; Aegerion Pharmaceuticals. Consultant; Self; Roche Diagnostics Corporation, Eli Lilly and Company. A. Natalicchio: None. S. Perrini: None. V. Margari: None. D. Paparella: None. L. Laviola: Advisory Panel; Self; AstraZeneca, Animas Corporation. Speaker's Bureau; Self; A. Menarini Diagnostics. Advisory Panel; Self; Boehringer Ingelheim GmbH, Eli Lilly and Company. Speaker's Bureau; Self; Medtronic, Merck Sharp &amp; Dohme Corp.. Advisory Panel; Self; Novo Nordisk Inc., Roche Diabetes Care Health and Digital Solutions, Sanofi-Aventis, Takeda Development Centre Europe Ltd. F. Giorgino: Consultant; Self; Abbott, AstraZeneca, Boehringer Ingelheim GmbH. Research Support; Self; Eli Lilly and Company, Johnson &amp; Johnson Services, Inc.. Consultant; Self; MedImmune, Merck Sharp &amp; Dohme Corp., Roche Diabetes Care Health and Digital Solutions, Sanofi. Research Support; Self; Takeda Development Centre Europe Ltd..

Improved Cost-Effectiveness and Blood Product Utilization From Instituting a Blood Ordering Algorithm for Cardiac Surgical Cases.

Results of a previous study revealed an over-ordering of blood products for cardiac surgery and led to the creation of a new blood ordering algorithm. This follow-up study has been conducted to evaluate improvement in ordering practices. Retrospective data were collected for 171 patients who underwent coronary artery bypass grafting or valve surgery from March 2015 to March 2016 to determine the crossmatch-to-transfusion ratio (C:tx) and potential cost savings. Results were compared with pre-algorithm values and considered statistically significant if the 95% confidence interval did not include zero. Prior to the algorithm, 100% of patients undergoing cardiac surgery were crossmatched. After instituting the algorithm, this decreased to 15%. The overall C:tx decreased from 7.97 to 2.14. Cost savings were calculated as $114.79 (coronary artery bypass grafting) and $129.05 (valve surgery) per patient. The creation of a new algorithm to guide ordering practices has significantly improved the C:tx, reduced unnecessary crossmatching, and lowered costs.

Short Term Outcome of Urgent Coronary Artery Bypass Grafting (CABG) Surgery

Short Term Outcome of Urgent Coronary Artery Bypass Grafting (CABG) Surgery

Cost-Effectiveness Evaluation of Heparin Coated Versus Standard Graft for Bypass Surgery in Peripheral Artery Disease Alongside a Randomised Controlled Trial

Heparin coating has recently been shown to reduce the risk of graft failure in arterial revascularisation, at least transiently. The aim of this study was to assess the cost-effectiveness of heparin coated versus standard polytetrafluoroethylene grafts for bypass surgery in peripheral artery disease from a long-term healthcare system perspective. Cost-effectiveness evaluation was conducted alongside the Danish part of the Scandinavian Propaten trial in which 431 patients planned for femoro-femoral or femoro-popliteal bypass surgery were randomised to either type of graft and followed for 5 years. Based on the intention to treat principle, the differences in healthcare costs (general practice, prescription medication, hospital admission, rehabilitation, and long-term care in 2015 Euros), life years (LYs), and quality adjusted life years (QALYs) were analysed as arithmetic means with bootstrapped 95% confidence intervals. Cost-effectiveness acceptability curves were used to illustrate the probability of cost-effectiveness for a range of threshold values of willingness to pay (WTP). No statistically significant differences between the randomisation groups were observed for costs or gains of LYs or QALYs. The average cost per QALY was estimated at €10,792. For a WTP threshold of €40,000 per QALY, the overall probability of cost-effectiveness was estimated at 62%, but owing to cost savings in patients with critical ischaemia (cost per QALY <€0), it increased to 89% for this subgroup. Until further evidence, heparin coated grafts appear overall, to be cost-effective over standard grafts, but important heterogeneity between claudication and critical ischaemia should be noted. While the optimal choice for claudication remains uncertain, heparin coated grafts should be used for critical ischaemia.

Abstract 133: Using Administrative Data Registries and Clinical Data Registries to Identify Discrepancies and Improve Data Quality

Background: The California (CA) Office of Statewide Health Planning and Development (OSHPD) collects three types of patient-level administrative data: patient discharge (PDD), ambulatory surgery (AS), and emergency room (ER). CA hospitals are mandated to submit clinical data to OSHPD for all adult coronary artery bypass graft (CABG) surgeries. This submission is usually a subset of hospital’s Society of Thoracic Surgeons Adult Cardiac Surgery Database submissions. In addition, OSHPD receives clinical data from the National Cardiac Data Registry CathPCI for CA hospitals certified to perform elective PCIs without onsite surgery available. OSHPD implements various data quality efforts to ensure accuracy in each data source, including using data from administrative registries to confirm clinical data and using data from clinical registries to confirm administrative data. Methods: The clinical CABG data submitted to OSHPD is linked to the PDD. The resulting discrepancy reports are shared with hospitals to assist them when revising their data. The reports show discrepancies in over- and under-reporting of CABG cases, isolated and non-isolated CABGs, and post-op complications. For PCI reporting, clinical data from the CathPCI registry is compared to the PDD, AS, and ER to look for discrepancies. Results: For the 2016 CABG data, discrepancy reports issued to 126 hospitals submitting clinical CABG data to OSHPD showed potential under-reporting of 417 CABGs that appeared in the PDD but were not submitted in the clinical data. The report showed an additional 437 CABGs that were submitted in the clinical data, but did not appear in the PDD. Hospital review and response to these reports resulted in an overall increase of 296 CABGs to the clinical database. Discrepancy reports also alerted hospitals to 66 cases where a post-operative stroke occurred but was not reported in the clinical database. Hospital review resulted in 22 post-operative strokes added to the clinical registry. The 2016 CathPCI data for CA certified elective PCI hospitals showed potential under reporting of PCIs in PDD, AS, and ER. Possible missing PCIs ranged from 0.4% to 21.6% per hospital. OSHPD worked with staff at the clinical data and administrative data units at these hospitals to understand the discrepancies. The main issue identified was that AS data submitted by some hospitals used alternate coding (Healthcare Common Procedure Coding System) and failed to convert these codes to Current Procedural Terminology codes as required. The findings plan to be used in an outreach effort to all CA hospital submitting administrative PCI data to OSHPD to ensure accurate reporting. Conclusion: Comparing administrative and clinical data registries data is an effective quality tool to identify discrepancies in each source of data. Sharing discrepancies with hospitals results in improved understanding of data standards and data quality.

Abstract 18: Center Variation in 90-Day Episode Expenditures for Cardiac Surgery - The Role of Healthcare-Associated Pnuemonia

Objective: Pneumonia is the most common healthcare-associated infection following cardiac surgery, and associated with poorer clinical outcomes and substantially higher hospital costs. Less understood is the role that the care and treatment of post-operative pneumonia may have on a hospital’s 90-day episode payments. We hypothesize that expenditures associated with pneumonia may significantly impact a hospital’s 90-day episode payments for coronary artery bypass graft (CABG) surgery. Methods and Results: Using Medicare Part A and B claims data, we identified 49,573 patients undergoing isolated CABG in 1,001 hospitals with greater than 10 cases (2014-15). We applied an established claims-based algorithm to identify 3,135 (6.3%) patients as having a new onset of pneumonia during their index admission and after their surgical procedure. Using hierarchical logistic regression models, we estimated risk-adjusted hospital-level pneumonia rates, adjusted for age, sex, race, Medicaid eligibility, Elixhauser comorbidities, and hospital-random effect. There was weak correlation (r=0.20, p&lt;0.001) between observed and predicted (adjusting for only patient factors) hospital-level pneumonia rates, indicating patient factors explained little of the variation between hospitals. We placed patients into quartiles based on rank-order of hospital risk-adjusted pneumonia rates; the pneumonia rate in the lowest and highest quartile was 3.4% and 13.9% (p&lt;0.001), respectively (Table). Average risk-adjusted 90-day episode expenditures were 10% higher for patients in the highest quartile hospitals compared to the lowest quartile ($41,936 vs. $46,095 vs., p&lt;0.001). Payments for outlier hospitalizations were 100% greater in the highest quartile hospitals compared to the lowest quartile, and accounted for 28.5% of the total difference between high and low spending hospitals. Conclusion: New onset pneumonia after cardiac surgery varies widely across hospitals, and counter to conventional wisdom, is not driven by patient risk. Cardiac surgical programs should consider the prevention and management post-operative pneumonia as a component of their overall strategy for reducing 90-day episode payments.

Prediction of Patient Length of Stay on the Intensive Care Unit Following Cardiac Surgery: A Logistic Regression Analysis Based on the Cardiac Operative Mortality Risk Calculator, EuroSCORE

The aim of this study was to develop a statistical model based on patient parameters to predict the length of stay (LOS) in the intensive care unit (ICU) following cardiac surgery in a single center. Data were collected from patients admitted to the ICU following cardiac surgery over a 10-year period (2006-2016). Both the additive and logistic EuroSCORE were calculated, and logistic regression analysis was carried out to formulate a model relating the predicted LOS to the EuroSCORE. This model was used to stratify patients into short stay (less than 48 hours) or long stay (more than 48 hours). ICU at Papworth Hospital, Cambridgeshire. A total of 18,377 consecutive patients who had been in ICU following cardiac surgery (coronary graft bypass surgery, valve surgery, or a combination of both). This was an observational study. The authors have shown that both the additive and logistic EuroSCORE can be used to stratify cardiac surgical patients in various predicted LOS in ICU. Further adjustments can be made to increase the number of patients correctly identified as either short stay or long stay. Comparison of the model predictions to the data demonstrated a high overall accuracy of 79.77%, and receiver operating characteristic curve analysis showed the area under the curve to be 0.7296. This analysis of an extensive data set shows that patient LOS in ICU after cardiac surgery in a single center can be predicted accurately using the simple cardiac operative risk scoring tool EuroSCORE. Using such predictions has the potential to improve ICU resource management.