Cardiac Surgical Outcomes Research Articles

Feasibility of Report Cards for Measuring Anesthesiologist Quality for Cardiac Surgery.

In creating the Merit-Based Incentive Payment System, Congress has mandated pay-for-performance (P4P) for all physicians, including anesthesiologists. There are currently no National Quality Forum-endorsed risk-adjusted outcome metrics for anesthesiologists to use as the basis for P4P. Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 55,436 patients undergoing cardiac surgery between 2009 and 2012. Hierarchical logistic regression modeling was used to examine the variation in in-hospital mortality or major complications (Q-wave myocardial infarction, renal failure, stroke, and respiratory failure) among anesthesiologists, controlling for patient demographics, severity of disease, comorbidities, and hospital quality. Although the variation in performance among anesthesiologists was statistically significant (P = 0.025), none of the anesthesiologists in the sample was classified as a high- or low-performance outliers. The contribution of anesthesiologists to outcomes represented 0.51% of the overall variability in patient outcomes (intraclass correlation coefficient [ICC] = 0.0051; 95% confidence interval [CI], 0.002-0.014), whereas the contribution of hospitals to patient outcomes was 2.90% (ICC = 0.029; 95% CI, 0.017-0.050). The anesthesiologist median odds ratio (MOR) was 1.13 (95% CI, 1.08-1.24), suggesting that the variation between anesthesiologist was modest, whereas the hospital MOR was 1.35 (95% CI, 1.25-1.48). In a separate analysis, the contribution of surgeons to overall outcomes represented 1.76% of the overall variability in patient outcomes (ICC = 0.018, 95% CI, 0.010-0.031), and the surgeon MOR was 1.26 (95% CI, 1.19-1.37). Twelve of the surgeons were identified as performance outliers. The impact of anesthesiologists on the total variability in cardiac surgical outcomes was probably about one-fourth as large as the surgeons' contribution. None of the anesthesiologists caring for cardiac surgical patients in New York State over a 3+ year period were identified as performance outliers. The use of a performance metric based on death or major complications for P4P may not be feasible for cardiac anesthesiologists.

Preoperative Renal Function Predicts Hospital Costs and Length of Stay in Coronary Artery Bypass Grafting

Renal failure remains a major source of morbidity after cardiac surgery. Whereas the relationship between poor renal function and worse cardiac surgical outcomes is well established, the ability to predict the impact of preoperative renal insufficiency on hospital costs and health care resource utilization remains unknown. Patient records from a statewide The Society for Thoracic Surgeons (STS) database linked with estimated cost data were evaluated for isolated coronary artery bypass graft (CABG) operations (2000 to 2012). Patients with documented preoperative renal failure/dialysis were excluded. Preoperative renal function was determined using calculated creatinine clearance (CrCl). Multivariable regression analyses utilizing restricted cubic splines evaluated the continuous relationship between CrCl and risk-adjusted outcomes. A total of 46,577 isolated CABG operations were evaluated with a median STS predicted risk of mortality score of 1.2% (interquartile range, 0.7% to 2.4%), including 9% off-pump CABG. Median CrCl was 85 mL/min (range, 2 to 120 mL/min), and median total cost was $25,011. After adjustment for preoperative risk factors, worsening CrCl (declining renal function) was highly associated with greater total costs of hospitalization (coefficient=-122, p < 0.001) and postoperative length of stay (coefficient=-0.03, p < 0.001). Furthermore, predicted total costs were incrementally increased by 10%, 20%, and 30% with worsening of CrCl from 80 mL/min to 60, 40, and 20 mL/min. As expected, decreasing CrCl was also associated with an increased risk-adjusted likelihood for hemodialysis and mortality (both p < 0.001). Preoperative renal function is highly associated with the cost of CABG. Assessment of renal function may be used to preoperatively predict cost and resource utilization. Optimizing renal function preoperatively has the potential to improve patient quality and costs by approximately 6% ($1,250) for every 10 mL/min improvement in creatinine clearance.

Impact of Variability in Echocardiographic Interpretation on Assessment of Adequacy of Repair Following Congenital Heart Surgery: A Pilot Study.

Technical Performance Score (TPS) is based largely on the presence and magnitude of residual lesions on postoperative echocardiograms; this score correlates with outcomes following repair of congenital heart defects. We evaluated reader variability for echocardiographic components of TPS for complete repair of tetralogy of Fallot (TOF) and arterial switch operation (ASO) in two centers and measured its effect on TPS. Postoperative echocardiograms were evaluated in 67 children (39 TOF and 28 ASO). Two readers (one per center) interpreted each echocardiogram. Reader variability in image quality assessments and measurements was compared using weighted kappa (κ), percent agreement, and intra-class correlation. TPS class (1 optimal-no residua, 2 adequate-minor residua, 3 inadequate-major residua) was assigned for each echocardiographic review by an independent investigator. The effect of reader interpretation variability on TPS classification was measured. There was strong agreement for TPS between the two readers (κ = 0.88). The readers were concordant for TPS classes for 57 children (85%) and discordant for classes 2 (minor residua) versus 3 (major residua) in six (9%). Coronary arteries and branch pulmonary arteries were frequently suboptimally visualized. Although inter-reader agreement for TPS was strong, inter-reader variation in echocardiographic interpretations had a small, but important effect on TPS for TOF and ASO, particularly for the distinction between minor and major residua. Further studies of generalizability and reproducibility of TPS and refinement of scoring modules may be needed before it can be used as a tool to assess pediatric cardiac surgical performance and outcomes.

Contemporary Outcomes of Coronary Artery Bypass Grafting Among Patients With Insulin-Treated and Non–Insulin-Treated Diabetes

More than 40% of patients undergoing coronary artery bypass grafting (CABG) have diabetes. However, it is unknown how insulin treatment status influences cardiac surgical outcomes among patients with diabetes. All isolated CABG, CABG plus aortic valve replacement or plus mitral valve repair/replacement procedures performed in 2012 were extracted from the California CABG Outcomes Reporting Program database. Patients were grouped into three categories: (1) no diabetes, (2) non-insulin-treated diabetes (NITDM), and (3) insulin-treated diabetes (ITDM). Demographic and clinical baseline characteristics and observed postoperative major adverse events, including 30-day mortality, stroke, deep sternal wound infection, prolonged ventilation, new dialysis requirement, renal failure, and 30-day readmission were compared. Multivariable logistic regression models were developed for predicting the impact of NITDM and ITDM on postoperative major adverse events. A total of 14,051 patients underwent isolated CABG or CABG plus aortic/mitral valve procedures in California during 2012; 6700 (47.7%) had no diabetes, 5165 (36.8%) had NITDM, and 2183 (15.6%) had ITDM. Compared with the nondiabetic and NITDM groups, the ITDM group was younger, more frequently women and nonwhite, and had a higher prevalence of preoperative comorbidities (all p < 0.05). After adjusting for baseline risk factors and surgery type compared with patients without diabetes, both NITDM and ITDM were associated with significantly increased risk of major adverse events [NITDM: adjusted odds ratio (AOR), 1.15, 95 % confidence interval (CI), 1.04 to 1.26, p = 0.005; ITDM: AOR, 1.49, 95% CI, 1.32 to 1.68, p < 0.0001]. A subgroup comparison indicated a similar gradient of risk for each category of cardiac surgery. Patients with diabetes undergoing CABG have substantially increased risk of major adverse events. Patients with ITDM represent an especially high-risk group.

Impact of Intrauterine Growth Restriction on Cardiac Surgical Outcomes and Resource Use

We sought to evaluate outcomes of congenital heart operations and resource use in patients with intrauterine growth restriction (IUGR). This was a retrospective matched case-control study of 41 consecutive patients with IUGR matched 1:2 with a comparison cohort of 82 contemporaneous patients without IUGR who underwent congenital heart operations during the interval from January 1, 2000 to January 1, 2012. Matching was based on the Risk Adjustment for Congenital Heart Surgery (RACHS)-1 risk category, diagnostic category, age at operation, and gestational age. Operative mortality (6 of 41 cases [14.6%] for the study group versus 5 of 82 cases [6.1%] for controls) and any major adverse event (14 of 41 cases [34.2%] for the study group versus 23 of 82 cases [28%] for controls) occurred in a higher percentage of study patients, with insignificant p values. Important differences in secondary outcomes included the following: mean total length of stay (56.3 days versus 28.0 days for controls; p < 0.0001), postoperative days of mechanical ventilation (25.8 days versus 5.4 days for controls; p = 0.002), postoperative cardiopulmonary arrest (7 of 41 cases [17.1%] versus 4 of 82 cases [4.9%] for controls; p = 0.03), and postoperative infection (13 of 41 cases [31.7%] versus 13 of 81 cases [16.1%] for controls; p = 0.04). The mean charge for the study group was considerably higher than that for the control group: $493,915 versus $175,144; p < 0.0001. IUGR is associated with a substantially increased length of hospital stay, postoperative morbidity, and resource use. These findings are relevant to risk stratification, prognosis, and potentially to contracting and reimbursement. IUGR merits further attention as an important risk factor in congenital heart operations.

Preoperative Cardiac Risk Assessment and Surgical Outcomes of Patients with Gastric Cancer.

To evaluate the incidence of major adverse cardiac events (MACE) and long-term surgical outcomes after gastrectomy for gastric cancer using the revised cardiac risk index (RCRI), which is based on preoperative insulin use, serum creatinine >2.0 mg/dL, and history of ischemic or congestive heart failure or cerebrovascular disease. We allocated 1000 patients who underwent elective gastrectomy to three groups with ≥3 (group A, n = 32), 2 (group B, n = 142), or 1 (group C, n = 826) of these factors and compared surgical complications and prognoses. Groups A and B had older patients than group C. Group B had more male patients than groups A and C. Tumor staging and gastrectomy type were similar among all groups. D1 lymph node dissection was more frequent in group A than in groups B or C. The incidence of MACE in groups A, B, and C was 25.0, 9.9, and 1.1 %, respectively. RCRI was associated with MACE. Furthermore, the incidence of pneumonia and in-hospital mortality was associated with RCRI risk factors. However, the incidence of anastomotic leakage, intra-abdominal abscess, wound infection, and pancreas-related infection were similar among the groups. The 5-year overall survival rates of the three groups were 44.3, 65.2, and 80.8 %, which were significantly different. Patients with RCRI factors have an increased risk of MACE, pneumonia, and higher mortality after gastrectomy; thus, careful patient selection and meticulous perioperative care are crucial for successful gastrectomy.

Impact of long-axis function on cardiac surgical outcomes in patients with radiation-associated heart disease

BackgroundMalignancy-associated thoracic radiation leads to radiation-associated cardiac disease (RACD) that often necessitates cardiac surgery. Myocardial dysfunction is common in patients with RACD. We sought to determine the predictive value of global left ventricular ejection fraction and long-axis function left ventricular global longitudinal strain (LV-GLS) in such patients. MethodsWe studied 163 patients (age, 63 ± 14 years; 74% women) who had RACD and underwent cardiac surgery (20% had reoperations) between 2000 and 2003. In addition to standard echocardiography, LV-GLS (%) was derived from the average of 18 segments in 3 apical views of the left ventricle, using velocity vector imaging. Standard clinical and demographic parameters were recorded. All-cause mortality was recorded. ResultsThe mean duration between cardiac surgery and the last chest radiation was 18 ± 12 years. The median European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 8, and 88 patients died over 6.6 ± 4 years. A total of 52% of patients had ≥II+ mitral regurgitation; 23% of patients had severe aortic stenosis; and 39% of patients had ≥II+ tricuspid regurgitation. The mean left ventricular ejection fraction was 54% ± 13%, and the mean LV-GLS was −12.9% ± 4%. In a Cox proportional survival analysis, lower LV-GLS was predictive of mortality in univariable analysis (hazard ratio, 1.07 (95% confidence interval, 1.01-1.14); P = .006); however, after adjustment for other variables, the association became nonsignificant. In patients with a EuroSCORE <median, abnormal LV-GLS (<−14.5%) was associated with significantly higher mortality (48%), compared with those with normal LV-GLS (32%). ConclusionsIn patients who have RACD and undergo cardiac surgery, LV-GLS does not sufficiently discriminate and is not independently predictive of long-term outcomes. However, in patients with a low EuroSCORE, abnormal LV-GLS was associated with higher mortality, compared with those with normal LV-GLS.

The science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care.

Although significant progress has been made in the care of patients with paediatric and congenital cardiac disease, optimization of outcomes remains a constant goal. This review article will discuss the latest advances in the science of assessing the outcomes and improving the quality of the congenital and paediatric cardiac care, and will also review some of the latest associated research. Important advances continue to be made in each of the following domains: standardized nomenclature; established uniform core dataset; evaluation of case complexity; verification of the completeness and accuracy of the data; collaboration between subspecialties; strategies for longitudinal follow-up; and incorporating quality improvement. In January 2015, the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) will begin voluntary public reporting of programmatic congenital cardiac surgical outcomes using a new risk model that includes both procedural risk (as defined by the procedure itself and STAT Categories) and a number of patient-specific characteristics including age, weight, prior cardiothoracic operation, prematurity, chromosomal abnormalities, syndromes, noncardiac congenital anatomic abnormalities and preoperative factors. Clinical databases have been linked with administrative database to answer questions neither dataset can answer independently, providing new information about long-term mortality, rates of rehospitalization, long-term morbidity, comparative effectiveness of various treatments, and the cost of healthcare. Multiple research initiatives have recently been published using STS-CHSD. The science of assessing the outcomes and improving the quality of congenital and paediatric cardiac care continues to evolve. Recent advances will facilitate the continued evolution of a meaningful method of multiinstitutional outcomes analysis for congenital and paediatric cardiac surgery.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: The Driving Force for Improvement in Cardiac Surgery

Initiated in 1989, the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) includes more than 1085 participating centers, representing 90%-95% of current US-based adult cardiac surgery hospitals. Since its inception, the primary goal of the STS ACSD has been to use clinical data to track and improve cardiac surgical outcomes. Patients' preoperative risk characteristics, procedure-related processes of care, and clinical outcomes data have been captured and analyzed, with timely risk-adjusted feedback reports to participating providers. In 2006, STS initiated an external audit process to evaluate STS ACSD completeness and accuracy. Given the extremely high inter-rater reliability and completeness rates of STS ACSD, it is widely regarded as the "gold standard" for benchmarking cardiac surgery risk-adjusted outcomes. Over time, STS ACSD has expanded its quality horizons beyond the traditional focus on isolated, risk-adjusted short-term outcomes such as perioperative morbidity and mortality. New quality indicators have evolved including composite measures of key processes of care and outcomes (risk-adjusted morbidity and risk-adjusted mortality), longer-term outcomes, and readmissions. Resource use and patient-reported outcomes would be added in the future. These additional metrics provide a more comprehensive perspective on quality as well as additional end points. Widespread acceptance and use of STS ACSD has led to a cultural transformation within cardiac surgery by providing nationally benchmarked data for internal quality assessment, aiding data-driven quality improvement activities, serving as the basis for a voluntary public reporting program, advancing cardiac surgery care through STS ACSD-based research, and facilitating data-driven informed consent dialogues and alternative treatment-related discussions.

Nonagenarians undergoing cardiac surgery.

As life expectancy continues to rise and cardiac surgical outcomes improve, the number of nonagenarian (age > 90 years) patients undergoing cardiac operations is increasing. However, little has been reported on cardiac surgical outcomes in this select patient population. The purpose of this study was to examine current cardiac surgical outcomes for nonagenarian patients and determine the impact of extreme age on contemporary risk calculations. From 2002 to 20012, 61,303 patients underwent cardiac operations as reported in a statewide Society of Thoracic Surgeons (STS) Adult Cardiac Surgery database, including 108 nonagenarians. Patient and operative factors, including STS Predicted Risk of Mortality (PROM), were analyzed in order to compare to estimated risk measures. Nonagenarian patients (median age = 92 years) had a high prevalence of preoperative cerebrovascular disease (23.1% [25/108]) and arrhythmia (55.6% [60/108]). Isolated coronary artery bypass grafting (CABG) (39.8% [43/108]) was the most common operation performed within this cohort, followed by aortic valve replacement (AVR: 35.2% [38/108], AVR + CABG 23.1% [25/108]) operations. Overall nonagenarian mortality was 13% [14/108] and was greatest for AVR. Among nonagenarians with calculated STS PROM, observed to expected (O:E) ratios for mortality ranged from 1.45 to 2.65 annually over the study period. Nonagenarian patients represent a high-risk, elderly patient population with higher morbidity than predicted. Mortality is greatest following aortic valve operations. These results suggest that current risk calculations may underestimate the impact of extreme age on perioperative mortality.

Invited Commentary

The seminal report of 20-year survivors after cardiac transplantation, by Biefer and colleagues [1Biefer H.R.C. Sündermann S.H. Emmert M.Y. et al.Surviving 20 years after heart transplantation: a success story.Ann Thorac Surg. 2014; 97: 499-505Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar] portrays a remarkable success story for this life-extending therapy. The 55% actuarial survival at 20 years defines a highly effective, although not curative, therapy for an otherwise fatal condition. The evolution of heart transplantation has been well chronicled in the annals of transplant history [2Kirklin J.K. Young J.B. McGiffin D.C. History of cardiac transplantation.in: Kirklin J.K. Young J.B. McGiffin D.C. Heart transplantation. Churchill Livingstone, New York, NY2002: 3-13Google Scholar]. After Barnard's historic first successful heart transplant in 1967, survival over the next year was generally miserable, with mortality among the first 100 patients exceeding 50% by the eighth postoperative day and a median survival of only 29 days! By the end of the next decade (before the introduction of cyclosporine), survival at 1 year was barely more than 60%. Few would have predicted a subsequent experience in which nearly half the patients are still alive 20 years after transplantation, outcomes that would impress even the most ardent skeptic. So, what lessons and paradigm shifts in the cardiac surgical landscape have emanated from this experience? Cardiac transplantation set the paradigm for other complex cardiac surgical endeavors with its evolution from a solely surgical-driven event to a comprehensive, multidisciplinary endeavor. The recognition of the need for multiple medical subspecialties to collaborate and share in “ownership” of patient outcomes was critical to the achievement of near routine long-term survival. This paradigm, rare in cardiac surgery before 1980, became the standard for two other areas of complex cardiac surgery—infant cardiac surgery and mechanical circulatory support—in which participants from multiple disciplines are involved in the decision-making process for surgery, daily rounding, and longer-term patient care management, and often during the operation itself. This multidisciplinary commitment to successful cardiac transplantation (and later, lung transplantation) spawned an international society (International Society for Heart and Lung Transplantation) that attracted specialists from numerous disciplines nearly from the time of its inception in 1981. During the first 25 years after the advent of successful operations with cardiopulmonary bypass [3Kirklin J.W. DuShane J.W. Patrick R.T. et al.Intracardiac surgery with the aid of a mechanical pump-oxygenator system (Gibson type): report of eight cases.Mayo Clin Proc. 1955; 30: 201Google Scholar], success for most cardiac procedures was measured by hospital mortality. Cardiac transplantation was perhaps the first instance in which success required longer-term survival metrics. Improved outcomes mandated routine long-term surveillance and proactive intervention, concepts that have expanded to the care of patients receiving circulatory support [4Pamboukian S.V. Tallaj J.A. Brown R.N. et al.Improvement in 2-year survival for ventricular assist device patients after implementation of an intensive surveillance protocol.J Heart Lung Transplant. 2011; 30: 879-887Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar] and infants with complex conditions such as hypoplastic left heart syndrome that require staged surgical palliation. Finally, the era of government regulation in cardiac surgery really began in the mid 1980s when the United Network of Organ Sharing was awarded a federal contract for data collection from all heart transplant centers [2Kirklin J.K. Young J.B. McGiffin D.C. History of cardiac transplantation.in: Kirklin J.K. Young J.B. McGiffin D.C. Heart transplantation. Churchill Livingstone, New York, NY2002: 3-13Google Scholar]. A system evolved whereby government oversight of outcomes after transplantation linked Medicare reimbursements to satisfactory institutional performance in cardiac transplantation. Public reporting of cardiac surgical outcomes is now common in many states, and more recently the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) was created as a partnership between the National Heart, Lung, and Blood Institute, the Centers for Medicare and Medicaid Services, and the Food and Drug Administration [5Kirklin J.K. Naftel D.C. Stevenson L.W. et al.INTERMACS database for durable devices for circulatory support: first annual report.J Heart Lung Transplant. 2008; 27: 1065-1072Abstract Full Text Full Text PDF PubMed Scopus (270) Google Scholar]. Federal oversight of transcutaneous aortic valve replacement (TAVR) procedures is now occurring through required participation in the national TAVR registry. So, despite the limited (by donor availability) number of patients who have received a heart transplant for end-stage heart disease, this amazing procedure and multifaceted discipline have generated far-reaching effects on the overall field of cardiac surgery. Surviving 20 Years After Heart Transplantation: A Success StoryThe Annals of Thoracic SurgeryVol. 97Issue 2PreviewWe report the long-term outcomes of patients who survived 20 years or greater after heart transplantation. Full-Text PDF

Influence of Cardiac Surgeon Report Cards on Patient Referral by Cardiologists in New York State After 20 Years of Public Reporting

The use of public reporting for quality initiative metrics for cardiac surgery is now commonplace throughout the United States and internationally. This is especially true for the most commonly performed adult cardiac surgical procedures, coronary artery bypass grafting (CABG), and aortic valve surgery (AVR). In 1989, the Society of Thoracic Surgeons (STS) developed an Adult Cardiac Surgery Database (ACSD), which is a clinical data registry promoting quality improvement in cardiac surgical outcomes. Baseline and intraoperative patient characteristics and operative outcomes are collected using standard definitions, with routine data auditing that has shown >95% accuracy versus chart abstraction. 1 More than 90% of the ≈1100 US cardiac surgery programs participate in the registry. 2 Throughout the years, surgeons have used this database for quality improvement and research initiatives, many of which have changed the contemporary practice in cardiac surgery. Each participating program gets an institutional risk-adjusted report card for process improvement. More recently, each surgical program is given a star rating (1–3) based on measures of quality used by the STS in the ratings for CABG. This National Quality Forum-endorsed rating system allows programs to compare themselves with other hospital programs performing CABG. Although this process had many initial critics, the public reporting of outcomes in those undergoing cardiac surgery attests to the goal for transparency and physician and hospital reimbursement based on the quality of the surgical intervention. In concert, the New York State Department of Health developed a registry to collect clinical data on all patients undergoing CABG in the state of New York. 3 Similarly, Pennsylvania was 1 of the earlier states to provide report cards for cardiac surgeons performing CABG. However, in that state as in New York, Dr Epstein 4 has failed to detect a significant change in referral pat

Impact of the Anesthesiologist and Surgeon on Cardiac Surgical Outcomes

To determine the impact of anesthesiologists, surgeons, and their monthly caseload volume on mortality after cardiac surgery. Ten-year audit of prospectively collected cardiac surgical data. Large adult cardiothoracic hospital. A total of 18,569 cardiac surgical patients in the decade from April 2002 through March 2012, plus 21 consultant surgeons and 29 consultant anesthesiologists. Major risk-stratified cardiac surgical operations. The primary outcome was in-hospital death. Random intercept models for the surgeon and anesthesiologist cluster, respectively, were fitted, achieving risk-adjustment through the logistic EuroSCORE. The intraclass correlation coefficient (ICC) subsequently was used to measure the amount of outcome variation due to clustering. After exclusions (duplicates, very-short-term appointments, and cases performed by more than one consultant), there were 18,426 patients with 581 (3.15%) in-hospital deaths. The overwhelming factor associated with outcome variation was the patient risk profile, accounting for 97.14% of the variation. The impact of the surgeon was small (ICC = 2.78%), and the impact of the anesthesiologist was negligible (ICC = 0.08%). Low monthly surgeon volume of surgery, adjusted for average case mix, was associated with higher risk-adjusted mortality (odds ratio = 0.93, 95% CI 0.87-0.98). Outcome was determined primarily by the patient. There were small but significant differences in outcome between surgeons. The attending anesthesiologist did not affect patient outcome in this institution. Low average monthly surgeon volume was a significant risk factor. In contrast, low average monthly anesthesiologist volume had no effect.

TCT-89 Percutaneous Leaflet Therapy of Severe Primary Mitral Regurgitation: Totality of Evidence From the EVEREST II Randomized, Continued Access, and High Risk Clinical Programs

a degenerative MR patient after 3.2 years. There were no strokes with an average follow-up of 2.4 1.8 years. There were sustained improvements in New York Heart Association class (from 2.8 0.6 to 1.6 0.5, p <0.001) and MR grade (from 3.5 0.9 to 0.4 0.5, p <0.001) at follow-up. Conclusions: In this large single center experience, no patient required urgent cardiac surgery for failed MitraClip procedure. Mitral valve repair rate in patients with degenerative MR was high, and surgical options were preserved in the remaining patients. Overall, cardiac surgical outcomes were excellent.

EComment. Management of percutaneous coronary intervention complications

We read with great interest the article by Almdahl et al., regarding the cardiac surgical outcome of patients with complications of percutaneous coronary intervention (PCI) [1]. Complications of PCI include perforation (of the coronary artery or ventricle), retained wires, dissection, bleeding (subepicardial or not), tamponade and myocardial ischaemia or infarction [1, 2]. There is an angiographic classification of three types of coronary artery perforation post PCI according to Ellis et al. [3]. In Type I, the angiographic findings are consistent with extraluminal crater with no contrast extravasation. In Type II the contrast extravasation is limited to ‘blushing’ in the myocardial or epicardial fat. In Type III there is a contrast extravasation through frank (>1 mm) perforations or Type III ‘cavity spilling’ extravasation into either the left ventricle, the coronary sinus, any of the cardiac chambers, or the pericardium [3]. This classification is quite important as a useful tool for the diagnosis, management and prognosis of this potentially severe complication. Type I perforations are associated with the lowest incidence of tamponade (8%) with no reported incidence of myocardial infarction or mortality. As a result, the vast majority (85%) of Type I are treated conservatively. Type II perforations show a higher incidence of tamponade and myocardial infarction (13% and 14%, respectively) with no reported mortality, and conservative treatment is successful in 90% of cases. In contrast, Type III perforations have a high morbidity with a much higher incidence of tamponade and myocardial infarction (63% and 50%, respectively) and conservative treatment has been reported to be successful in only 44% of cases, with a mortality independent of treatment in 19% of cases [2, 3]. Shimony et al., in their recent systematic review and meta-analysis (16 studies, 197 061 PCIs), reported that the incidence of PCI complications was 0.43%. Furthermore, the tamponade rates were 0.4%, 3.3% and 45.7% for patients with Ellis classes I to III coronary artery perforations, respectively [4]. It is important to take into consideration the fact that currently (to the best of our knowledge), no established protocol guidelines exist regarding management strategies for PCI complications [2–4]. According to the suggested algorithm of Shimony et al., which is consistent with our department's practice as well, all these patients should be under continuous monitoring and assessment (sequential echocardiography studies). In the case of haemodynamic instability (mainly Ellis class III), the patient is either initially treated conservatively under the care of the cardiologists [pericardiocentesis (definitive or bridging treatment for open surgical intervention), heparin reversal, discontinuation of IIb/IIIa inhibitors/bivalirudin, prolonged balloon inflation for 5 to 15 minutes, embolization, polytetrafluoroethylene-covered stent etc], or surgically by the cardiac surgeons [4]. Surgical management is not standardized and depends on the surgical anatomy, patient co-morbidities and clinical condition. Surgical reports include simple suturing of the perforation, ligation of bleeding vessels, pericardial patch application, surgical glues, CABG (on or off CBP) with and without endarterectomy, stent removal, or vein patch [1–5]. Conflict of interest: none declared

Analysis of Mitral Valve Replacement Outcomes is Enhanced by Meaningful Clinical Use of Electronic Health Records

Cardiac surgical mortality has improved during the last decade despite the aging of the population. An integrated US health plan developed a heart valve registry to track outcomes and complications of heart valve operations. This database was used for longitudinal evaluation of mitral valve (MV) outcomes from 1999 to 2008 at four affiliated hospitals. We identified 3130 patients in the Apollo database who underwent 3180 initial MV procedures. Internal administrative and Social Security Administration databases were merged to determine survival rates. Electronic health records were searched to ascertain demographics, comorbidities, and postoperative complications. Cox regression was used to evaluate mean survival and identify risk factors. The procedures included 1160 mechanical valve replacements, 1159 tissue valve replacements, and 861 annuloplasties. The mean age of patients undergoing these procedures was 58 ± 11 years, 69 ± 12 years, and 62 ± 12 years, respectively. Mean survival was 8.9 ± 0.1 years for mechanical valve replacement, 7.0 ± 0.1 years for tissue valve replacement, and 7.7 ± 0.1 years for annuloplasty. Early in the study, there was a preference for implanting mechanical MVs. Beginning in 2003, more patients received tissue valve replacements rather than mechanical valves. Over time, there was an increasing trend of annuloplasty. Cox regression analysis identified the following risk factors for increased ten-year mortality: tissue valve implantation; advanced age; female sex; nonelective, nonisolated procedure; diabetes; postoperative use of banked blood products; previous cardiovascular intervention; dialysis; and longer perfusion time. Hospital location, reoperation, preoperative anticoagulation, and cardiogenic shock were not statistically significant risk factors. When controlling for other risk factors, we observed a lower long-term survival rate for tissue valve replacement compared with mechanical valve replacement. Integrating electronic health records with existing electronic databases provided near-real-time analysis of longitudinal cardiac surgical outcomes.

Public Reporting of Cardiovascular Care: An Opportunity to Shape the Future

William A. Zoghbi MD, FACC ACC President The unstated rationale for public reporting is that this information has impacts on market forces, payers, and practitioners to improve health care quality and reduce costs. In one of the first public reporting efforts, the Health Care Financing Administration (HCFA) published hospital mortality rates for Medicare patients undergoing coronary artery bypass graft surgery (CABG) (1). These data, derived from administrative and claims information, were not originally intended for this use and the report was criticized by hospitals and providers because they feared that the risk adjustment models were inadequate. Although adjustments were made, the usefulness of these reports has never been established, and many express negative opinions about these data (2). The HCFA experience led to the development of several private quality improvement registries and public state-wide reporting systems, such as the Northern New England Cardiovascular Study Group and the Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database (3). New York, Pennsylvania, Massachusetts, and California subsequently developed public reporting mechanisms for cardiac surgical outcomes (4–7). Some states even report physician-specific data and have expanded reporting to include percutaneous coronary interventions (PCI) (8). In 2005, the Centers for Medicare and Medicaid Services (CMS) launched the Hospital Compare website to publicly report hospital quality information derived from several sources (9). Certain core measures are reported for cardiac patients along with risk-adjusted mortality and readmission rates for acute myocardial infarction and heart failure derived from Medicare enrollment and claims data. The site also reports the results of patient surveys about their hospitalization and is considering adding measures from the Hospital Value Based Purchasing Program. The number of resources currently devoted to public reporting is unknown, but public reporti ng initiatives continue to proliferate with additional state initiatives, reports from payers that focus on costs, and reports from business consumer groups (10). There are now several internet-based forums where patients can report their individual experiences with physicians, both good and bad, in an unregulated and nonscientific manner. This, in turn, has resulted in some physicians requiring patients to agree to not participate in such activities before any treatment is provided. January 2011, under the authority of the Patient Protection and Affordable Care Act of 2010 (PPACA), CMS implemented the Physician Compare website (11). Several benchmarks for this effort were established: 1) providing information on the performance of physicians (and other health care providers) enrolled in Medicare; 2) reporting to Congress on the plans to use these data for value-based purchasing and consumer choice; and 3) demonstrating how financial incentives will be applied to beneficiaries who use “high-quality physicians.”

Cardiac surgery-associated acute kidney injury

Cardiac surgery-associated acute kidney injury (AKI) is a major health problem that is extremely common and has a significant effect on cardiac surgical outcomes. AKI occurs in nearly 30% of patients undergoing cardiac surgery, with about 1-2% of these ultimately requiring dialysis. The development of AKI predicts a significant increase in morbidity and mortality independent of other risk factors. The pathogenetic mechanisms associated with cardiac surgery-associated AKI include several biochemical pathways, of which the most important are hemodynamic, inflammatory and nephrotoxic factors. Risk factors for AKI have been identified in several models, and these facilitate physicians to prognosticate and develop a strategy for tackling patients predisposed to developing renal dysfunction. Effective therapy of the condition is still suboptimal, and hence the accent has always been on risk factor modification. Thus, strategies for reducing preoperative anemia, perioperative blood transfusions and surgical re-explorations may be effective in attenuating the incidence and severity of this complication.

Cardiac surgical outcomes in abdominal solid organ (renal and hepatic) transplant recipients: a case-matched study

This study aims to investigate the outcomes of cardiac surgery in patients with abdominal solid organ transplants and to compare them with the case-matched population undergoing cardiac surgery. Data from all transplant recipients abdominal solid organ transplant (ASOT) N = 36 (30 renal and 6 hepatic) who underwent cardiac surgery in a single centre during the period from January 1997 to December 2010 were collected from hospital transplant registries and the cardiac database. The transplant recipients were case matched (CM) with 104 patients in terms of the variables of age, sex and the type of cardiac surgery. Follow-up data were obtained from medical records and by a set of questionnaire through telephonic interviews. Follow-up times were 4.5 ± 3.2 and 3.9 ± 3.2 years in the transplant and CM groups, respectively. Follow-up in the transplant group was 100%. There was no 30-day mortality in the transplant group. Thirty-day combined major morbidities were 9% in the matched group vs 11% in the transplant patients (P = 0.6). Median length of stay was 6 days (inter-quartile range, IQR 5.9) for ASOT vs 5 days (IQR 4.6) for CM (P < 0.01). New dialysis was 8.3% in transplant patients compared with 0.96% in the matched population, while infection was 16.66 vs 0.42% in the CM cohort. There was no allograft failure/dysfunction at the time of death or latest follow-up. Late deaths were 8 of 36 (22%) in ASOT vs 6 of 104 (6%) in CM. Infection (63%) was the most frequent major cause of death in transplant patients. One-, 2-, 5- and 10-year survivals for ASOT vs CM were 94, 88, 80, 59 vs 99, 99, 91, 85%, respectively. Multivariate predictors of mortality were increasing age (hazard ratio, HR 1.1, 95% confidence interval, CI 1.04-1.18; P = 0.003) and solid organ transplantation (HR 3.44, CI 1.19-9.98; P = 0.023). Cardiac surgery can be performed in patients with abdominal solid organ tranpslant recipients with acceptable early morbidity and mortality. However, long-term survival in transplant patients is poor. Infection remains the most common cause of death.

Putting the Pediatric Cardiac Care Consortium in Context

Collaborative multi-institutional clinical registries are critical in pediatric cardiology, with its diverse diagnoses and procedures and relatively low event rates.1,2 Founded in 1982 to support quality improvement,3 the Pediatric Cardiac Care Consortium (PCCC) contains clinical information on over 137 000 patients (through 2007). Centers participate voluntarily and membership has varied over time; of the 57 PCCC centers, 35 have contributed at least 10 years of data. Analyses of PCCC data have contributed to an understanding of cardiac surgical outcomes in children (see online-only Data Supplement Table I).4 Centers of the size range represented in the PCCC (< 500 operations/year) may vary systematically in their case mix relative to larger centers. To provide context for outcomes research reports from the PCCC, we analyzed (1) how the case mix at PCCC centers compares with that in published …