Low Operative Risk Research Articles

The efficacy of early postoperative enteral immunonutrition on T-lymphocyte count: A randomised control study in low-risk cardiac surgery patients.

Patients undergoing cardiac surgery have a pronounced immune response that leads to a reduction in cellular immunity. Immune-modulating nutritional supplements are considered to be beneficial for patients undergoing major surgery. However, due to the lack of studies in the cardiac surgery population, the effect of immunonutrition remains unclear in this patient group. Our purpose was to research the efficacy of early postoperative enteral immunonutrition on T-lymphocyte count in the cardiac surgery population. This was a randomised control study of low operative risk adult patients, who underwent elective cardiac surgery. These patients were randomised into immunonutrition and control groups. The immunonutrition group was supplemented with immune nutrients for five postoperative days. The counts of T-lymphocytes, as well as the counts for the CD4+ and CD8+ cell subpopulations were determined on the day of surgery and on the sixth postoperative day. Fifty-five patients were enrolled in the study, the mean age was 69.7±6.3 years, 28 (50.9%) of them were males, the median operative risk was 1.75%. Twenty-seven (49.1%) were randomised into the immunonutrition group. The control and the immunonutrition groups were similar before the intervention. The counts of the CD3+ T cells and CD4+ T cells on the sixth postoperative day were significantly higher in the immunonutrition group compared to the control group with 1.42±0.49 vs. 1.12±0.56 (∗109/l), p=0.035 and 1.02±0.36 vs. 0.80±0.43 (∗109/l), p=0.048, respectively. Regression analysis was performed to determine the efficacy of the immunonutrition on the counts of the CD3+ and CD4+ T cells; CD3+ T and CD4+ T cell counts were increased to 0.264 (∗109/l), p=0.039 and 0.232 (∗109/l), p=0.021, respectively. Early postoperative immunonutrition increases the count of the CD3+ and CD4+ T cells in cardiac surgical patients. Clinical trials identifier number: NCT04047095.

Government contracts and trade credit

This study examines the association between government contracts and firms' use of trade credit. Firms with government contracts may demand less trade credit because of their lower operational risk, higher firm performance, stronger capacity to generate internal funds, and better access to other sources of financing. On the other hand, government contractors could receive more trade credit extensions from suppliers. We examine a sample of U.S. listed firms from 2000 to 2016 and find that firms with government contracts have a lower level of trade credit. We also find that government contractors make quicker payments for trade credit contracts than other firms. Moreover, we provide empirical evidence of government contractors' lower levels of operational risk and higher firm performance, which may enable government contractors to generate adequate internal funds for their operations or to obtain other forms of financing at a lower cost and thus lower their demand for trade credit. Incremental to prior research, our study suggests that having government contracts is one of the factors determining trade credit and firms' financing decisions.

Transapical aortic valve replacement versus surgical aortic valve replacement: A subgroup analyses for at-risk populations

BackgroundIf the transfemoral access is not feasible, a transapical access or surgical aortic valve replacement (SAVR) are alternatives for patients with aortic valve stenosis. ObjectivesTo identify patient groups who benefit from SAVR or transapical transcatheter aortic valve replacement (TA-TAVR), we compared in-hospital outcomes of patients in a nationwide dataset. MethodsWe identified 19,016 isolated SAVR and 6432 TA-TAVR performed in Germany from 2014 to 2016. We adjusted for risk factors using a covariate- and propensity-adjusted analysis. ResultsPatients undergoing TA-TAVR were older, had more comorbidities, and accordingly greater estimated operative risk (logistic European System for Cardiac Operative Risk Evaluation 5.3 vs 17.0, P < .001). However, adjusted risk for in-hospital complications such as stroke, acute kidney injury, relevant bleeding, and prolonged mechanical ventilation >48 hours was lower in patients undergoing TA-TAVR (all P < .001). When we compared in-hospital mortality of all patients undergoing either TA-TAVR or SAVR, neither treatment strategy had a clear advantage (covariate-adjusted odds ratio [caOR], 1.13, P = .251; propensity-adjusted OR [paOR], 1.12, P = .309). Two patient subgroups seem to benefit more from SAVR than TA-TAVR: patients <75 years (caOR, 1.29, P = .237; paOR, 2.12, P = .001) and those with European System for Cardiac Operative Risk Evaluation 4-9 (caOR, 1.32, P = .114; paOR, 1.43, P = .041). Female patients had a tendency toward lower risk for in-hospital mortality when undergoing SAVR (caOR, 1.42, P = .030). In patients with chronic renal failure, TA-TAVR was superior (caOR, 0.56, P = .039, P = .040). ConclusionsPatients <75 years and those at low operative risk who underwent SAVR had lower in-hospital mortality than those undergoing TA-TAVR. Patients with chronic renal failure who underwent TA-TAVR had lower in hospital mortality than those that underwent SAVR.

Active Aortic Endocarditis in Young Adults: Long-term Results of the Ross Procedure

The best valvular substitute remains controversial in young adults with active aortic valve endocarditis. The Ross procedure has gained interest because of its theoretical resistance to infection. We aimed to report our long-term outcomes of the Ross procedure in this indication. Between March 1992 and January 2019, 511 patients underwent a Ross procedure in our institution. Among them, we included 38 patients who suffered from an active aortic valve infective endocarditis. The mean age was 33.9 ± 8.1 years. Six patients had emergent procedures and 17 patients had perivalvular involvement. A pulmonary autograft was implanted using the full root technique in 78.9% of patients. Median follow-up was 12 (interquartile range, 1.75-16.25) years. The hospital mortality rate was 5.3%. Estimated overall survival was 84.2% ± 6.6% at 10 years. There were 2 cases of recurrent endocarditis, both requiring reoperation. Six other patients required reoperation on an autograft or homograft. Estimated freedom from recurrent endocarditis or reoperation was 89.4% ± 5.9% at 10 years. In experienced centers, the Ross procedure is a reliable alternative to prosthetic or homograft valve replacement in young adults experiencing active aortic valve endocarditis, with a low operative risk and good long-term results.

Predictive scores for major bleeding after coronary artery bypass surgery in low operative risk patients.

Cardiac surgery is associated with perioperative bleeding and carries high risk of allogeneic blood transfusion. Recently new scores for prediction of severe bleeding have been developed. This study aims to compare the WILL-BLEED, CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting major bleeding after CABG in patients with low estimated operative risk. A multicenter observational study included 1391 patients who underwent isolated CABG from July 2015 to January 2018. We tested the hypothesis that the WILL-BLEED score, specifically designed for CABG, would perform at least as well as the CRUSADE, PAPWORTH, TRUST, TRACK and ACTION scores in predicting postoperative major bleeding in low operative risk patients. The primary endpoint was the performance of known bleeding risk scores after CABG. The secondary endpoint was the evaluation of in-hospital mortality. Mean age was 68.2±9.4 years and median Euroscore II value was 1.69% (IQR 1.15-2.81%). Mean blood losses in the first 12 postoperative hours was 339.75 mL. Seventy-three (5.2%) subjects underwent administration of blood products. The rate of severe-massive bleeding according to UDPB grades 3-4 was 1.5%. WILL-BLEED, TRUST, TRACK and ACTION scores were significantly associated with severe postoperative bleeding. WILL-BLEED presented the best c-index (AUC: 0.658; 95% CI: 0.600,0.716). Reclassification analysis showed a worsening in sensitivity and significant negative reclassification of CRUSADE, PAPWORTH, TRACK and ACTION scores when compared with WILL-BEED. The combination of WILL-BLEED and TRUST scores improved the prediction ability (AUC: 0.673; 95% CI: 0.615-0.732). Overall in-hospital mortality was 1.65%. Early mortality in patients with severe versus no-severe bleeding was found to be 11.8% vs. 1.0% Severe bleeding (OR: 13.26; P value<0.001) was found to be significantly associated with early mortality. Severe bleeding after CABG is a harmful event associated with adverse outcomes. WILL-BLEED Score has the better performance in predicting severe-massive bleeding after CABG. The TRUST Score, although suboptimal, represents a valuable alternative in this setting.

Macro-Economic Variables and Stock Market Performance: Empirical Evidence from Colombo Stock Exchange

Stock market performance is considered as a significant indicator of financial and economic circumstances of a country. In a nutshell, a secured and regulated financial environment is being provided by the stock market where shares can be transacted at lower operational risk. The stock market also functions as a platform through savings, and investments of individuals are channelized into productive investment proposals. It allows capital formation and economic growth for the nation. The ultimate objective of this study is to examine the impact of macroeconomic variables on stock market performance. The macroeconomic variables (independent variables) used in this research study are Inflation, Interest Rate, and GDP. Stock market performance (All-Share Price Index) is the dependent variable. 120 Monthly observations from January 2009 to December 2018 had been taken for the study. The Augmented Dickey Fuller’s unit root test, Ordinary Least Squares Regression and Correlation analysis were applied to the variables. The results of correlation analysis indicated that inflation and Stock market performance are positively associated meanwhile interest rate, and GDP and Stock market performance are negatively correlated. The Ordinary Least Square results showed that nearly 75% of the variation in all share price index is explained by the three macroeconomic variables, GDP, TB and WPI. The study suggested some of the possible reasons for the positive impact of Inflation on the Colombo Stock market performance, and negative impact of Interest Rate on Stock market performance and recommended that efforts should be made to improve the Stock market performance.

Surgical Therapy for Patients with Severe Aortic Stenosis in the Era of Transcatheter Aortic Valve Replacement.

Aortic stenosis (AS) is the most common valvular heart disease and is most frequently recognized among elderly people. Surgical aortic valve replacement (SAVR) is the most effective therapy, but its indication is sometimes difficult, and is impossible for high operative risk patients. Transcatheter aortic valve replacement (TAVR) was recently approved in Japan for high risk and inoperable patients with severe AS. TAVR is a less invasive method because it does not require a cardiopulmonary bypass and is associated with excellent surgical outcomes. In Western countries, the indication of TAVR has already been extended to moderate operative risk patients with severe AS, and is going to be further extended to low risk patients. The number of patients undergoing TAVR is increasing progressively, and there are effective alternative therapies for patients with severe AS. Selection of these surgical methods will be important in the near future. In regard to low operative risk patients especially, not only operative mortality, but also long-tern mortality and morbidity and quality of life should be taken into consideration. It is considered that some comorbidities in AS patients will be revealed to have an impact on surgical outcomes at the time when these surgical methods are selected. In this review, we examine end-stage renal disease on hemodialysis, functional tricuspid regurgitation, and sigmoid septum, and give an outline of what influence SAVR and TAVR have on the surgical outcomes of severe AS patients.

Comparison of Survival of Transfemoral Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement for Aortic Stenosis in Low-Risk Patients Without Coronary Artery Disease

Increasing data support transcatheter aortic valve implantation (TAVI) as a valid option over surgical aortic valve replacement (SAVR) in the treatment for severe aortic stenosis (AS) also in patients with low operative risk. However, limited data exist on the outcome of TAVI and SAVR in low-risk patients without coronary artery disease (CAD). The FinnValve registry included data on 6463 patients who underwent TAVI or SAVR with bioprosthesis between 2008 and 2017. Herein, we evaluated the outcome of low operative risk as defined by STS-PROM score <3% and absence of CAD, previous stroke and other relevant co-morbidities. Only patients who underwent TAVI with third-generation prostheses and SAVR with Perimount Magna Ease or Trifecta prostheses were included in this analysis. The primary endpoints were 30-day and 3-year all-cause mortality. Overall, 1,006 patients (175 TAVI patients and 831 SAVR patients) met the inclusion criteria of this analysis. Propensity score matching resulted in 140 pairs with similar baseline characteristics. Among these matched pairs, 30-day mortality was 2.1% in both TAVI and SAVR cohorts (p = 1.00) and 3-year mortality was 17.0% after TAVI and 14.6% after SAVR (p = 0.805). Lower rates of bleeding and atrial fibrillation, and shorter hospital stay were observed after TAVI. The need of new permanent pacemaker implantation and the incidence of early stroke did not differ between groups. In conclusion, TAVI using third-generation prostheses achieved similar early and mid-term survival compared with SAVR in low-risk patients without CAD.

P1851Long-term outcomes of transcatheter versus surgical aortic valve replacement in low risk, elderly patients with severe aortic stenosis

Abstract Background Although surgical aortic valve replacement (SAVR) is recommended for symptomatic severe aortic stenosis (AS) patients at low surgical risk, there is a growing need for an expansion of transcatheter aortic valve replacement (TAVR) as an alternative to SAVR for elderly AS patients at low operative risk. Purpose We tried to compare the long-term clinical outcomes of TAVR versus SAVR in elderly AS patients (≥80 years old) at low surgical risk. Methods We consecutively enrolled 261 elderly patients (131 men; 83±3 years of age) with symptomatic severe AS and EuroSCORE II &lt;4%, who underwent SAVR or TAVR from 2010 to 2018. Heart Team made the decision between SAVR and TAVR according to the individual patient's preference and characteristics. SAVR was performed on 93 patients (SAVR group), whereas TAVR was chosen for 168 patients (TAVR group). The primary end point was cardiac mortality including procedure-related death, and the secondary end point was all-cause death and cardiovascular event. Results Baseline characteristics were similar between the two groups, but the TAVR group was significantly older than the SAVR group (83±3 vs 82±2 years; p&lt;0.01). Device was successfully implanted in all the patients and there was 1 in-hospital mortality in the TAVR group and 3 in-hospital mortalities in the SAVR group (p=0.13). During a median follow-up of 24 months (IQR, 9–45 months), there were 22 deaths (13.1%) including 8 cardiac deaths (4.8%) in the TAVR group and 16 deaths (17.2%) including 9 cardiac deaths (9.7%) in the SAVR group. The rates of the primary and secondary end points were similar between two groups in the overall cohort and the propensity score-matched cohort (table). On subgroup analysis according to the presence of coronary artery disease (CAD), the only independent variable associated with cardiac mortality, the SAVR group had a significantly higher cardiac mortality rate than the TAVR group (15±7% vs 7±6% at 5 years, p=0.048) in 185 (71%) patients without CAD, whereas there was no significant difference among those with CAD. Harzard ratio for clinical outcomes TAVR (n=168) SAVR (n=93) Overall cohort TAVR (n=76) SAVR (n=76) PS-matched cohort HR (95% CI) p value HR (95% CI) p value Cardiac mortality 8 9 0.65 (0.25–1.71) 0.386 2 7 0.34 (0.07–1.61) 0.173 All-cause mortality 22 16 1.08 (0.56–2.08) 0.831 6 12 0.86 (0.30–2.43) 0.774 Cardiovascular event* 18 12 1.09 (0.52–2.28) 0.826 6 10 0.72 (0.26–1.98) 0.525 *Cardiovascular event was defined as the composite of cardiac mortality, hospitalization for heart failure, stroke, myocardial infarction, and reoperation. Conclusion In elderly AS patients at low surgical risk, TAVR was similar to SAVR with respect to long-term clinical outcomes. TAVR should be considered a treatment option for elderly patients who refuse to undergo surgery despite low risk.

Expanding the indications for transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of symptomatic severe aortic valve stenosis. Current guidelines recommend TAVI in patients at increased operative risk of death. Advanced imaging planning, new transcatheter valve platforms, procedure streamlining and growing operator experience have improved procedural safety and bioprosthetic valve performance. As a result, TAVI has been explored for other indications. Two randomized trials published in 2019 to assess TAVI in patients with symptomatic severe aortic stenosis at low operative risk have set the stage for a new wave of indications. Inyounger and low-risk patients, TAVI had an early safety benefit over surgical aortic valve replacement and was associated with faster discharge from hospital and recovery and fewer rehospitalizations. In patients with symptomatic severe aortic stenosis, TAVI has now been explored across the entire spectrum of operative risk, from inoperable to low-risk populations, in properly designed, randomized clinical trials, although data on the long-term durability of these valves are lacking. The use of TAVI in severe bicuspid aortic valve stenosis, asymptomatic severe aortic stenosis, moderate aortic stenosis in combination with heart failure with reduced ejection fraction, and isolated pure aortic regurgitation is now under investigation in clinical trials. In this Review, we provide our perspective on these evolving indications for TAVI, discuss relevant available data from clinical trials, and highlight procedural implications and caveats of new and future indications.

Pulmonary Artery Resection During Lung Resection for Malignancy

Complete resection of central tumors invading the main pulmonary artery (PA) requires arterial reconstruction to avoid pneumonectomy. Oncologic equivalence with pneumonectomy has been suggested. We review clinical selection and outcome for these uncommon procedures in the context of candidacy for pneumonectomy. From 2000 to 2018, 9 different surgeons performed 34 pulmonary arterial resections for primary or metastatic pulmonary malignancy, with independent determination of pneumonectomy candidacy and arterioplasty technique. Patients undergoing limited lateral stapled PA resection (n= 3) or resection for metastasis (n= 3) were excluded from survival analysis. The PA was resected as a sleeve with primary anastomosis (14.7%) or noncircumferentially with primary (61.8%), stapled (8.8%), or patch (14.7%) closure. Arterial resections represented between 2.5% and 43% of each surgeon's pneumonectomy volume. Sixteen (47%) patients were candidates for pneumonectomy. There was no operative mortality and 1 death at 47 days. Postoperative complications occurred in 21 (61.8%) patients. No patient required completion pneumonectomy. Overall 5-year survival was 33% (95% confidence interval [CI], 12-53). Compared with pulmonary arterioplasty alone, patients undergoing bronchial sleeve resection and pulmonary arterioplasty had better disease-free 5-year survival (50% [95% CI, 18-82] vs 19% [95% CI, 5-43]; P= .04), higher complete resection rate (100% [95% CI, 83-100] vs 80% [95% CI, 56-94]; P= .23) and lower disease recurrence (8% [n= 1 of 13] vs 47% [n= 7 of 15]; P= .04); 80% of disease recurrence was distant. Resection and reconstruction of the PA for malignant lung disease may be safely performed. In candidates for pneumonectomy, arterial resection offers low operative risk. Long-term survival is impaired by distant, not local, recurrence emphasizing the importance of systemic therapy.

Board busyness, performance and financial stability: does bank type matter?

ABSTRACTThis study examines the impact of board busyness (i.e. multiple directorships of outside board members) on the performance and financial stability of banks in a dual banking system (Islamic and conventional). We consider banks from 14 countries for the period 2010–2015. The results provide strong evidence that conventional banks with busy boards exhibit high bank performance (i.e. high profitability and low cost to income) and greater financial stability (i.e. low insolvency risk, credit risk, liquidity risk, asset risk, and operational risk). These findings are in line with the reputation hypothesis, which asserts that the expertise and connections of busy outside directors lead to better decision making, more efficient resource utilisation and more effective monitoring. In contrast, Islamic banks’ performance and stability are adversely affected by the presence of busy board members, with Islamic banks show low profitability, high cost to income and high risk-taking. This result might be attributed to the complex governance structure of Islamic banks and the uniqueness of their financial products, which require additional effective monitoring.

Comparison of Outcomes After Transcatheter Aortic Valve Replacement vs Surgical Aortic Valve Replacement Among Patients With Aortic Stenosis at Low Operative Risk

Transcatheter aortic valve replacement (TAVR) has been shown to be a valid alternative to surgical aortic valve replacement (SAVR) in patients at high operative risk with severe aortic stenosis (AS). However, the evidence of the benefits and harms of TAVR in patients at low operative risk is still scarce. To compare the short-term and midterm outcomes after TAVR and SAVR in low-risk patients with AS. This retrospective comparative effectiveness cohort study used data from the Nationwide Finnish Registry of Transcatheter and Surgical Aortic Valve Replacement for Aortic Valve Stenosis of patients at low operative risk who underwent TAVR or SAVR with a bioprosthesis for severe AS from January 1, 2008, to November 30, 2017. Low operative risk was defined as a Society of Thoracic Surgeons Predicted Risk of Mortality score less than 3% without other comorbidities of clinical relevance. One-to-one propensity score matching was performed to adjust for baseline covariates between the TAVR and SAVR cohorts. Primary TAVR or SAVR with a bioprosthesis for AS with or without associated coronary revascularization. The primary outcomes were 30-day and 3-year survival. Overall, 2841 patients (mean [SD] age, 74.0 [6.2] years; 1560 [54.9%] men) fulfilled the inclusion criteria and were included in the analysis; TAVR was performed in 325 patients and SAVR in 2516 patients. Propensity score matching produced 304 pairs with similar baseline characteristics. Third-generation devices were used in 263 patients (86.5%) who underwent TAVR. Among these matched pairs, 30-day mortality was 1.3% after TAVR and 3.6% after SAVR (P = .12). Three-year survival was similar in the study cohorts (TAVR, 85.7%; SAVR, 87.7%; P = .45). Interaction tests found no differences in terms of 3-year survival between the study cohorts in patients younger than vs older than 80 years or in patients who received recent aortic valve prostheses vs those who did not. Transcatheter aortic valve replacement using mostly third-generation devices achieved similar short- and mid-term survival compared with SAVR in low-risk patients. Further studies are needed to assess the long-term durability of TAVR prostheses before extending their use to low-risk patients.

The industry effect and the decision to integrate vertically in a crisis context

ABSTRACTThe objective of this work is twofold: firstly, to study if the characteristics of the industry affect certain financial and strategic decisions of manufacturing firms and, secondly, to determine if the strategy of diversifying the activity through vertical integration generates good financial results in times of crisis, depending on the industry. To this end, an analysis is carried out with panel data from 9,523 firms in the period between 2008 and 2013. The results show that there are different strategies that firms must follow, depending on the industry to which they belong. In sectors with lower operational risk, those firms characterized by greater specificity and better product quality obtained higher profitability. However, in riskier sectors, firms with more specific assets assumed too many risks and in times of crisis have seen their profitability fall. Likewise, it is observed that the decision to integrate vertically has mitigated the weak points of each sector, allowing firms to better weather the economic–financial crisis in which this research is framed.

TAVR versus surgery in low-risk patients.

The Evolut Low Risk trial and the PARTNER 3 trial both show that transcatheter aortic valve replacement is at least equivalent to surgery in terms of efficacy and safety for patients with severe aortic stenosis at low operative risk.

Giant coronary aneurysms producing chest pain

BackgroundCoronary artery aneurysms (CAA) are defined as localized coronary artery dilations more than 1.5 times the diameter of the adjacent segments [1]. Giant coronary aneurysms (GCAA) are unusual and aneurysms on the left side are even rarer. Mechanisms are unclear, but seem predominated by atherosclerosis. Until now, management of giant coronary aneurysm is still unclear.Case presentationA 62-year-old man, presented a 4-month history of progressive chest pain aggravated by physical CAAs: 3 on the right coronary artery (RCA), including a giant one, and one on the intermediate branch. Intraoperatively, we found two proximal RCA CAAs of 2 cm each, a 6 cm distal RCA CAA partially thrombosed, and a 3 cm CAA on the intermediate branch.The two largest CAAs were resected and two saphenous graft bypasses were performed.ConclusionsTreatment options include medical treatment (antiaggregation, anticoagulation), percutaneous coronary angioplasty and surgery. Results of observational or conservative management in the few cases of GCAA described in literature, appear to have poor results. Surgery is a good option with low operative risk, especially in giant coronary aneurysms.

Valve-sparing root replacement and composite valve graft replacement in patients with aortic regurgitation: From the Japan Cardiovascular Surgery Database

ObjectivesThe advantage of valve-sparing root replacement (VSRR) over aortic root replacement with a composite valve graft (CVG) remains unclear. We compared these 2 procedures with regard to early outcomes with propensity score matching using the Japan Cardiovascular Surgery Database. MethodsOf 5303 patients from the Japan Cardiovascular Surgery Database who had undergone aortic root replacement in 2008 to 2017, emergent/urgent or redo cases and those with infective endocarditis or aortic stenosis were excluded (included n = 3841). Two propensity score–matched groups treated with VSRR or CVG replacement (n = 1164 each) were established. ResultsOverall, VSRR was more frequently performed for younger patients with Marfan syndrome with lower operative risk and aortic regurgitation grade compared with CVG replacement. After matching, a weaker but similar trend still existed in baseline characteristics. Although more concomitant procedures were performed in the CVG group, myocardial ischemia and cardiopulmonary bypass time was significantly longer in the VSRR group (median, 193 and 245 minutes) than the CVG group (172 and 223 minutes, both P < .01). The CVG group was associated with a significantly greater incidence of postoperative stroke (2.5% vs 1.1%, P = .01) and prolonged ventilation >72 hours (7.0% vs 4.6%, P = .02). In-hospital mortality rates were significantly greater in the CVG group (1.8%) than the VSRR group (0.8%, P = .02). ConclusionsIn overall Japanese institutions, VSRR was more frequently performed for patients at low risk and was associated with better morbidity and mortality rates than CVG replacement. After matching, VSRR was also associated with better morbidity and mortality rates despite longer procedure time.

Impact of transfer status on real-world outcomes in nonelective cardiac surgery

ObjectiveTransfer from hospital to hospital for cardiac surgery represents a large portion of some clinical practices. Previous literature in other surgical fields has shown worse outcomes for transferred patients. We hypothesized that transferred patients would be higher risk and demonstrate worse outcomes than those admitted through the emergency department. MethodsAll patients undergoing cardiac operations with a Society of Thoracic Surgeons Predicted Risk of Mortality were evaluated from a multicenter, statewide Society of Thoracic Surgeons database. Only patients requiring admission before surgery were included. Patients were stratified by admission through the emergency department or in transfer. Transfers were further stratified by the cardiothoracic surgery capabilities at the referring center. ResultsA total of 13,094 patients met the inclusion criteria of admission before surgery. This included 7582 (57.9%) transfers, of which 502 (6.6%) were referred from cardiac centers. Compared with emergency department admissions, transfers had increased hospital costs despite lower operative risk (Predicted Risk of Mortality 1.5% vs 1.6%, P < .01) and equivalent postoperative morbidity (15.6% vs 15.3% P = .63). In risk-adjusted analysis, transfer status was not independently associated with worse outcomes. Patients transferred from centers that perform cardiac surgery are higher risk than general transfers (Predicted Risk of Mortality 2.5% vs 1.5, P < .01), but specialized care results in excellent risk-adjusted outcomes (observed/expected: mortality 0.81; morbidity or mortality 0.90). ConclusionsTransfer patients have similar rates of postoperative complications but increased resource use compared with patients admitted through the emergency department. Patients transferred from centers that perform cardiac surgery represent a particularly high-risk subgroup.

Hepatic Resection for Isolated Breast Cancer Liver Metastasis; Single Center Experience

Background: Liver metastases occur frequently in women with metastatic breast cancer, but metastatic breast cancer almost associated with extrahepatic metastasis. Hepatic metastases without extrahepatic metasases are 4-5% of metastatic breast cancer, and the available treatments are limited and ineffective. The aim of this study is to review the outcome of selected patients with BCLM after hepatic resection. Methods: Between 2011 and 2014, 6 patients underwent hepatic resection for BCLM. All patients received hepatic resection to achieve an R0 resection. The patients without extrahepatic disease in imaging study, was selected for hepatic resection. If R0 resection available and low operative risk in preoperative tests, the patients underwent surgery. Results: The time interval between initial breast cancer and detection of liver metastases excluding 1 patients with synchronous metastases was 55.2 months. Major liver resection was performed in 4 patients. There was difference in hormone receptor status between primary breast cancer and liver metastases, but no difference in HER-2 status. The 1-year and 3-year overall and disease free survival rates after hepatic resection were 100%, 83.3% and 66.7%, 50.0%. Conclusion: Curative resection of breast cancer liver metastasis may be considered as one of a multimodal treatment of the metastatic disease. It has benefit for a few patients, and should be needed absolute selection criteria.

Hepatic resection for isolated breast cancer liver metastasis; single center experience

Background: Liver metastases occur frequently in women with metastatic breast cancer, but metastatic breast cancer almost associated with extrahepatic metastasis. Hepatic metastases without extrahepatic metasases are 4-5% of metastatic breast cancer, and the available treatments are limited and ineffective. The aim of this study is to review the outcome of selected patients with BCLM after hepatic resection. Methods: Between 2011 and 2014, 6 patients underwent hepatic resection for BCLM. All patients received hepatic resection to achieve an R0 resection. The patients without extrahepatic disease in imaging study, was selected for hepatic resection. If R0 resection available and low operative risk in preoperative tests, the patients underwent surgery. Results: The time interval between initial breast cancer and detection of liver metastases excluding 1 patients with synchronous metastases was 55.2 months. Major liver resection was performed in 4 patients. There was difference in hormone receptor status between primary breast cancer and liver metastases, but no difference in HER-2 status. The 1-year and 3-year overall and disease free survival rates after hepatic resection were 100%, 83.3% and 66.7%, 50.0%. Conclusion: Curative resection of breast cancer liver metastasis may be considered as one of a multimodal treatment of the metastatic disease. It has benefit for a few patients, and should be needed absolute selection criteria.