Difference In 1-year Mortality Research Articles

Impact of red blood cell transfusion and hemoglobin threshold on 1-year mortality among surgical sepsis survivors: A propensity score matching study

BackgroundDespite the fact that red blood cell (RBC) transfusion is commonly applied in surgical intensive care unit (ICU), the effect of RBC transfusion on long-term outcomes remains undetermined. We aimed to explore the association between RBC transfusion and the long-term prognosis of surgical sepsis survivors. MethodsThis retrospective study was conducted on adult sepsis patients admitted to a tertiary surgical ICU center in China. Patients were divided into transfusion and non-transfusion groups based on the presence of RBC transfusion. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW)were performed to balance the potential confounders. ResultsA total of 1421 surgical sepsis survivors were enrolled, including 403 transfused patients and 1018 non-transfused patients. There was a significant difference in 1-year mortality between the two groups (23.1 ​% vs 12.7 ​%, HR: 1.539, 95 ​% confidence interval [CI]: 1.030–2.299, P ​< ​0.001). After PSM and IPTW, transfused patients still showed significantly increased 1-year mortality risks compared to non-transfused individuals (PSM: 23.6 ​% vs 15.9 ​%, HR 1.606, 95 ​% CI 1.036–2.488 ​P ​= ​0.034; IPTW: 20.1 ​% vs 12.9 ​%, HR 1.600, 95 ​% CI 1.040–2.462 ​P ​= ​0.032). Among patients with nadir hemoglobin below 70 ​g/L, 1-year mortality risks in both groups were similar (HR 1.461, 95 ​% CI 0.909–2.348, P ​= ​0.118). However, among patients with nadir hemoglobin above 70 ​g/L, RBC transfusion was correlated with increased 1-year mortality risk (HR 1.556, 95 ​% CI 1.020–2.374, P ​= ​0.040). ConclusionFor surgical sepsis survivors, RBC transfusion during ICU stay was associated with increased 1-year mortality, especially when patients show hemoglobin levels above 70 ​g/L.

Abstract PO2-06-02: Characteristics and Treatment Patterns of de novo Oligometastatic Stage IV Breast Cancer: A Single-Center Retrospective Cohort Study

Abstract Background: Retrospective studies suggest that patients with oligometastatic breast cancer (≤ 5 metastatic lesions) have improved prognosis and may benefit from multimodality treatment. Randomized clinical trials, however, with mostly recurrent oligometastatic breast cancer have not shown improved prognosis with this approach. Real-world data on de novo oligometastatic stage IV (oligo-stage IV) disease are limited. We therefore investigated differences in 5-year mortality in patients with de novo oligo-stage IV vs de novo extensive-stage IV breast cancer who received curative vs palliative chemotherapy at our institution. Methods: In a retrospective cohort design, using the Yale tumor registry, we identified de novo stage IV breast cancer (metastatic to distant sites at diagnosis), diagnosed 2012-2016. Clinical characteristics and treatment patterns were compared between oligo-stage IV vs extensive-stage IV. Curative regimens were defined as TCHP or AC-THP for HER2+, ddAC- &amp;gt;T or TC for ER+, and ddAC- &amp;gt;T for TNBC. Palliative regimens were defined as THP for HER2+ or single agent chemotherapy. 5-year mortality rates were calculated from date of diagnosis to date of death, with living patients censored at date of last contact. Kaplan-Meier curves were estimated and compared using log-rank tests. Multivariable Cox proportional hazards models assessed the association between oligo-stage IV vs extensive-stage IV breast cancer, curative vs palliative regimen, and 5-year mortality. Models were adjusted for receptor status, age at diagnosis, receipt of surgery, and radiation. Models were then stratified by receptor status. Results: Of the 202 de novo stage IV cases, 140 (69.3%) were extensive-stage IV and 62 (30.4%) were oligo-stage IV. A larger proportion of oligo-stage IV vs extensive-stage IV was TNBC (19.4% vs 8.8%, p=0.03), lower proportion was ER+ (65.6% vs 81.5%, p=0.01), and no difference in HER2 (30.5% vs 29.0%, p=0.83). Higher proportion of oligo-stage IV vs extensive-stage IV received curative chemotherapy (24.2% vs 7.9%, p &amp;lt; 0.001) and breast surgery (25.0% vs 13.6%, p &amp;lt; 0.001). There was no difference in receipt of radiation to distant sites (25.0% vs 27.5%, p=0.70). Patients who received curative vs palliative chemotherapy were younger (55.3 vs 62.1yo, p=0.02). Oligo-stage IV had lower 5-year mortality (64.7%) vs extensive-stage IV (70.6%; HR=0.58, 95% CI 0.39-0.89), with no significant difference in 5-year mortality between curative vs palliative chemotherapy. When stratifying by receptor status, ER+ had the strongest association between oligo-stage IV and decreased 5-year mortality (HR=0.56, 95% CI 0.34 – 0.92). There was no significant association between surgery or radiation and 5-year mortality (HR = 0.62, 95% CI 0.38-0.99; HR= 1.33, 95% CI 0.91-1.95, respectively). Only a small number of patients received all 3 components; curative chemotherapy, surgery, and radiation (N=5; 18.5%). The dose of radiation (palliative vs ablative) is unknown. Conclusions: Patients with oligo-stage IV breast cancer had lower 5-year mortality vs extensive-stage IV breast cancer. Neither curative intent chemotherapy, breast surgery nor radiation were associated with lower 5-year mortality. However, very few patients received all 3 modalities with curative intent. These results are consistent with prior randomized clinical trials that showed no survival benefit to escalating therapy, but leave the question unanswered if combining all 3 modalities may improve overall survival in de novo oligometastatic stage IV breast cancer. Multivariable-Adjusted Association Between Disease Status and 5-Year Mortality Among Patients with De Novo Stage IV Breast Cancer, Stratified by Receptor Status. *Further adjusted for age at diagnosis; HR – hazard ratio, CI – confidence interval Citation Format: Deanna Blansky, Maryam Lustberg, Lajos Pusztai, Mariya Rozenblit. Characteristics and Treatment Patterns of de novo Oligometastatic Stage IV Breast Cancer: A Single-Center Retrospective Cohort Study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-06-02.

Comparison of Medical Therapy, Valve Surgery, and Percutaneous Mechanical Aspiration for Tricuspid Valve Infective Endocarditis

BackgroundThe opioid pandemic, and particularly injection drug use, has led to an increase in cases of tricuspid valve infective endocarditis. Indications for valve surgery in right-sided infective endocarditis are not well-defined. Percutaneous mechanical aspiration is considered an alternative in patients at high risk for re-infection of a prosthetic valve but lacks robust outcomes data.This retrospective analysis compares the primary outcome of death within 1 year for patients with isolated tricuspid valve infective endocarditis treated with medical therapy alone vs percutaneous mechanical aspiration or valve surgery. MethodsThe authors performed a retrospective cohort study of patients with isolated tricuspid valve infective endocarditis over a 10-year period. Medical record review was performed to collect demographic-and outcomes-related data. The association between treatment group and outcomes was assessed using Cox proportional hazard regression with inverse probability of treatment weighting. ResultsBetween January 1, 2009, and December 31, 2018, 215 patients with isolated tricuspid valve infective endocarditis and surgical indications were identified. One hundred patients (46.5%) were managed medically, 49 (22.8%) were managed surgically, and 66 (30.7%) underwent percutaneous mechanical aspiration. There was no significant difference in 1-year mortality between the 3 treatment groups (P = .15). Vegetation size > 2.0 cm was associated with increased 1-year mortality (hazard ratio 3.01; P = .03). Addiction medicine consultation was associated with decreased 1-year mortality (hazard ratio 0.117; P = .0008). ConclusionThe study highlights that surgery or percutaneous mechanical aspiration in addition to medical therapy does not improve 1-year mortality in patients with isolated tricuspid valve infective endocarditis. Addiction medicine consultation was associated with decreased 1-year mortality in patients with injection drug use-associated isolated tricuspid valve infective endocarditis.

Sex differences in the outcomes after transcatheter aortic valve replacement with newer generation devices: A meta-analysis.

Transcatheter aortic valve replacement (TAVR) is a reasonable therapeutic approach among patients with symptomatic severe aortic stenosis irrespective of surgical risk. Data regarding sex-specific differences in the outcomes with newer generation valves are limited. Electronic databases were searched for studies assessing sex differences in the outcomes of patients undergoing TAVR with newer generation valves (SAPIEN 3 or Evolut). Random effects model was constructed for summary estimates. Four observational studies with 4522 patients (44.8% women) were included in the meta-analysis. Women were older and had a lower prevalence of coronary artery disease and mean EuroScore. Women had a higher incidence of short-term mortality (up to 30 days) (risk ratio [RR]: 1.60, 95% confidence interval [CI]: 1.14-2.25), but no difference in 1-year mortality (RR: 0.92, 95% CI: 0.72-1.17). There was no significant difference in the incidence of major bleeding (RR: 1.16, 95% CI: 0.86-1.57), permanent pacemaker (PPM) (RR: 0.80, 95% CI: 0.62-1.04), or disabling stroke (RR: 1.16, 95% CI: 0.54-2.45). In this meta-analysis, we found that women undergoing TAVR with newer-generation devices were older but had a lower prevalence of comorbidities. Women had a higher incidence of short-term mortality but no difference in the 1-year mortality, bleeding, PPM, or stroke compared with men. Future studies are required to confirm these findings.

Epidemiology and outcomes associated with enterococcal blood stream infection among liver and kidney transplant recipients.

Bloodstream infections (BSIs) account for 18% of bacterial infections in the first year after solid organ transplantation (SOT). Enterococcus accounts for up to 20% of BSIs in this population, with vancomycin-resistant enterococcus (VRE) posing a particular risk. This is a retrospective, case-control study of adult liver and kidney transplant recipients between 01/01/2016 and 06/30/2021 that characterizes the epidemiology and outcomes of enterococcal BSIs in liver and kidney transplantations at a single institution. Subjects with an enterococcal BSI within the first 6 months post-transplant were compared to those with non-enterococcal BSIs in the same period. We identified 26 subjects with enterococcal BSIs and 28 controls with non-enterococcal BSIs (n=54; 10.3%). Cases were mostly liver transplant recipients (n=20; 77%) with a median MELD at transplant of 33 (range 14-43); controls included 14 KT recipients (50%). Groups differed significantly (all p<.05) by factors including perioperative transfusion requirements, need for reoperation, and number of interventions post-transplant. Cases had a median time of 25.5 days to infection and controls 100.5 days (p<.0001). There were no differences in 1-year mortality between the groups. Enterococcus faecium was the predominant species of Enterococcus (n=23; 88.5%), with a majority (91.3%) of the isolates being VRE. In our liver and kidney transplants, enterococcal BSIs occurred early among liver transplant recipients. The high incidence of VRE among E. faecium isolates in this population warrants further investigation into the optimal approach to empiric antimicrobials for bacteremia in the early post-transplant period.

Race-ethnicity and sex differences in 1-year survival following percutaneous coronary intervention among Medicare fee-for-service beneficiaries.

Existing literature describing differences in survival following percutaneous coronary intervention (PCI)by patient sex, race-ethnicity and the role of socioeconomic characteristics (SEC)is limited. Evaluate differences in 1-year survival after PCI by sex and race-ethnicity, and explore the contribution of SEC to observed differences. Using a 20% sample of Medicare claims data for beneficiaries aged 65+, we identified fee-for-service patients who received PCI from 2007 to 2015. We performed logistic regression to assess how sex and race-ethnicity relate to procedural indication, inpatient versus outpatient setting, and 1-year mortality. We evaluated whether these relationships are moderated by sequentially controlling for factors including age, comorbidities, presence of acute myocardial infarction (AMI),county SEC, medical resource availabilityand inpatient versus outpatient procedural status. We identified 300,491 PCI procedures, of which 94,863 (31.6%) were outpatient. There was a significant transition to outpatient PCI during the study period, especially for men compared with women and White patients compared with Black patients. Black patients were 3.50 percentage points (p < 0.001) and women were 3.41 percentage points (p < 0.001) more likely than White and male patients to undergo PCI at the time of AMI, which typically occurs in the inpatient setting. Controlling for age and calendar year, Black patients were 2.87 percentage points more likely than non-Hispanic White patients to die within 1 year after PCI. After controlling for Black-White differences in comorbidities, the differences in 1-year mortality decreased to 0.95 percentage points, which then became nonsignificant when further controlling for county resources and state of residence. Women were more likely to experience PCI in the setting of AMI and had less transition to outpatient care during the period. Black patients experienced higher 1-year mortality following PCI, which is explained by differences in baseline comorbidities, county medical resources, and state of residence.

Association of Neighborhood-Level Marginalization With Health Care Use and Clinical Outcomes Following Hospital Discharge in Patients Who Underwent Coronary Catheterization for Acute Myocardial Infarction in a Single-Payer Health Care System.

Canadian data suggest that patients of lower socioeconomic status with acute myocardial infarction receive less beneficial therapy and have worse clinical outcomes, raising questions regarding care disparities even in universal health care systems. We assessed the contemporary association of marginalization with clinical outcomes and health services use. Using clinical and administrative databases in Ontario, Canada, we conducted a population-based study of patients aged ≥65 years hospitalized for their first acute myocardial infarction between April 1, 2010 and March 1, 2019. Patients receiving cardiac catheterization and surviving 7 days postdischarge were included. Our primary exposure was neighborhood-level marginalization, a multidimensional socioeconomic status metric. Neighborhoods were categorized by quintile from Q1 (least marginalized) to Q5 (most marginalized). Our primary outcome was all-cause mortality. A proportional hazards regression model with a robust variance estimator was used to quantify the association of marginalization with outcomes, adjusting for risk factors, comorbidities, disease severity, and regional cardiologist supply. Among 53 841 patients (median age, 75 years; 39.1% female) from 20 640 neighborhoods, crude 1- and 3-year mortality rates were 7.7% and 17.2%, respectively. Patients in Q5 had no significant difference in 1-year mortality (hazard ratio [HR], 1.08 [95% CI, 0.95-1.22]), but greater mortality over 3 years (HR, 1.13 [95% CI, 1.03-1.22]) compared with Q1. Over 1 year, we observed differences between Q1 and Q5 in visits to primary care physicians (Q1, 96.7%; Q5, 93.7%) and cardiologists (Q1, 82.6%; Q5, 72.6%), as well as diagnostic testing. There were no differences in secondary prevention medications dispensed or medication adherence at 1 year. In older patients with acute myocardial infarction who survived to hospital discharge, those residing in the most marginalized neighborhoods had a greater long-term risk of mortality, less specialist care, and fewer diagnostic tests. Yet, there were no differences across socioeconomic status in prescription medication use and adherence.

Mortality in ST-Segment Elevation Myocardial Infarction With Nonobstructive Coronary Arteries and Mimickers

The clinical characteristics and prognosis of patients with ST-segment elevation myocardial infarction (STEMI) with nonobstructive coronaries (MINOCA) are largely unknown. To assess differences in 5-year mortality in patients presenting with STEMI due to MINOCA and MINOCA mimickers as compared with obstructive disease. A retrospective analysis of a prospective registry-based cohort study of consecutive STEMI activations at 3 regional Midwest STEMI programs. STEMI without a culprit artery and elevated troponin levels were categorized as MINOCA (absence of coronary artery stenosis >50% and confirmed or suspected coronary artery plaque disruption, epicardial coronary spasm, or coronary embolism/thrombosis) or MINOCA mimickers (takotsubo cardiomyopathy, myocarditis, or nonischemic cardiomyopathy). Data were analyzed from March 2003 to December 2020. Adjusted Cox regression analysis was used to assess 5-year mortality risk in STEMI presenting with MINOCA and MINOCA mimickers in comparison with obstructive disease. Among 8560 consecutive patients with STEMI, mean (SD) age was 62 (14) years, 30% were female (2609 participants), and 94% were non-Hispanic White (4358 participants). The cohort included 8151 patients with STEMI due to obstructive disease (95.2%), 120 patients with MINOCA (1.4%), and 289 patients with MINOCA mimickers (3.8%). Patients were followed up for a median (IQR) of 7.1 (3.6-10.7) years. Patients with MINOCA and MINOCA mimickers were less likely to be discharged with cardiac medications compared with obstructive disease. At 5-year follow-up, mortality in STEMI presenting with obstructive disease (1228 participants [16%]) was similar to MINOCA (20 participants [18%]; χ21 = 1.1; log-rank P = .29) and MINOCA mimickers (52 participants [18%]; χ21 = 2.3; log-rank P = .13). In adjusted Cox regression analysis compared with obstructive disease, the 5-year mortality hazard risk was 1.93 times higher in MINOCA (95% CI, 1.06-3.53) and similar in MINOCA mimickers (HR, 1.08; 95% CI, 0.79-1.49). In this large multicenter cohort study of consecutive clinical patients with STEMI, presenting with MINOCA was associated with a higher risk of mortality than obstructive disease; the risk of mortality was similar in patients with MINOCA mimickers and obstructive disease. Further investigation is necessary to understand the pathophysiologic mechanisms involved in this high-risk STEMI population.

Racial Differences in 1-Year Mortality after Hospitalization for Chronic Obstructive Pulmonary Disease in the United States.

Rationale: One quarter of Medicare beneficiaries hospitalized for chronic obstructive pulmonary disease (COPD) die within 1 year. Although overall mortality rates are higher among White patients with COPD, racial and ethnic differences in the vulnerable period following hospitalization are unknown.Objectives: To determine the association between race and ethnicity and mortality following COPD hospitalization and to evaluate the extent to which differences are explained by clinical, geographic, socioeconomic, and post-acute care factors among Medicare beneficiaries in the United States.Methods: In this retrospective cohort study of Medicare beneficiaries hospitalized for COPD exacerbation, we constructed Cox regression models for 1-year mortality accounting for hospital-level clustering; sequentially adjusting for clinical, geographic, neighborhood socioeconomic, and post-acute care characteristics; and stratifying by sex and individual socioeconomic status.Results: Among 244,624 hospitalizations, Medicare beneficiaries of racial and ethnic minority groups had a lower risk of dying within 1 year of hospitalization than those of White race (hazard ratios, 0.78 [95% confidence interval, 0.75-0.80] for Black patients, 0.79 [0.76-0.82] for Hispanic patients, and 0.82 [0.77-0.86] for others). Differences in visits to physicians, attendance of pulmonary rehabilitation, and discharge disposition explained some of the mortality gap among dual-eligible beneficiaries but not among non-dual-eligible beneficiaries.Conclusions: Medicare beneficiaries of White race are at greater risk of mortality following COPD hospitalization compared with beneficiaries of minority race and ethnicity groups. Our findings should be interpreted in the context of the selection of a hospitalized population and a potentially incomplete assessment of illness severity in administrative data, and warrant further investigation.

Abstract 17764: Clinical Outcomes and Predictors of Vasoplegia in Patients Undergoing Orthotopic Cardiac Transplantation at a High-Volume Single-Center

Background: Patients undergoing heart transplantation are at significant risk of the developing post-operative vasoplegia, which is associated with poor outcomes. Despite significant burden to these patients, risk factors for development of vasoplegia are poorly understood. We assess these risk factors and outcomes in patients undergoing orthotopic heart transplant at our high-volume academic center. Methods: 173 patients underwent cardiac transplantation between January 1 st , 2015 and February 28 th 2022 at the Ohio State University Wexner Medical Center. Baseline demographics, operative characteristics, peri-operative management, and long-term follow-up data were obtained. Vasoplegia was defined as provider documentation of vasoplegia for patients with persistent hypotension requiring the use of one or more vasopressors to maintain mean arterial pressures &gt;65 mmHg in the absence of other explainable causes (cardiogenic shock, sepsis, etc.) The two primary endpoints assessed were development of vasoplegia in the 48 hours post-transplant and all-cause mortality. Statistical significance was assessed using Chi-squared, analysis of variance, or Kruskal-Wallis where appropriate. Results: In total, 173 patients underwent cardiac transplantation. 89 (51.4%) developed vasoplegia in the post-operative period. 130 (75.1%) were males. The average age at transplant was 56 years. Patients with vasoplegia were more likely to have history of atrial fibrillation (p=0.01) and had higher BMI (p&lt;0.01) compared to those without. There were otherwise no significant differences in demographic data such as past medical history and medication history in those with and without vasoplegia. Patients with vasoplegia had significantly higher cardiopulmonary bypass times (p=0.01), aortic cross-clamp times (p&lt;0.01) and need for red blood cell transfusion peri-operatively (p=0.02). Patients with vasoplegia had higher 30-day mortality (p=0.03), however there was no significant difference in 1-year mortality for those with and without vasoplegia. Conclusions: Vasoplegia is common following orthotopic heart transplant, and short-term mortality is high. Appropriate risk-stratification is paramount in caring for these high-risk patients.

Contemporary use of cefazolin for MSSA infective endocarditis: analysis of a national prospective cohort

ObjectivesThis study aimed to assess the real use of cefazolin for methicillin-susceptible Staphylococcus aureus (MSSA) infective endocarditis (IE) in the Spanish National Endocarditis Database (GAMES) and to compare it with antistaphylococcal penicillin (ASP). MethodsProspective cohort study with retrospective analysis of a cohort of MSSA IE treated with cloxacillin and/or cefazolin. Outcomes assessed were relapse; intra-hospital, overall, and endocarditis-related mortality; and adverse events. Risk of renal toxicity with each treatment was evaluated separately. ResultsWe included 631 IE episodes caused by MSSA treated with cloxacillin and/or cefazolin. Antibiotic treatment was cloxacillin, cefazolin, or both in 537 (85%), 57 (9%), and 37 (6%) episodes, respectively. Patients treated with cefazolin had significantly higher rates of comorbidities (median Charlson Index 7, P <0.01) and previous renal failure (57.9%, P <0.01). Patients treated with cloxacillin presented higher rates of septic shock (25%, P = 0.033) and new-onset or worsening renal failure (47.3%, P = 0.024) with significantly higher rates of in-hospital mortality (38.5%, P = 0.017). One-year IE-related mortality and rate of relapses were similar between treatment groups. None of the treatments were identified as risk or protective factors. ConclusionOur results suggest that cefazolin is a valuable option for the treatment of MSSA IE, without differences in 1-year mortality or relapses compared with cloxacillin, and might be considered equally effective.

Survival benefit with checkpoint inhibitors versus chemotherapy is modified by brain metastases in patients with recurrent small cell lung cancer.

Small cell lung cancer (SCLC) is a rapidly growing malignancy with early distant metastases. Up to 70% will develop brain metastases, and the poor prognosis of these patients has not changed considerably. The potential of checkpoint inhibitors (CPI) in treating recurrent (r/r) SCLC and their effect on brain metastases remain unclear. In this retrospective multicenter study, we analyzed r/r SCLC patients receiving second or further-line CPI versus chemotherapy between 2010 and 2020. We applied multivariable-adjusted Cox regression analysis to test for differences in 1-year mortality and real-world progression. We then used interaction analysis to evaluate whether brain metastases (BM) and/or cranial radiotherapy (CRT) modified the effect of CPI versus chemotherapy on overall survival. Among 285 patients, 99 (35%) received CPI and 186 (65%) patients received chemotherapy. Most patients (93%) in the CPI group received nivolumab/ipilimumab. Chemotherapy patients were entirely CPI-naïve and only one CPI patient had received atezolizumab for first-line treatment. CPI was associated with a lower risk of 1-year mortality (adjusted Hazard Ratio [HRadj] 0.59, 95% CI 0.42 to 0.82, p=0.002). This benefit was modified by BM and CRT, indicating a pronounced effect in patients without BM (with CRT: HRadj 0.34, p=0.003; no CRT: HRadj 0.50, p=0.05), while there was no effect in patients with BM who received CRT (HRadj 0.85, p=0.59). CPI was associated with a lower risk of 1-year mortality compared to chemotherapy. However, the effect on OS was significantly modified by intracranial disease and radiotherapy, suggesting the benefit was driven by patients without BM.

The impact of on-site cardiac surgical backup on clinical outcomes of acute coronary syndrome-analysis of the ACSIS national registry.

The availability of advanced technologies for mechanical support in hospitals with on-site cardiac surgery (CS), along with the ability to perform urgent coronary artery bypass graft (CABG) surgery, may result in improved clinical outcomes in patients with acute coronary syndrome (ACS). We conducted a retrospective analysis of the bi-annually Acute Coronary Syndrome Israeli Survey (ACSIS) registry from the year 2000 to 2020, performed in hospitals with and without CS. Mortality rates and major adverse cardiac and cerebrovascular events (MACCE) rates are reported. We evaluated two periods of the study-early (2000-2010) vs. late (2011-2020). Propensity score matching was performed to reduce bias between the two groups. The study included 16,979 patients (52.3% in the on-site CS group). Patients in the on-site CS group were more likely to undergo percutaneous coronary intervention (PCI), (odds ratio [OR], 1.26 [95% CI, 1.18-1.35]; p < 0.001) and CABG [OR, 1.91 (95%CI, 1.63-2.24); P < 0.001], and patients in hospitals without on-site CS had higher 30-day MACCE [OR, 1.17 (95% CI, 1.07-1.27); p < 0.0005]. Overall, there was no difference in 1-year mortality (hazard ratio [HR], 0.98 [95% CI, 0.89-1.08]; p = 0.71) between the groups. During the late period of the study, patients in the group without on-site CS had lower 30-day mortality [OR, 0.69 (95% CI, 0.49-0.97); P = 0.04], yet with no difference in 1-year mortality [HR, 0.81 (95% CI, 0.65-1.01); p = 0.07]. The availability of on-site CS resulted in variations in treatment modality, yet it did not affect the clinical outcomes of ACS. A trend to a better short-term outcomes was noted in hospitals without CS during the late period of the study, which warrants further investigation.

254. THE IMPACT OF D2 VERSUS D1 LYMPHADENECTOMY IN SIEWERT II GASTROESOPHAGEAL JUNCTION (GEJ) CANCER

Abstract Background Though a myriad of multimodal treatment options exist for gastroesophageal junction (GEJ) cancer, surgical resection remains the mainstay for potential cure. Extended nodal dissection with a D2 lymphadenectomy (LAD) beyond the D1 peri-gastric dissection remains controversial for Siewert II GEJ cancer. Though D2 LAD may lead to increased lymph node harvest, its effect on overall survival remains elusive. We hypothesize that additional D2 dissection in Siewert II GEJ cancer does not lead to increased survival. Methods We reviewed Siewert II GEJ cancer patients who received either a D1 or D2 LAD after receiving neoadjuvant chemoradiation or perioperative chemotherapy from 2012 through 2022. Chi-square and Fisher exact tests were used to compare categorical variables and two-sample Wilcoxon rank sum tests for non-normally distributed continuous variables. The main outcomes measured were 1-year mortality from date of diagnosis, number of nodes sampled, and operative time. Results Among the 155 patients identified, 75% of Siewert II underwent a D1 and 25% underwent a D2 LAD. Patients with a D2 LAD more often had &amp;gt;15 lymph nodes harvested than D1 (83% vs 48%, p &amp;lt; 0.001) but had no significant difference in median number of positive nodes (Figure 1). Patients with a D2 LAD had a median operative time approximately 2 hours longer than D1, 362 min vs 244 min (p &amp;lt; 0.001). On multivariable logistic regression adjusting for patient and clinical characteristics, there was no significant difference in 1-year mortality from patients undergoing a D2 vs D1 LAD. Conclusion Despite the associated high mortality associated with gastroesophageal junction (GEJ) cancer, there remains little consensus guidelines regarding the optimal preoperative and operative management. Though D2 LAD may theoretically lead to more lymph node harvest, its role in staging may be unnecessarily excessive as there is no gain in number of positive nodes leading to increased operative morbidity with no significant change in survival.

The Hemodynamic Effects of Aortic Regurgitation in Patients Supported by a HeartMate 3 Left Ventricular Assist Device

Aortic regurgitation (AR) is a common complication following left ventricular assist device (LVAD) implantation. We evaluated the hemodynamic implications of AR in patients with HeartMate 3 (HM3) LVAD at baseline and in response to speed changes. Clinically stable outpatients supported by HM3 who underwent a routine hemodynamic ramp test were retrospectively enrolled in this analysis. Patients were stratified based on the presence of at least mild AR at baseline speed. Hemodynamic and echocardiographic parameters were compared between the AR and non-AR groups. Sixty-two patients were identified. At the baseline LVAD speed, 29 patients (47%) had AR, while 33 patients (53%) did not. Patients with AR were older and supported on HM3 for a longer duration. At baseline speed, all hemodynamic parameters were similar between the groups including central venous pressure, pulmonary capillary wedge pressure, pulmonary arterial pressures, cardiac output and index, and pulmonary artery pulsatility index (p > 0.05 for all). During the subacute assessment, AR worsened in some, but not all, patients, with increases in LVAD speed. There were no significant differences in 1-year mortality or hospitalization rates between the groups, however, at 1-year, ≥ moderate AR and right ventricular failure (RVF) were detected in higher rates among the AR group compared to the non-AR group (45% vs. 0%; p < 0.01, and 75% vs. 36.8%; p = 0.02, respectively). In a cohort of stable outpatients supported with HM3 who underwent a routine hemodynamic ramp test, the presence of mild or greater AR did not impact the ability of HM3 LVADs to effectively unload the left ventricle during early subacute assessment. Although the presence of AR did not affect mortality and hospitalization rates, it resulted in higher rates of late hemodynamic-related events in the form of progressive AR and RVF.

Waitlist and Transplant Outcomes in Organ Donation After Circulatory Death: Trends in the United States.

To summarize waitlist and transplant outcomes in kidney, liver, lung, and heart transplantation using organ donation after circulatory death (DCD). DCD has expanded the donor pool for solid organ transplantation, most recently for heart transplantation. The United Network for Organ Sharing registry was used to identify adult transplant candidates and recipients in the most recent allocation policy eras for kidney, liver, lung, and heart transplantation. Transplant candidates and recipients were grouped by acceptance criteria for DCD versus brain-dead donors [donation after brain death (DBD)] only and DCD versus DBD transplant, respectively. Propensity matching and competing-risks regression was used to model waitlist outcomes. Survival was modeled using propensity matching and Kaplan-Meier and Cox regression analysis. DCD transplant volumes have increased significantly across all organs. Liver candidates listed for DCD organs were more likely to undergo transplantation compared with propensity-matched candidates listed for DBD only, and heart and liver transplant candidates listed for DCD were less likely to experience death or clinical deterioration requiring waitlist inactivation. Propensity-matched DCD recipients demonstrated an increased mortality risk up to 5 years after liver and kidney transplantation and up to 3 years after lung transplantation compared with DBD. There was no difference in 1-year mortality between DCD and DBD heart transplantation. DCD continues to expand access to transplantation and improves waitlist outcomes for liver and heart transplant candidates. Despite an increased risk for mortality with DCD kidney, liver, and lung transplantation, survival with DCD transplant remains acceptable.

THE RISK OF EARLY REVISION SURGERY AFTER TRAINEE-LED PRIMARY TOTAL HIP ARTHROPLASTY

Primary total hip replacement (THR) is a successful and common operation which orthopaedic trainees must demonstrate competence in prior to completion of training. This study aimed to determine the impact of operating surgeon grade and level of supervision on the incidence of 1-year patient mortality and all-cause revision following elective primary THR in a large UK training centre.National Joint Registry (NJR) data for all elective primary THR performed in a single University Teaching Hospital from 2005–2020 were used, with analysis performed on the 15-year dataset divided into 5-year temporal periods (B1 2005–2010, B2 2010–2015, B3 2015–2020). Outcome measures were mortality and revision surgery at one year, in relation to lead surgeon grade, and level of supervision for trainee-led operations.9999 eligible primary THR were undertaken, of which 5526 (55.3%) were consultant led (CL), and 4473 (44.7%) trainees led (TL). Of TL, 2404 (53.7%) were non-consultant supervised (TU), and 2069 (46.3%) consultant supervised (TS). The incidence of 1-year patient mortality was 2.05% (n=205), and all-cause revision was 1.11% (n=111). There was no difference in 1-year mortality between TL (n=82, 1.8%) and CL (n=123, 2.2%) operations (p=0.20, OR 0.78, CI 0.55–1.10). The incidence of 1-year revision was not different for TL (n=56, 1.3%) and CL (n=55, 1.0%) operations (p=0.15, OR 1.37, CI 0.89–2.09). Overall, there was no temporal change for either outcome measure between TL or CL operations. A significant increase in revision within 1-year was observed in B3 between TU (n=17, 2.7%) compared to CL (n=17, 1.0%) operations (p=0.005, OR 2.81, CI 1.35–5.87).We found no difference in 1-year mortality or 1-year all-cause revision rate between trainee-led primary THR and consultant-led operations over the entire fifteen-year period. However, unsupervised trainee led THR in the most recent 5-year block (2015–2020) has a significantly increased risk of early revision, mainly due to instability and prosthetic joint infection. This suggests that modern surgical training is having a detrimental effect on THR patient outcomes. More research is needed to understand the reasons if this trend is to be reversed.

Long-term cardiovascular outcomes among immigrants and non-immigrants in cardiac resynchronization therapy: a nationwide study.

To date, potential differences in outcomes for immigrants and non-immigrants with a cardiac resynchronization therapy (CRT), in a European setting, remain underutilized and unknown. Hence, we examined the efficacy of CRT measured by heart failure (HF)-related hospitalizations and all-cause mortality among immigrants and non-immigrants. All immigrants and non-immigrants who underwent first-time CRT implantation in Denmark (2000-2017) were identified from nationwide registries and followed for up to 5 years. Differences in HF related hospitalizations and all-cause mortality were evaluated by Cox regression analyses. From 2000 to 2017, 369 of 10 741 (3.4%) immigrants compared with 7855 of 223 509 (3.5%) non-immigrants with a HF diagnosis underwent CRT implantation. The origins of the immigrants were Europe (61.2%), Middle East (20.1%), Asia-Pacific (11.9%), Africa (3.5%), and America (3.3%). We found similar high uptake of HF guideline-directed pharmacotherapy before and after CRT and a consistent reduction in HF-related hospitalizations the year before vs. the year after CRT (61% vs. 39% for immigrants and 57% vs. 35% for non-immigrants). No overall difference in 5-year mortality among immigrants and non-immigrants was seen after CRT [24.1% and 25.8%, respectively, P-value = 0.50, hazard ratio (HR) = 1.2, 95% confidence interval (CI): 0.8-1.7]. However, immigrants of Middle Eastern origin had a higher mortality rate (HR = 2.2, 95% CI: 1.2-4.1) compared with non-immigrants. Cardiovascular causes were responsible for the majority of deaths irrespective of immigration status (56.7% and 63.9%, respectively). No overall differences in efficacy of CRT in improving outcomes between immigrants and non-immigrants were identified. Although numbers were low, a higher mortality rate among immigrants of Middle Eastern origin was identified compared with non-immigrants.

Frailty Trends in an Older Veteran Subpopulation 1 Year Prior and Into the COVID-19 Pandemic Using CAN Scores.

We studied the effects of the first year of the COVID-19 pandemic on frailty trends in a subset of older veterans at the Phoenix Veterans Affairs Health Care System. We identified 3538 and 6103 veterans aged 70 to 75 years as of February 8, 2019, with a calculated Care Assessment Need (CAN) score of ≥ 75 for 1-year mortality and hospitalization, respectively. After excluding veterans with insufficient 2020 and 2021 data, we compared the difference in 1-year mortality and hospitalization CAN scores from 2019 to 2020 with 2020 to 2021 using a paired t test. The difference in mean (SD) 1-year mortality CAN scores from 2020 to 2021 was 0.2 (13.4) when compared with the previous year's -4.9 (12.5) (P < .0001), indicating increased frailty. The difference in 1-year hospitalization CAN scores from 2020 to 2021 was -1.5 (12.0) when compared with the previous year's -2.8 (9.9) (P < .0001). Frailty in our veteran subpopulation as calculated by 1-year mortality CAN scores increased in the first year of the COVID-19 pandemic when compared with a recovering trend the previous year.

Valve-in-valve/valve-in-ring transcatheter mitral valve implantation vs. redo surgical mitral valve replacement for patients with failed bioprosthetic valves or annuloplasty rings: A systematic review and meta-analysis

BackgroundValve-in-valve (ViV)/valve-in-ring (ViR) transcatheter mitral valve implantation (TMVI) is a less invasive alternative to redo surgical mitral valve replacement (SMVR). To further verify its feasibility, we aimed to appraise early clinical outcomes after either ViV/ViR TMVI or redo SMVR for failed bioprosthetic valves or annuloplasty rings, as a comparison of long-term follow-up results are not available for these procedures. MethodsWe systematically searched PubMed, Cochrane Controlled Trials Register, EMBASE, and Web of Science to identify studies that compared ViV/ViR TMVI and redo SMVR. Fixed- and random-effects meta-analyses were used to compare the early clinical results between these two groups. ResultsA total of 3,890 studies published from 2015 to 2022 were searched, and ten articles comprising 7,643 patients (ViV/ViR TMVI, 1,719 patients; redo SMVR, 5,924 patients) were included. In this meta-analysis, ViV/ViR TMVI significantly improved in-hospital mortality (fixed-effects model: odds ratio [OR], 0.72; 95% confidence interval [CI], 0.57–0.92; P = 0.008) and for the matched populations (fixed-effects model: OR, 0.42; 95% CI, 0.29–0.61; P < 0.00001). ViV/ViR TMVI also outperformed redo SMVR in 30-day mortality and in rates of early postoperative complications. ViV/ViR TMVI resulted in less time spent in the ICU and hospital, whereas it showed no significant difference in one-year mortality. A lack of comparison of long-term clinical outcomes and postoperative echocardiographic results are important limitations of our results. ConclusionsViV/ViR TMVI is a reliable alternative to redo SMVR for failed bioprosthetic valves or annuloplasty rings as a result of lower in-hospital mortality, higher 30-day survival, and lower early postoperative complication rates, although there is no significant difference in 1-year mortality.