Volume Centers Research Articles

Reduction in use of MRI and arthroscopy among patients with degenerative knee disease in independent treatment centers versus general hospitals: a time series analysis.

The use of MRI and arthroscopy are considered low-value care in most patients with degenerative knee disease. To reduce these modalities, there have been multiple efforts to increase awareness. Reductions have been shown for general hospitals (GH), but it is unclear whether this may be partly explained by a shift of patients receiving these modalities in independent treatment centers (ITCs). The aims of this study were to assess (i) whether the trend in use of MRI and arthroscopy in patients with degenerative knee disease differs between ITCs and GH, and (ii) whether the Dutch efforts to raise awareness on these recommendations were associated with a change in the trend for both types of providers. All patients insured by a Dutch healthcare insurer aged ≥50 years with a degenerative knee disease who were treated in a GH or ITC between July 2014 and December 2019 were included. Linear regression was used with the quarterly percentage of patients receiving an MRI or knee arthroscopy weighted by center volume, as the primary outcome. Interrupted time-series analysis was used to evaluate the effect of the Dutch efforts to raise awareness. A total of 14 702 patients included were treated in 90 GHs (n = 13 303, 90.5%) and 29 ITCs (n = 1399, 9.5%). Across the study period, ITCs on an average had a 16% higher MRI use (P < .001) and 9% higher arthroscopy use (P = .003). MRI use did not change in both provider types, but arthroscopy use significantly decreased and became stronger in ITCs (P = .01). The Dutch efforts to increase awareness did not significantly influence either MRI or arthroscopy use in ITCs (P = .55 and P = .84) and GHs (P = .13 and P = .70). MRI and arthroscopy uses were higher in ITCs than GHs. MRI use did not change significantly among patients ≥ 50 years with degenerative knee disease in both provider types between 2014 and 2019. MRI- and arthroscopy use decreased with ITCs on average having higher rates for both modalities, but also showing a stronger decrease in arthroscopy use. The Dutch efforts to increase awareness did not accelerate the already declining trend in the Netherlands.

Impact of facility volume on outcomes in patients with pancreatic cancer treated with radiotherapy.

644 Background: The impact of facility volume on overall survival (OS) outcomes in patients with pancreatic cancer (PC) treated with radiotherapy (RT), both standard chemoradiation (CRT) and stereotactic body radiation therapy (SBRT) is not well-defined. Methods: This retrospective study analyzed 16,315 patients with locally advanced (LA) or borderline resectable (BR) PC from the National Cancer Database (2004-2019) who received neoadjuvant RT or RT without surgery across RT facilities with low- (&lt;10 cases/yr), intermediate- (10-20 cases/yr), and high-volumes (&gt;20 cases/yr) of PC cases. Log rank and cox regression were used for univariable and multivariable survival analysis, and Kaplan-Meier curves were generated. Results: Patients were largely treated at low (n=8055) volume centers, followed by intermediate (n=3783), and high (n=4477). Approximately half of the cohort were male (51.4%), and predominantly white (82.5%), and non-Hispanic (92%). On univariable analysis (Table), high-volume centers had improved survival outcomes in the overall population, as well as in both SBRT and CRT subsets (p&lt;0.0001). On multivariable analysis, treatment during the most recent time period: 2016-2019 (HR 0.646, p&lt;0.001), receiving care at a high-volume center (HR 0.844, p&lt;0.001), use of SBRT (HR 0.915, p&lt;0.001), administration of multiagent chemotherapy (HR 0.706, p&lt;0.001) and undergone surgical resection (HR 0.405, p&lt;0.001) were associated with improved OS. In a subgroup analysis of patients receiving SBRT, median OS was 22.6 months for high-volume, 20.0 for intermediate-volume and 18.4 months at low-volume centers (p&lt;0.001). Conclusions: Patients receiving RT for LAPC or BRPC at high-volume centers had longer OS compared to those receiving radiation at intermediate- or low-volume centers. In those undergoing SBRT, treatment at high-volume centers had improved OS compared to intermediate- and low-volume centers. These findings suggest that radiation oncologists’ expertise is critical for providing high-quality RT in PC, especially for SBRT.[Table: see text]

Impact of Center Volume on Chronic Graft Versus Host Disease in Patients With Allogeneic Stem Cell Transplantation

BackgroundChronic graft-versus-host disease (cGVHD) is a complication of allogeneic hematopoietic stem cell transplantation (HSCT), negatively impacting quality of life (QoL) and increasing the risk of death. Complexity in cGVHD diagnosis and treatment causes significant variations in cGVHD management strategies across medical centers and physicians despite the existence of published guidelines. Thus, we hypothesized that center volume is associated with cGVHD incidence and outcomes after cGVHD develops. ObjectiveThis study aimed to evaluate the effect of center volume on the incidence of cGVHD in patients who underwent HSCT and outcomes in patients with cGVHD. Study DesignOur retrospective study included 28,786 patients who underwent their first HSCT (overall cohort) and 7,664 who developed cGVHD (cGVHD cohort). We categorized institutions into quartiles (very low, low, high, and very high) using the number of HSCTs performed during the study period. We assessed cGVHD incidence in overall cohort and overall survival (OS) in cGVHD cohort. ResultsThe very high-volume group showed significantly higher cGVHD incidence (adjusted hazard ratio [HR], 1.38; 95% confidence interval [CI]: 1.30–1.46) compared to the very low-volume group. However, the cGVHD incidence was similar among very low-, low- and high-volume groups. Low, high, and very high-volume groups showed significantly higher OS with adjusted HRs of 0.83 (95% CI: 0.73–0.94), 0.69 (95% CI: 0.61–0.79), and 0.68 (95% CI: 0.60–0.76), respectively, compared with the very low-volume group. ConclusionIn conclusion, we revealed a higher incidence of cGVHD in the very high-volume group and a poor survival outcome in the very low-volume group in patients with cGVHD.

Impact of center volume on outcomes after ventricular assist device implantation in pediatric patients: An analysis of the STS-Pedimacs database

To date, no pediatric studies have highlighted the impact of center's ventricular assist device (VAD) volumes on postimplant outcomes. Children (age <19) enrolled in Pedimacs undergoing initial left ventricular assist device implantation from 2012 to 2020 were included. Center volume was analyzed as a continuous and categorical variable. For categorical analysis, center volumes were divided as: low volume (1-15 implants), medium volume (15-30 implants), and high volume (>30 implants) during our study period. Patient characteristics and outcomes were compared by center's VAD volumes. Of 44 centers, 16 (36.4%) were low, 11 (25%) weremedium, and 17 (38.6%) werehigh-volume centers. Children at high-volume centers were least likely intubated, sedated, or paralyzed, and most likely ambulating preimplant (p<0.05 for all). Center's VAD volumes were not a significant risk factor for mortality postimplant when treated as a continuous or a categorical variable (p>0.05). Compared to low volume, children at high-volume centers had fewer early neurological events. Compared to medium volume, those at high-volume centers had fewer late bleeding events(p<0.05 for all). There were no significant differences in survival after an adverse event by hospital volumes (p>0.05). Althoughhospital volume does not affect post-VAD implant mortality, pediatric centers with higher VAD volumes have fewer patients intubated, sedated, paralyzed preimplant, and have lower adverse events. Failure to rescue was not significantly different between low, medium, and high-volume VAD centers.

In-hospital outcomes predictors and trends of redo sternotomy aortic root replacements: insights from a UK registry analysis.

Redo sternotomy aortic root surgery is technically demanding, and the evidence on outcomes is mostly from retrospective, small sample, single-centre studies. We report the trend, early clinical results and outcome predictors of redo aortic root replacement over 20 years in the United Kingdom. We retrospectively analysed collected data from the UK National Adult Cardiac Surgery Audit (NACSA) on all redo sternotomy aortic root replacements performed between 30th January 1998 and 19th March 2019. We analysed trends in the volume of operations, characteristics of hospital survivors vs. non-survivors, and predictors of in-hospital outcomes. During the study period, 1,107 redo sternotomy aortic root replacements were performed (median age 59, 26% of patients were females). Eighty-four per cent of cases (N = 931) underwent a composite root replacement, 11% (N = 119) had homograft root replacement and valve-sparing root replacement was performed in 5.1% (N = 57) of cases. There was a steady increase in the volume of redo sternotomy root replacements beyond 2006, from an annual volume of 22 procedures in 2006 to 106 procedures in 2017. Hospital mortality was 17% (n = 192), postoperative stroke or TIA occurred in 5.2% (n = 58), and postoperative dialysis was required in 11% (n = 109) of patients. Return to the theatre for bleeding/tamponade was required in 9% (n = 102) and median in-hospital stay was 9 days. Age >59 (OR: 2.99, CI: 1.92-4.65, P < 0.001), recent myocardial infarction (OR: 6.42, CI: 2.24-18.41, P = 0.001) were associated with increased in-hospital mortality. Emergency surgery (OR: 3.95, 2.27-6.86, P < 0.001), surgery for endocarditis (OR: 2.05, CI: 1.26-3.33, P = 0.001), salvage coronary artery bypass grafting (OR: 2.20, CI: 1.37-3.54, P < 0.001), arch surgery (OR: 2.47, CI: 1.30-3.61, P = 0.018) and aortic cross-clamp longer than 169 min (OR: 2.17, CI: 1.00-1.01, P = 0.003) were associated with increased risk of mortality. We found no effect of the centre or surgeon volume on mortality (P > 0.05). Redo sternotomy aortic root replacement still carries significant morbidity and mortality and is sporadically performed across surgeons and centres in the UK.

Genetic risk score for Alzheimer's disease predicts brain volume differences in mid and late life in UK biobank participants.

We estimated the ages when associations between Alzheimer's disease (AD) genes and brain volumes begin among middle-aged and older adults. Among 45,616 dementia-free participants aged 45-80, linear regressions tested whether genetic risk score for AD (AD-GRS) had age-dependent associations with 38 regional brain magnetic resonance imaging volumes. Models were adjusted for sex, assessment center, genetic ancestry, and intracranial volume. AD-GRS modified the estimated effect of age (per decade) on the amygdala (-0.41 mm3 [-0.42, -0.40]); hippocampus (-0.45 mm3 [-0.45, -0.44]), nucleus accumbens (-0.55 mm3 [-0.56, -0.54]), thalamus (-0.38 mm3 [-0.39, -0.37]), and medial orbitofrontal cortex (-0.23 mm3 [-0.24, -0.22]). Trends began by age 45 for the nucleus accumbens and thalamus, 48 for the hippocampus, 51 for the amygdala, and 53 for the medial orbitofrontal cortex. An AD-GRS excluding apolipoprotein E (APOE) was additionally associated with entorhinal and middle temporal cortices. APOE and other genes that increase AD risk predict lower hippocampal and other brain volumes by middle age.

Center Volume Predicts Improved Early Outcomes in Multiorgan Heart Transplantation

Center volume is associated with improved survival after isolated heart transplant, but its impact on multiorgan heart transplant (MHT) outcomes is unknown. This study examines the impact of institutional MHT volume on MHT outcomes. Adult patients undergoing first time MHT from 2011 to 2021 were identified in the United Network for Organ Sharing database. Transplant centers were annually classified as low-, medium-, or high-volume if they performed <3, 3 to 5, or ≥6 MHTs that year, respectively. Graft failure was defined as death, failure, or re-transplantation of any allograft. A total of 1860 MHTs were performed at 104 centers, including 482 (26%) at low-, 601 (32%) at medium-, and 777 (42%) at high-MHT volume centers. Noncardiac allografts included kidney (83%), liver (16%), and lung (2%). The proportion of MHTs performed at high-volume centers increased from 10% in 2011 to 62% in 2021. Recipient age, race, and body mass index did not vary by center volume (all P > .05). Patients at high-volume centers were more likely to be in the intensive care unit pre-transplant (58% vs 44%, P < .001) and have shorter waitlist times (47 vs 92 days, P < .001) than those at low-volume centers. 30-day graft survival was higher in combined medium- and high-volume compared with low-volume centers (95% vs 92%, P = .004). Increasing center MHT volume was protective against 30-day graft failure (adjusted hazard ratio 0.93 [0.88-0.98]) on multivariate Cox regression. Higher MHT volume is associated with improved early graft survival after MHT, which may justify centralizing the performance of MHTs to high-volume centers.

Dissemination and implementation analysis of the Ross procedure in adults: time to update the guidelines?

BackgroundThe science of dissemination and implementation (D&I) aims to improve the quality and effectiveness of care by addressing the challenges of incorporating research and evidence-based practice into routine clinical practice. This lens of D&I has challenged the interpretation and incorporation of data, noting that failure of a given therapy may not reflect lack of efficacy, but instead reflect an imperfect implementation. The aim of this manuscript is to review the influence of the Ross procedure’s historical context on its D&I.MethodsA contextual baseline of the Ross procedure was defined from the procedure’s original description in the literature to major publications since the 2017 valvular heart disease guidelines. D&I evaluation was conducted using the Consolidated Framework for Implementation Research (CFIR), using constructs from each of the five respective domains to define the main determinants.ResultsEach of the five CFIR domains appears to be correlated with a factor influencing the Ross procedure’s varied history of enthusiasm and acceptance. The complex nature of Ross required adaptation for optimization, with a strong correlation of center volume on outcomes that were not considered in non-contemporary studies. Outcomes later published from those studies influenced social and cultural contexts within the aortic surgery community, and led to further organizational uncertainty, resulting in slow guideline incorporation.ConclusionsThe D&I of the Ross procedure was a result of inadequate appreciation of technical complexity, effect of patient selection, and complex aortic surgery experience, resulting in dismissal of an efficacious procedure due to a misunderstanding of effectiveness.

Assessing the impact of center volume on the cost-effectiveness of centralizing ERCP

Background and AimsERCP is a complex endoscopic procedure in which the center's procedure volume influences outcomes. With the increasing healthcare expenses and limited resources, promoting cost-effective care becomes essential for healthcare provision. This study performed a cost-effectiveness analysis to evaluate the hypothesis that high-volume (HV) centers perform ERCP with higher quality at lower costs than low-volume (LV) centers. MethodsA baseline case compared the current distribution of ERCPs among HV and LV centers with a hypothetical scenario in which all ERCPs are performed at HV centers. A cost-effectiveness analysis was constructed, followed by one-way and two-way sensitivity analyses and probabilistic sensitivity analysis (PSA) using Monte Carlo simulations. ResultsIn the baseline case, the ICER was -141,017€/year, due to the hypothetical scenario's lower costs and slightly higher QALYs. The model was most sensitive to changes in the transportation costs (109.34%), probability of significant adverse events (AEs) after successful ERCP at LV centers (42.12%), utility after ERCP with significant AEs (30.10%), and probability of significant AEs after successful ERCP at HV centers (23.53%) but only transportation cost above 3,407€ changed the study outcome. The current ERCP distribution would only be cost-effective if LV centers achieved higher success (≥ 92.4% vs. 89.3%) with much lower significant AEs (≤ 0.5% vs 6.7%). The study's main findings remained unchanged while combining all model parameters in the PSA. ConclusionsOur findings show that HV centers have high-performance rates at lower costs, raising the need to consider the principle of centralization of ERCPs into HV centers to improve the quality of care.

Examining the complex relations between climate and streamflow in the mid-atlantic region of the United States

Abstract We explored the complex relations between climate and streamflow in the Mid-Atlantic region of the United States. In 124 watersheds across this region, we quantified spatial and temporal variation in air temperature (AT), precipitation (P), and streamflow (Q) from 1981 through 2020. Upward directional trends in monthly values of AT, P, and Q indicated an increase of 0.27–1.9 degrees Celsius, 0.12–1.9 millimeters day−1, and 0.01–7.1 cubic meters s−1 day−1, respectively, over the 40-year period. Comparison of the first 20 years to the last 20 years of data indicated an acceleration in the trend slopes in AT, P, and Q. Changes also were observed in temporal trends in the center of volume (CV) of both P and Q, which generally occurred later in the year; the 7-day mean low flow increased, and the annual day of occurrence of the 7-day mean low flow occurred earlier in the year. Principal components analysis revealed differences in P, Q, CVP, and CVQ trends in watersheds with median elevations greater than and less than 400 meters, as well as by latitude. A seasonal analysis revealed that P increased throughout the study area in spring, summer, and fall but decreased in winter. AT, P, and Q have broadly increased across the region over the 40-year period, and the temporal, spatial, and seasonal changes in P have affected Q. Results highlight the strong couplings between climatic variability and watershed responses.

Association between ICU quality and in-hospital mortality of V-V ECMO-supported patients-the ECMO quality improvement action (EQIA) study: a national cohort study in China from 2017 to 2019.

This cohort study was performed to explore the influence of intensive care unit (ICU) quality on in-hospital mortality of veno-venous (V-V) extracorporeal membrane oxygenation (ECMO)-supported patients in China. The study involved all V-V ECMO-supported patients in 318 of 1700 tertiary hospitals from 2017 to 2019, using data from the National Clinical Improvement System and China National Critical Care Quality Control Center. ICU quality was assessed by quality control indicators and capacity parameters. Among the 2563 V-V ECMO-supported patients in 318 hospitals, a significant correlation was found between ECMO-related complications and prognosis. The reintubation rate within 48 hours after extubation and the total ICU mortality rate were independent risk factors for higher in-hospital mortality of V-V ECMO-supported patients (cutoff: 1.5% and 7.0%; 95% confidence interval: 1.05-1.48 and 1.04-1.45; odds ratios: 1.25 and 1.23; P = 0.012 and P = 0.015, respectively). Meanwhile, the V-V ECMO center volume was a protective factor (cutoff of ≥ 50 cases within the 3-year study period; 95% confidence interval: 0.57-0.83, odds ratio: 0.69, P = 0.0001). The subgroup analysis of 864 patients in 11 high-volume centers further strengthened these findings. Thus, ICU quality may play an important role in improving the prognosis of V-V ECMO-supported patients.

In-hospital safety of catheter based left atrial appendage closure in Germany 2016 - 2020

Abstract Background New catheter based left atrial appendage (LAA) occlusion devices were introduced in the past decade. Catheter based LAA occlusion can be performed through a permanently implanted intracardiac LAA occlusion device or a loop stitch around the base of the LAA via an additional pericardial access. Knowledge about recent in-hospital safety trends and center volume dependent outcomes is limited. Methods Catheter based LAA closures in Germany were identified via ICD and OPS codes from 2016 - 2020. Adjusted risk differences for loop stitch procedures were calculated using an inverse probability weighting approach taking into account 17 predefined baseline characteristics. Center volume dependent outcomes were calculated using a risk adjusted logistics regression analysis taking into account the same predefined baseline characteristics. Results 28 039 permanently intracardiac implanted LAA occlusion device procedures and 213 loop stitch LAA occlusions were performed from 2016 - 2020. Numbers of permanently implanted occlusion device procedures increased from 5 259 in 2016 to 5 917 in 2020 (p = 0.020) without a significant trend for in-hospital safety parameters. Risk adjusted logistic regression analysis of center volume depended MACCE and pericardial puncture for permanently implanted occlusion devices did not show a significant trend. Patients receiving the loop stitch procedure were younger (76.17 +/- 8.16 vs. 73.16 +/- 8.99, p &amp;lt; 0.001), had a lower comorbidity index (2.29 +/- 1.93 vs. 1.92 +/- 1.64, 0.005) and less previous myocardial infarctions (7.82 % vs. 3.29 %, p = 0.014) or cardiac surgeries (12.34 % vs. 6.57 %, p = 0.011). Adjusted risk difference of pericardial effusion (8.04 %; 95% CI: 3.01 % – 13.08 %; p = 0.002) and pericardial puncture (6.60 %; 95% CI: 3.85 % – 9.35 %; p &amp;lt; 0.001) was higher for the LAA loop stitch procedure, while risk of bleeding (-1.85 %; 95% CI: -3.01 % to -0.69 %; p = 0.002), intracerebral bleeding (-0.37 %; 95% CI: -0.59 % to -0.15 %; p = 0.001) and shock (-1.41 %; 95% CI: -2.44 % to -0.39 %; p = 0.007) was lower. No significant difference was observed for in-hospital MACCE. Conclusions Permanently implanted occlusion devices were the major catheter based LAA closure procedure in Germany without improvements in in-hospital safety from 2016 – 2020. Center volumes did not influence in-hospital MACCE and pericardial puncture for the permanently implanted LAAC devices. LAA loop stitch occlusion was used much less frequently and was associated with a higher risk of pericardial effusion and pericardial puncture, a lower risk of bleeding and shock and no significant risk difference in MACCE.

Differences in diagnostic yield of invasive coronary function testing between high and low volume centres, in patients with angina and no obstructive coronary artery disease

Abstract Introduction Coronary angiograms for stable angina frequently show no obstructive coronary artery disease (ANOCA). A large proportion of ANOCA patients have underlying coronary vasomotor dysfunction. They can be divided into different endotype subgroups, according to their invasive coronary function test (CFT) results. A complete CFT in the studied cohort consists of both spasm provocation with acetylcholine as well as testing physiology of the microcirculation with adenosine and bolus thermodilution. There is a high prevalence of vasomotor dysfunction in our tertiary, high volume CFT centre where &amp;gt;100 CFT s are performed each year. No data is available yet on the prevalence in low volume centres. Purpose To compare CFT results of patients who underwent complete CFT in a high volume centre versus low volume centres. Methods We included all consecutive patients from the pilot version of a prospective national registry of coronary function tests in the Netherlands (NL-CFT) who underwent a complete standardized CFT between February 2019 and January 2023 (n=593). We compared CFT diagnosis (endotypes) in high versus low volume centres by acetylcholine spasm provocation and adenosine bolus thermodilution test results. A high volume CFT centre was defined as performing more than 100 CFT’s per year. Coronary microvascular dysfunction (CMD) was defined as a coronary flow reserve CFR &amp;lt;2 and/or index of microvascular resistance IMR ≥25. Coronary vasomotor dysfunction was present when epicardial or microvascular spasm was diagnosed, when CFR and/or IMR was abnormal, or when both parts of the CFT were abnormal. We expect to be able to present expanded data on approximately 1000 patients with complete CFTs around the ESC congress. Results Currently, 593 patients underwent complete CFT (83% female, mean age 60 ± 9.5 years). The high volume centre performed 307 (52%) of all CFTs in the studied period. The four low volume centres combined performed the other 286 (48%). A total of 461 (78%) of patients had coronary vasomotor dysfunction. Prevalence of coronary vasomotor dysfunction was significantly higher in a high volume centre compared to low volume centres (88% vs 66% p&amp;lt;0.001). Coronary spasm was present in 84% of CFTs in a high volume centre: 54% isolated and 30% combined with CMD. Isolated CMD was present in 4% and only 12% had a normal CFT. In low volume centres coronary spasm was present in 54% of patients: 36% isolated and 19% combined with CMD. Isolated CMD was present in 12% and 34% of all performed CFT’s was normal. Conclusions In this pilot data of NL-CFT, a large prospective registry, 593 patients underwent complete CFT. We show that the prevalence of coronary vasomotor dysfunction is significantly higher in a high volume CFT centre compared to low volume centres. Vasospasm is the predominant endotype, either isolated or combined with CMD. Nevertheless, prevalence of vasomotor dysfunction in low volume centres is still high and warrants attention.Distribution of endotypes

Center Volumes Correlate with Likelihood of Stent Implantation in German Coronary Angiography.

Literature on percutaneous coronary intervention (PCI) stated an inverse relationship between hospital volume and mortality, but the effects on other characteristics are unclear. Using German national records, all coronary angiographies with coronary artery disease in 2017 were identified. We applied risk-adjustment to account for differences in population characteristics. Of overall 528,188 patients, 55.22% received at least one stent, with on average 1.01 stents implanted in all patients. Based on those patients who received at least one stent, this corresponds to an average number of 1.82 stents. In-hospital mortality across all patients was 2.93%, length of hospital stay was 6.46 days, and mean reimbursement was €5,531. There were comparatively more emergency admissions in low volume centers and more complex cases (3-vessel disease, left main stenosis, and in-stent stenosis) in high volume centers. In multivariable regression analysis, volume and likelihood of stent implantation (p=0.003) as well as number of stents (p=0.020) were positively correlated. No relationship was seen for in-hospital mortality (p=0.105), length of stay (p=0.201), and reimbursement (p=0.108). Nonlinear influence of volume suggests a ceiling effect: In hospitals with ≤100 interventions, likelihood and number of implanted stents are lowest (∼34% and 0.6). After that, both rise steadily until a volume of 500 interventions. Finally, both remain stable in the categories of over 500 interventions (∼60% and 1.1). In PCI, lower volume centers contribute to emergency care. Higher volume centers treat more complex cases and show a higher likelihood of stent implantations, with a stable safety.

Abstract 12859: Clinical Correlates and Prognostic Value of B-type Natriuretic Peptide in Left Ventricular Assist Device Recipients With Cardiogenic Shock: Insights From INTERMACS

Introduction: B-type natriuretic peptide (BNP) is a robust predictor of outcomes across the heart failure (HF) spectrum. However, data characterizing BNP levels in end-stage HF with cardiogenic shock (CS) is lacking. Furthermore, the prognostic value of BNP in left ventricular assist device (LVAD) receiving Stage D HF patients with CS has not been assessed previously. Methods: Continuous flow LVAD recipients with CS enrolled in INTERMACS between 2005 to 2017 were included. CS was defined as INTERMACS profile 1-3. The primary outcome of the study was long-term mortality. Long-term mortality was assessed in patients alive at 1-month post-surgery. Secondary outcomes included peri-operative mortality (&lt;30 days of surgery), cardiovascular mortality, arrhythmia, and right HF. The cohort was stratified by quartiles of BNP levels. Multivariable Cox proportional hazard models, adjusted for age, sex, body mass index, INTERMACS profile, center volume, implantation year, device strategy, estimated glomerular filtration rate, employment status, and education level, were used to assess the association between BNP levels and outcomes. Results: Among 7,290 LVAD recipients with CS, the median pre-implantation BNP value was 859 (427, 1,614) pg/mL. Males [851(429, 1,557) pg/mL, P =0.07], non-Hispanic Blacks [777 (362, 1,514) pg/mL, P =&lt;0.001], and obese [642 (311, 1,170) pg/mL, P =&lt;0.001] patients had lower BNP values. Over a median follow-up of 14.7 (6.9, 28.7) months, the risk of long-term mortality was similar in the second [HR adj :1.06 (0.94-1.20)], third [HR adj :0.97 (0.85-1.10)], and fourth [HR adj :1.04 (0.91-1.18)] quartiles of BNP compared with the first quartile of BNP. Similarly, the risk of peri-operative mortality, cardiovascular mortality, arrhythmia, and right HF did not vary by the quartiles of BNP. Conclusions: BNP has poor prognostic value in LVAD recipients with CS and the value of routine measurement of BNP in this population needs further investigation.

Does Hospital Operative Volume Influence the Outcomes of Patients After Heated Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis?

For some cancer operations, center volume is associated with improved patient outcomes. Whether this association is true for cytoreductive surgery/heated intraperitoneal chemotherapy (CRS/HIPEC) is unclear. Given the rapidly expanding use of CRS/HIPEC, the aim of this analysis was to determine whether a volume-outcome relationship exists for this strategy. The Vizient Clinical Database® was queried for CRS/HIPEC cases from January 2020 through December 2022. Low-, medium-, and high-volume designations were made by sorting hospitals by case volume and creating equal tertiles based on total number of cases. Analysis was performed via one-way ANOVA with post-hoc Tukey test, as indicated. In the 36-month study period, 5165 cases were identified across 149 hospitals. Low- (n = 113), medium- (n = 25), and high-volume (n = 11) centers performed a median of 4, 21, and 47 cases per annum, respectively. Most cases were performed for appendiceal (39.3%) followed by gynecologic neoplasms (20.4%). Groups were similar with respect to age, gender, race, comorbidities, and histology. Low-volume centers were more likely to utilize the ICU post-operatively (59.6% vs. 40.5% vs. 36.3%; p = 0.02). No differences were observed in morbidity (9.4% vs. 7.1% vs. 9.0%, p = 0.71), mortality (0.9% vs. 0.6% vs. 0.7%, p = 0.93), length of stay (9.3 vs. 9.4 vs. 10 days, p = 0.83), 30-day readmissions (5.6% vs. 5.6% vs. 5.6%, p = 1.0), or total cost among groups. No association was found between CRS/HIPEC hospital volume and post-operative outcomes. These data suggest that in academic medical centers with HIPEC programs, outcomes for commonly treated cancers are not associated with hospital volume.

The impact of urgency of repair on outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury

ObjectiveCurrent societal recommendations regarding the timing of thoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) vary. Prior studies have shown that elective repair was associated with lower mortality after TEVAR for BTAI. However, these studies lacked data such as Society for Vascular Surgery (SVS) aortic injury grades and TEVAR-related postoperative outcomes. Therefore, we used the Vascular Quality Initiative registry, which includes relevant anatomic and outcome data, to examine the outcomes following urgent/emergent (≤ 24 hours) vs elective TEVAR for BTAI. MethodsPatients undergoing TEVAR for BTAI between 2013 and 2022 were included, excluding those with SVS grade 4 aortic injuries. We included covariates such as age, sex, race, transfer status, body mass index, preoperative hemoglobin, comorbidities, medication use, SVS aortic injury grade, coexisting injuries, Glasgow Coma Scale, and prior aortic surgery in a regression model to compute propensity scores for assignment to urgent/emergent or elective TEVAR. Perioperative outcomes and 5-year mortality were evaluated using inverse probability-weighted logistic regression and Cox regression, also adjusting for left subclavian artery revascularization/occlusion and annual center and physician volumes. ResultsOf 1016 patients, 102 (10%) underwent elective TEVAR. Patients who underwent elective repair were more likely to undergo revascularization of the left subclavian artery (31% vs 7.5%; P < .001) and receive intraoperative heparin (94% vs 82%; P = .002). After inverse probability weighting, there was no association between TEVAR timing and perioperative mortality (elective vs urgent/emergent: 3.9% vs 6.6%; odds ratio [OR], 1.1; 95% confidence interval [CI], 0.27-4.7; P = .90) and 5-year mortality (5.8% vs 12%; hazard ratio [HR], 0.95; 95% CI, 0.21-4.3; P > .9).Compared with urgent/emergent TEVAR, elective repair was associated with lower postoperative stroke (1.0% vs 2.1%; adjusted OR [aOR], 0.12; 95% CI, 0.02-0.94; P = .044), even after adjusting for intraoperative heparin use (aOR, 0.12; 95% CI, 0.02-0.92; P = .042). Elective TEVAR was also associated with lower odds of failure of extubation immediately after surgery (39% vs 65%; aOR, 0.18; 95% CI, 0.09-0.35; P < .001) and postoperative pneumonia (4.9% vs 11%; aOR, 0.34; 95% CI, 0.13-0.91; P = .031), but comparable odds of any postoperative complication as a composite outcome and reintervention during index admission. ConclusionsPatients with BTAI who underwent elective TEVAR were more likely to receive intraoperative heparin. Perioperative mortality and 5-year mortality rates were similar between the elective and emergent/urgent TEVAR groups. Postoperatively, elective TEVAR was associated with lower ischemic stroke, pulmonary complications, and prolonged hospitalization. Future modifications in society guidelines should incorporate the current evidence supporting the use of elective TEVAR for BTAI. The optimal timing of TEVAR in patients with BTAI and the factors determining it should be the subject of future study to facilitate personalized decision-making.

An Analysis of 10,000 Cases of Living Donor Liver Transplantation in Japan: Special Reference to the Graft-Versus-Recipient Weight Ratio and Donor Age.

To analyze 10,000 cases of living donor liver transplantation (LDLT) recipient data to elucidate outcomes with special reference to the graft-versus-recipient weight ratio (GRWR), based on the Japanese Liver Transplantation Society (JLTS) registry. The JLTS registry has been accurate and complete in characterizing and following trends in patient characteristics and survival of all patients with LDLT. Between November 1989 and August 2021, 10,000 patients underwent LDLT in Japan. The procedures performed during the study period included pediatric liver transplantation (age <18 years, n = 3572) and adult liver transplantation (age ≥18 years, n=6428). Factors related to patient survival (PS) and graft survival (GS) were also analyzed. The GRWR was <0.7, 0.7 to <0.8, 0.8 to <3, 3 to <5, and ≥5 in 0.2%, 2.0%, 61.8%, 31.8%, and 2.6% of pediatric patients and <0.6, 0.6 to <0.7, 0.7 to <0.8, and ≥0.8 in 8.0%, 12.7%, 17.7%, and 61.5% of adult patients, respectively. Among pediatric recipients, the PS rate up to 5 years was significantly better in cases with a GRWR ≤5 than in those with a GRWR >5. When the GRWR and donor age were combined, among adult recipients 50 to 60 years old, the early PS and GS up to 5 years were significantly better in cases with a GRWR ≥0.7, than in those with a GRWR <0.7. (P = 0.02). In adults, a multivariate analysis showed that GRWR <0.6, transplant era (<2011), donor age (>60 years), recipient age (>60 years), model for end-stage liver disease score (≥20), and center volume (<10) were significant prognostic factors for long-term PS. Although a satisfactory long-term PS and GS, especially in the recent era (2011-2021), was achieved in the JLTS series, a GRWR ≥5 in pediatric cases and relatively old donors with a GRWR <0.7 in adult cases should be managed with caution.

Anticoagulation after pancreatic surgery with venous resection (TIGRESS): What should we do? Results from an international survey.

Patients who undergo pancreatic surgery with venous resection have high rates of morbidity/mortality. Also, they are high-risk for postoperative venous thromboembolism. Whether this group should be routinely anticoagulated is unknown. This study aimed to establish current anticoagulation practices. A survey (https://form.jotform.com/220242489107048) was sent out to pancreatic surgeons. Questions covered center volume, venous resection/reconstruction techniques and anticoagulation policies. Sixty-five centers from 17 countries responded. Following a "side-bite" venous resection with a patch repair, 40% used an autologous vein patch, 27% used peritoneum, and 27% used a bovine patch. After formally resecting a segment of vein, 17% of centers used an interposition graft (IG). Left renal vein (41%) and polytetrafluoroethylene (73%) grafts were the most commonly used autologous and prosthetic IGs, respectively. Following a prosthetic IG, an autologous IG, and a "side-bite" resection, 59%, 28%, and 19% of centers provided therapeutic anticoagulation, respectively (66% used low molecular-weight heparin). The duration of therapy provided varied from inpatient stay only (14%) to six months (32%). Our global survey indicates that anticoagulation practices are highly variable. Centers do not agree on when to anticoagulate, how to anticoagulate, or the duration of therapy. A robust trial is required to provide clarity.

Management of medial femorotibial osteoarthritis: Epidemiology, and survival of unicompartmental knee arthroplasty versus valgus high tibial osteotomy in France. Study of 108,007 cases from the French National Hospitals Database

IntroductionUnicompartmental knee arthroplasty (UKA) and valgus high tibial osteotomy (HTO) are two options for isolated medial femorotibial osteoarthritis in genu varum. In the absence of registries for osteotomies and for arthroplasty in the knee, epidemiological data are hard to obtain in France. We therefore performed a retrospective study, with the aims of: 1) estimating UKA and HTO survival without revision by total knee arthroplasty (TKA), and 2) assessing risk factors for revision according to treatment group. HypothesisMedium-term survival is better with HTO than UKA in under-70-year-olds. Materials and methodAll elderly patients undergoing HTO or UKA in the French National Hospitals Database for the period 2011–2020 were included: i.e., 108,007 patients; 43,537 HTO (29,330 male, 14,207 female; mean age 49.7 years, 95% CI 49.6–49.8) and 64,470 UKA (31,181 male, 33,289 female; mean age 60.5 years, 95% CI 60.5–60.6). ResultsSurvival free of revision by TKA was 75.8% (95% CI=75.2–76.4) for UKA and 80.6% (95% CI=80.0–81.3) for HTO (p<0.00001). In UKA, revision risk factors comprised: low annual center volume (<17 UKAs per year) (HR=1.50; 95% CI=1.41–1.59), obesity (HR=1.25; 95% CI=1.18–1.32), and age <60years, with maximum risk for 50–59years (HR=2.41; 95% CI=1.83–3.16 in 50–59 year-olds). In HTO, revision risk factors comprised: obesity (HR=1.42; 95% CI=1.31–1.53), rheumatoid arthritis (HR=2.75; 95% CI=1.37–5.51), joint chondrocalcinosis (HR=2.01; 95% CI=1.18–3.39), and age >60years (HR=8.81; 95% CI=7.23–19.73 in 60–69-year-olds). Male gender was a protective factor against revision in both groups: UKA, HR=0.75 (95% CI=0.72–0.79); HTO, HR=0.73 (95% CI=0.69–0.77). The number of UKAs increased over the years, matching the increase in arthroplasty in France, with a decrease in HTOs until 2019. ConclusionHTO showed better medium-term survival than UKA in under-70-year-olds in France. Even so, indications decreased in favor of UKA, although the respective risk factors differ. These findings suggest that conservative surgery still has a role, depending on osteoarthritis stage. Level of evidenceIII; retrospective comparative study.