Outcomes In Cardiac Surgery Research Articles

Effects of postoperative atrial fibrillation on cardiac surgery outcomes in Vietnam: a prospective multicenter study

ABSTRACT Background This study was designed to assess the impact of postoperative atrial fibrillation (POAF) on short- and long-term outcomes after cardiac surgery. Methods We prospectively assessed POAF concerning outcomes in 379 adult patients who had undergone cardiac surgery in two heart surgery centers with a follow-up period of one year for every patient. The effects of POAF on postoperative events were evaluated using Logistic regression, Cox regression (adjusted for propensity score), and Kaplan-Meier analysis. Results The incidence of POAF was 27.2%. Multivariable logistic regression analysis revealed POAF was associated with an increased risk of 6-month (OR = 5.36; CI: 1.51–18.94; p = 0.009), and 1-year mortality (OR = 4.56; CI: 1.29–16.04; p = 0.018) as well as Major Adverse Cardiocerebral Events (MACEs; acute MI, cardiac arrest, low cardiac output after surgery, third-degree atrioventricular block or stroke; OR = 3.02; CI: 1.29–7.05; p = 0.011), Intensive Care Unit (ICU) stay > 3 days (OR = 2.39; CI: 1.14–5.00; p = 0.021), and postoperative stay > 14 days (OR = 3.12; CI: 1.65–5.90; p < 0.001). Multivariable Cox regression analysis showed POAF as an independent predictor of mortality at one year (HR = 2.86; CI: 1.05–7.75; p = 0.038). Discharge plans including statin and beta-blocker had an independent association with a reduced mortality at one year (HR = 0.22; CI: 0.05–0.96; p = 0.045; HR = 0.16; CI: 0.03–0.87; p = 0.034, respectively). Conclusions POAF is associated with an increased risk of morbidity, all-cause mortality, and hospital duration. Statins and beta-blockers that were included in discharge plans had an independent association with reduction in 1-year all-cause mortality.

Evaluation of the Effects of an Extubation Protocol With Neostigmine on Duration of Mechanical Ventilation After Cardiac Surgery

Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. This study aimed to evaluate the effect of an extubation protocol incorporating neuromuscular blockade reversal (NMBR) by train-of-four monitoring on "fast-track" cardiac surgery outcomes. A retrospective cohort study. At a university hospital. Out of 1,843 cardiac surgery patients, from February 2, 2015, to March 31, 2017, 957 (52%) underwent cardiac surgery on or after February 29, 2016. An extubation protocol, comprised of weaning from mechanical ventilation and NMBR guidelines, was implemented on February 29, 2016. The associations of baseline characteristics with the postoperative duration of mechanical ventilation (primary outcome) and respiratory and/or adverse complications (secondary outcomes) were evaluated using regression and interrupted- time series models. The implementation of an extubation protocol was associated with an 18% decrease in the duration of mechanical ventilation (incident rate ratio [IRR] 0.82, 95% CI 0.72-0.94; p < 0.01), statistically insignificant 26% increase in patients extubated ≤6 hours (odds ratio [OR] 1.26, 95% CI 0.97-1.65; p=0.09), and 13% shorter intensive care unit length of stay (LOS) (IRR 0.87, 95% CI 0.79-0.97; p < 0.01). Patients undergoing isolated coronary artery bypass graft or isolated valve procedures, on or after February 29, 2016, had decreased extubation times (IRR 0.82, p < 0.01 and IRR 0.80, p=0.02). The protocol did not have a statistically significant association with hospital LOS (IRR 0.98, p=0.57) or readmission (OR 1.22, p=0.33), and differences in the occurrence of pulmonary complications and adverse outcomes between the pre- and postprotocol groups were clinically insignificant. The application of an extubation protocol incorporating NMBR based on neuromuscular monitoring was associated with a decrease in postoperative duration of mechanical ventilation and facilitated more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.

A szív- és érrendszeri betegségek és a pszichoszociális tényezők kapcsolata, valamint a beavatkozás lehetőségei

Coronary artery disease is a highly prevalent heart disease and the leading cause of morbidity and mortality in developed countries. During the last decades, numerous studies have focused on the comprehension of the relationship between coronary heart disease and different psychosocial factors. Coronary artery bypass graft surgery is a common treatment for coronary artery disease and is usually associated with improved clinical outcomes. Symptoms of anxiety and unipolar depression are common psychological disorders in patients awaiting coronary artery bypass graft surgery. Several prospective cohort studies have been carried out on the factors affecting the short- and long-term outcome of coronary artery bypass graft surgery. Scientific literature reports that not only clinical features, e.g., cardial state, comorbidity or intraoperative factors influence the outcome of cardiac surgery. In a comprehension of psychosocial factors over traditional risk factors (hypertension, LDL cholesterol level, diabetes mellitus, smoking, obesity and physical inactivity) on morbidity and mortality rates, the previously mentioned ones proved to be determinant. Gathering patients' psychological status before undergoing heart surgery and providing psychological interventions if they are indicated would be beneficial. A better understanding of whether and when psychological interventions affect specific outcomes may help design even more powerful interventions and make better predictions of which patients will benefit from which psychological intervention. Psychological assessment and intervention thus merit integration into routine surgical care. Orv Hetil. 2023; 164(11): 411-419.

The beneficial role of simple inflammatory blood indices in pediatric cardiology.

Simple whole blood analysis can effectively demonstrate complex changes in inflammatory responses to cardiovascular disorders in adults and enable the prediction of adverse outcomes or diminished survival. Such inflammatory activation has also been detected in the pediatric population. Blood analysis results are repeatable and readily available, which gives the method an advantage over others. Inflammatory phenomena such as a high leukocyte count and an increased neutrophil-to-lymphocyte ratio (NLR) are related to a poor prognosis of advanced heart defects and worse outcomes after pediatric cardiac surgery in the advanced stages of the disease. Surgery-associated inflammation exacerbates these diseases, and the inflammatory response may further complicate the postoperative period. Simple blood cell counts and indices may be beneficial for evaluating cardiac surgery outcomes and cardiovascular disorder prognosis in infants and children. This review summarizes current knowledge on inflammatory markers in pediatric cardiovascular diseases and surgery.

Cardiac Surgery Outcomes During the COVID-19 Pandemic Worsened Across All Socioeconomic Statuses

BackgroundIncreasing socioeconomic distress has been associated with worse cardiac surgery outcomes. The extent to which the pandemic affected cardiac surgical access and outcomes remains unknown. We sought to examine the relationship between the COVID-19 pandemic and outcomes after cardiac surgery by socioeconomic status. MethodsAll patients undergoing a Society of Thoracic Surgeons (STS) index operation in a regional collaborative, the Virginia Cardiac Services Quality Initiative (2011-2022), were analyzed. Patients were stratified by timing of surgery before vs during the COVID-19 pandemic (March 13, 2020). Hierarchic logistic regression assessed the relationship between the pandemic and operative mortality, major morbidity, and cost, adjusting for the Distressed Communities Index (DCI), STS predicted risk of mortality, intraoperative characteristics, and hospital random effect. ResultsA total of 37,769 patients across 17 centers were included. Of these, 7269 patients (19.7%) underwent surgery during the pandemic. On average, patients during the pandemic were less socioeconomically distressed (DCI 37.4 vs DCI 41.9; P < .001) and had a lower STS predicted risk of mortality (2.16% vs 2.53%, P < .001). After risk adjustment, the pandemic was significantly associated with increased mortality (odds ratio 1.398; 95% CI, 1.179-1.657; P < .001), cost (+$4823, P < .001), and STS failure to rescue (odds ratio 1.37; 95% CI, 1.10-1.70; P = .005). The negative impact of the pandemic on mortality and cost was similar regardless of DCI. ConclusionsAcross all socioeconomic statuses, the pandemic is associated with higher cost and greater risk-adjusted mortality, perhaps related to a resource-constrained health care system. More patients during the pandemic were from less distressed communities, raising concern for access to care in distressed communities.

Clinical stakeholder preferences for paediatric cardiac surgery outcome reporting in Australia and New Zealand.

Outcome reporting is an essential element of quality assurance. Evaluation of the information needs of stakeholders of outcome reporting is limited. This study aimed to examine stakeholder preferences for the content, format, and dissemination of paediatric cardiac surgery performance data in Australia and New Zealand. Semi-structured interviews were completed with a purposive sample of Queensland stakeholders to evaluate their attitudes and expectations regarding reporting of paediatric cardiac surgery outcomes. The interviews were audio-recorded and transcribed. Two researchers used an interpretive description approach to analyse the transcripts qualitatively. Nineteen stakeholders were interviewed including fifteen clinicians, four parents, one hospital administrator, and one consumer advocate were interviewed. Mortality was highlighted as the area of greatest interest in reports by clinical and consumer groups. The majority preferred hospital rather than individual/clinician-level reporting. Annual reports were preferred by clinicians who requested reports be distributed electronically. The evidence generated from outcome reporting in paediatric cardiac surgery is highly desired by clinicians, administrators, parents, families, and advocacy groups. Clinical users prefer information to assist in clinical decision-making, while families seek personalised information at crucial time points in their clinical journey.

Con: Modified Ultrafiltration Should Not Be Routinely Used in Adult Cardiac Surgery

CARDIOPULMONARY BYPASS (CPB) is known to induce a systemic proinflammatory state and may contribute to postoperative organ dysfunction, primarily through complement activation secondary to blood passing through an artificial extracorporeal circuit. 1 Hall RI Smith MS Rocker G. The systemic inflammatory response to cardiopulmonary bypass: Pathophysiological, therapeutic, and pharmacological considerations. Anesth Analg. 1997; 85: 766-782 Crossref PubMed Google Scholar , 2 Wang W Huang HM Zhu DM et al. Modified ultrafiltration in paediatric cardiopulmonary bypass. Perfusion. 1998; 13: 304-310 Crossref PubMed Scopus (39) Google Scholar , 3 Thapmongkol S Masaratana P Subtaweesin T et al. The effects of modified ultrafiltration on clinical outcomes of adult and pediatric cardiac surgery. Asian Biomedicine. 2015; 9: 591-599 Crossref Scopus (4) Google Scholar Ultrafiltration may minimize some of the impact of the CPB-induced systemic inflammatory response. 4 Huang H Yao T Wang W et al. Continuous ultrafiltration attenuates the pulmonary injury that follows open heart surgery with cardiopulmonary bypass. Ann Thorac Surg. 2003; 76: 136-140 Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Traditionally, ultrafiltration may be conventional (CUF) or modified (MUF). Conventional ultrafiltration has been employed extensively during CPB, and involves hemoconcentration of both the priming volume and patient's blood volume at any point during CPB. 5 Darup J Bleese N Kalmar P et al. Hemofiltration during extracorporeal circulation (ECC). Thorac Cardiovasc Surg. 1979; 27: 227-230 Crossref PubMed Scopus (30) Google Scholar ,6 Klineberg PL Kam CA Johnson DC et al. Hematocrit and blood volume control during cardiopulmonary bypass with the use of hemofiltration. Anesthesiology. 1984; 60: 478-480 Crossref PubMed Scopus (19) Google Scholar In the early 1990s, Naik et al. introduced the concept of MUF 7 Elliott MJ. Ultrafiltration and modified ultrafiltration in pediatric open heart operations. Ann Thorac Surg. 1993; 56: 1518-1522 Abstract Full Text PDF PubMed Scopus (205) Google Scholar ,8 Andreasson S Gothberg S Berggren H et al. Hemofiltration modifies complement activation after extracorporeal circulation in infants. Ann Thorac Surg. 1993; 56: 1515-1517 Abstract Full Text PDF PubMed Scopus (88) Google Scholar ,9 Naik SK Knight A Elliott MJ. A successful modification of ultrafiltration for cardiopulmonary bypass in children. Perfusion. 1991; 6: 41-50 Crossref PubMed Scopus (164) Google Scholar in which the patient's blood volume is hemoconcentrated after separation from CPB. 10 Wang S Palanzo D Undar A. Current ultrafiltration techniques before, during and after pediatric cardiopulmonary bypass procedures. Perfusion. 2012; 27: 438-446 Crossref PubMed Scopus (40) Google Scholar Naik et al. postulated it may permit blood-free cardiac surgery. 11 Naik SK Knight A Elliott M. A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery. Circulation. 1991; 84 (III422-31) PubMed Google Scholar Blood is typically removed from the arterial cannula and returned through the venous cannula. Others employ a modified technique in which blood is removed from the right atrium and infused into the aorta, potentially reducing concerns about cerebral shunting. 12 Myers GJ Leadon RB Mitchell LB et al. Simple modified ultrafiltration. Perfusion. 2000; 15: 447-452 Crossref PubMed Scopus (16) Google Scholar

24th hour vasoactive inotrope score is associated with poor outcome in adult cardiac surgery.

The aim of this study was to investigate the efficacy of vasoactive inotrope score at the 24th postoperative hour for mortality and morbidity in elective adult cardiac surgery. Consecutive patients who underwent elective adult coronary artery bypass and valve surgery in a single tertiary center for cardiac surgery between December 2021 and March 2022 were prospectively included. The vasoactive inotrope score was calculated with the dosage of inotropes that were continuing at the 24th postoperative hour. Poor outcome was defined as any event of perioperative mortality or morbidity. The study included 287 patients, of whom 69 (24.0%) were on inotropes at the 24th postoperative hour. The vasoactive inotrope score was higher (21.6±22.5 vs. 0.94±2.7, p=0.001) in patients with poor outcome. One unit increase in the vasoactive inotrope score had an odds ratio of 1.24 (95% confidence interval: 1.14-1.35) for poor outcome. The receiver operating characteristic curve of vasoactive inotrope score for poor outcome had an area under the curve of 0.857. Vasoactive inotrope score at the 24th hour can be a very valuable parameter for risk calculation in the early postoperative period.

Short- and Long-Term Outcomes of Cardiac Surgery in Kidney Transplant Recipients: A Review&amp;lt;br/&amp;gt;—Kidney Transplant and Cardiac Surgery

Short- and Long-Term Outcomes of Cardiac Surgery in Kidney Transplant Recipients: A Review&amp;lt;br/&amp;gt;—Kidney Transplant and Cardiac Surgery

Effect of Blood Transfusion on the Outcome of Cardiac Surgery Patients at Benghazi Medical Center (2014-2017)

Background: The effect of blood transfusion on cardiac surgery patients is dependent on other factors such as demographics, type of open heart surgery and hemoglobin level before surgery.&#x0D; Aims: to determine the risk factors that lead to a blood transfusion during cardiac surgery, and to find out the effect of blood transfusion on mortality in cardiac surgery patients.&#x0D; Methods: A cross-sectional survey study that included 240 patients who underwent cardiac surgery between 2014 and 2017 in Benghazi. All the data was collected from adults (≥ 18 years). The association between blood transfusion in patients of cardiac surgery and other pre-operative variables was assessed using the Chi-square test. Descriptive statistics such as mean, mode, median and standard deviation were used.&#x0D; Results: The database included 240 patients whose mean age was 57.9 ± 11.5 years and the male-to-female ratio was 2:1. 197 (82%) patients underwent a coronary artery bypass graft, 178 (74.2%) were anemic, and 74 (30.8%) patients received blood. The mortality rate was 9.2%. The outcome of surgery according to blood was statistically significant( p&lt; 0.003).&#x0D; Conclusion: The outcome of cardiac surgery is affected by blood transfusion. There is no relation between blood transfusion and other factors ( age, sex, type of surgery, hemoglobin level of patients) in cardiac surgery

Platelet Transfusion After Cardiac Surgery

To investigate the independent association of platelet transfusion with hospital mortality and key relevant clinical outcomes in cardiac surgery. A single-center, propensity score-matched, retrospective, cohort study. At an American tertiary teaching hospital data from the Medical Information Mart for Intensive Care III and IV databases from 2001 to 2019. Consecutive adults undergoing coronary artery bypass graft and/or cardiac valvular surgery. Platelet transfusion during perioperative intensive care unit (ICU) admission. Overall, 12,043 adults met the study inclusion criteria. Of these, 1,621 (13.5%) received apheresis-leukoreduced platelets, with a median of 1.19 units per recipient (IQR: 0.93-1.19) at a median of 1.78 hours (IQR: 0.75-4.25) after ICU admission. The platelet count was measured in 1,176 patients (72.5%) before transfusion, with a median count of 120×109/L (IQR: 89.0-157.0), and only 53 (3.3%) had platelet counts below 50×109/L. After propensity matching of 1,046 platelet recipients with 1,046 controls, perioperative platelet transfusion carried no association with in-hospital mortality (odds ratio [OR]: 1.28; 99% CI: 0.49-3.35; p=0.4980). However, it was associated with a pattern of decreased odds of suspected infection (eg, respiratory infection, urinary tract infection, septicaemia, or other; OR: 0.70; 99% CI: 0.50-0.97; p=0.0050), days in the hospital (adjusted mean difference [AMD]: 0.86; 99% CI: -0.27 to 1.98; p=0.048), or days in intensive care (AMD 0.83; 99% CI: -0.15 to 1.82; p=0.0290). Platelet transfusion was not associated with hospital mortality, but it was associated with decreased odds of suspected infection and with shorter ICU and hospital stays.

824 HEMODYNAMIC EFFECTS OF LEVOSIMENDAN IN PATIENTS WITH ACUTE HEART FAILURE AND SEVERE RENAL FAILURE

Abstract Background The inodilator levosimendan has shown improved outcomes in acute heart failure (AHF) and cardiac surgery. Its hemodynamic effect is persistent, owing to a long (70-80 hours) elimination half-life of its active metabolites. No robust data is available of the use of levosimendan in patients with severe renal failure (SRF), thus its use is contraindicated in patients with estimated glomerular filtration rate (eGFR≤30 mL/min). Hypothesis Different pharmacokinetics due to renal failure may alter levosimendan active metabolites elimination, causing more pronounced hemodynamic effects. We aimed to characterize the hemodynamic effect of levosimendan in a real-world cohort of SRF patients. Methods We reviewed patients who received levosimendan (12.5 mg) for AHF or cardiogenic shock in our CICU (N=132), excluding those without invasive hemodynamics (n=85), and those without data before and during levosimendan infusion (n=11), a total of 36 patients were finally included in this analysis. We compared hemodynamics before and during levosimendan infusion in the study cohort with CKD-EPI eGFR≤30 mL/min/1.73 m2 or CRRT and those without. Results Patients with low eGFR (n=11) were older, they had similar LVEF and invasive hemodynamics before levosimendan infusion to the higher eGFR cohort. Visual inspection of the LOESS regression plots (Figure) revealed an higher drop in mean arterial pressure (MAP) and diastolic arterial pressure (DAP) in the low eGFR cohort. The maximum drop was observed at day 4 from levosimendan initiation, invasive hemodynamics at this timepoint revealed a lower DAP (44.6±8.8 vs 62.6±11.9 mmHg; p=0.014) and a tendentially lower MAP (73.6±5.5 vs 84.4±11.5 mmHg; p=0.079) while systolic arterial pressure (125.0±24.6 vs 121.3±21.8 mmHg; p=0.779), cardiac index (2.1±0.5 vs 2.5±0.7 L/m2; p=0.211), and mean pulmonary arterial pressure (25.8±8.3 vs 24.8±9.6 mmHg; p=0.844) did not differ between groups. In-hospital death was not different in the two cohorts (27.3 vs 16.0%; p=0.650). Conclusions Patient with eGFR≤30 mL/min/1.73 m2 demonstrated a higher drop in DAP and MAP four days after levosimendan infusion start, without impact on hospital mortality. These findings may suggest a more pronounced hemodynamic effect of levosimendan in patients with SRF, possibly due to altered pharmacokinetics of its active metabolites.

1284: OUTCOMES FROM THE GIFT OF LIFE INTERNATIONAL SURGERY REGISTRY

Introduction: Of the 1.3 million children born with congenital heart disease annually, over 90% do not have access to cardiac care. Since 2020, Gift of Life International (GOLI) has collaborated with CEDIMAT Hospital in the Dominican Republic to perform pediatric cardiac surgery. With limited access to care and delayed surgical repair, this population is data rich in epidemiology, natural history, and clinical management strategies. There is limited research evaluating the outcomes of pediatric cardiac surgery in this middle-income country. Prior studies have raised concerns of limited published data and the need for an international database with better accountability and communication between charities being imperative for patient safety. Since 2021, GOLI has been collecting data for internal quality review. We hope this study will serve as a beacon for charitable organizations to provide quality cardiac surgery to children with limited access. Methods: Combined retrospective and prospective observational analysis of the GOLI Surgical Registry was performed. The registry was developed by GOLI team members, using definitions shared by the PC4 and STS databases for generalizability. All patients who underwent cardiac surgery with the GOLI team at CEDIMAT Hospital since March 2021 to date were included. Results: 55 subjects were identified. They were predominantly Hispanic females (55%) with a mean age at diagnosis of 1.9 years, and mean age at repair of 3.5 years. Primary diagnosis included ASD (9%), VSD (32%), PDA (11%), AV Canal (9%), Tetralogy of Fallot (16%), Single Ventricle (13%), and Coarctation (7%). Most common intraoperative complications were bleeding requiring transfusion (14%) and multiple CPB runs (7%). ICU complications included arrhythmias (17%), cardiac arrest (7%), LCOS (5%), and effusions requiring chest tube (5%). Mean duration of intubation was 17.8 hours with 2 reintubations. Mortality was 7.1%. Conclusions: Globally, there is limited access to cardiac care for children with CHD. While many organizations have tried to close this gap, there is little published data on the surgical outcomes in low/middle-income countries. This study demonstrates that emerging countries can safely perform cardiac surgery and track quality metrics in children with congenital heart disease.

A Randomized Trial of an Exclusive Human Milk Diet in Neonates with Single Ventricle Physiology

To determine whether weight gain velocity (g/kg/day) 30days after the initiation of feeds after cardiac surgery and other clinical outcomes improve in infants with single ventricle physiology fed an exclusive human milk diet compared with a mixed human and bovine diet. In this multicenter, randomized, single blinded, controlled trial, term neonates 7days of age or younger with single ventricle physiology and anticipated cardiac surgical palliation within 30days of birth were enrolled at 10 US centers. Both groups received human milk if fed preoperatively. During the 30days after feeds were started postoperatively, infants in the intervention group received human milk fortified once enteral intake reached 60mL/kg/day with a human milk-based fortifier designed for term neonates. The control group received standard fortification with formula once enteral intake reached 100mL/kg/day. Perioperative feeding and parenteral nutrition study algorithms were followed. We enrolled 107 neonates (exclusive human milk=55, control=52). Baseline demographics and characteristics were similar between the groups. The median weight gain velocity at study completion was higher in exclusive human milk vs control group (12g/day [IQR, 5-18g/day] vs 8g/day [IQR, 0.4-14g/day], respectively; P=.03). Other growth measures were similar between groups. Necrotizing enterocolitis of all Bell stages was higher in the control group (15.4 % vs 3.6%, respectively; P=.04). The incidence of other major morbidities, surgical complications, length of hospital stay, and hospital mortality were similar between the groups. Neonates with single ventricle physiology have improved short-term growth and decreased risk of NEC when receiving an exclusive human milk diet after stage 1 surgical palliation. This trial is registered with ClinicalTrials.gov (www. gov, Trial ID: NCT02860702).

Conventional Glycaemic Control May Not Be Beneficial in Diabetic Patients Following Cardiac Surgery

Stress hyperglycaemia is common following cardiac surgery. Its optimal management is uncertain and emerging literature suggests that flexible glycaemic control in diabetic patients may be preferable. This study aims to assess the relationship between maximal postoperative in-hospital blood glucose levels (BSL) and the morbidity and mortality outcomes of diabetic and non-diabetic cardiac surgery patients. A retrospective cohort analysis of all patients undergoing cardiac surgery at a tertiary single centre institution from 2015 to 2019 was undertaken. Early management and outcomes of hyperglycaemia following cardiac surgery were assessed via multivariable regression modelling. Follow-up was assessed to 1 year postoperatively. Consecutive non-diabetic patients (n=1,050) and diabetic patients (n=689) post cardiac surgery were included. Diabetics with peak BSL ≤13.9 mmol/L did not have an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. In non-diabetics, stress hyperglycaemia with peak BSL >10.0 mmol/L was associated with overall wound complications (5.7% vs 8.8%, OR 1.64 [1.00-2.69], p=0.049) and postoperative pneumonia (2.7% vs 7.3%, OR 2.35 [1.26-4.38], p=0.007). Diabetic patients with postoperative peak BSL >13.9 mmol/L were at an increased risk of overall wound complication (7.4% vs 14.8%, OR 2.47 [1.46-4.16], p<0.001), graft harvest site infection (3.7% vs 11.8%, OR 3.75 [1.92-7.30], p<0.001), and wound-related readmission (3.1% vs 8.8%, OR 3.11 [1.49-6.47], p=0.002) when compared to diabetics with peak BSL ≤13.9 mmol/L. In non-diabetics, stress hyperglycaemia with peak BSL >10.0 mmol/L is associated with morbidity. In diabetic patients, hyperglycaemia with peak BSL ≤13.9 mmol/L was not associated with an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. Further investigation of flexible glycaemic targets (target BSL ≤13.9 mmol/L) in diabetic patients is warranted.

Clinical presentation and in-hospital outcomes of intraoperative red blood cell transfusion in non-anemic patients undergoing elective valve replacement.

Intraoperative transfusion is associated with adverse clinical outcomes in cardiac surgery. However, few studies have shown the impact of intraoperative red blood cell (RBC) transfusion on non-anemic patients undergoing cardiac surgery. We assessed the in-hospital clinical outcomes of non-anemic patients undergoing isolated valve replacements and investigated the predictors associated with intraoperative RBC transfusion. We enrolled 345 non-anemic patients undergoing isolated valve replacements in our department from January 2015 to December 2019. The patients were stratified by the receipt of intraoperative RBC transfusion. Baseline characteristics were compared between groups and multiple logistic regression was used to identify the predictors for intraoperative RBC transfusion. The association between intraoperative RBC transfusion and in-hospital outcomes was also evaluated. Intraoperative RBC transfusion developed in 84 of the 345 enrolled patients (24.3%). Three independent predictors for intraoperative RBC transfusion of non-anemic patients undergoing isolated valve replacements were identified by multivariate logistic analysis, including female, iron deficiency and hemoglobin level. When the two groups were compared, a significant tendency of higher in-hospital mortality (6.0% vs. 1.1%, P = 0.033) and higher incidence of postoperative hypoxemia (9.5% vs. 2.7%, P = 0.007) were observed in the intraoperative RBC transfusion group. After adjustment, the presence of intraoperative RBC transfusion was associated with an increase in postoperative hypoxemia (OR = 3.36, 95% CI: 1.16-9.71, P = 0.026). Intraoperative RBC transfusion was associated with poorer clinical outcomes in non-anemic adults undergoing isolated valve replacements, which significantly increased the risk of postoperative hypoxemia. The independent predictors of intraoperative RBC transfusion, such as iron deficiency and female, were identified, which may be helpful for risk assessment and perioperative management.

The effect of socioeconomic factors on patient outcomes in cardiac surgery.

Healthcare delivery is heterogenous; the reasons for this are numerous and complex. Patient-specific factors including geography, income, insurance status, age, and gender have been shown to bias surgical outcomes. Utilizing a prospectively collected all-payer database, we aim to evaluate the influence of socioeconomic factors on mortality and length of stay (LOS) after common cardiac surgical procedures. We utilized the National Inpatient Sample,Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for the year 2019. We included patients undergoing coronary artery bypass grafting (CABG), aortic valve replacement (AVR), transcatheter aortic valve replacement (TAVR), and combined AVR/CABG using the 10th revision of the International Classification of Diseasesprocedure codes. AVR and CABG were combined into a separate cohort as this was felt to represent a different pathology than isolated valvular or coronary arterial disease. Baseline demographics were summarized. Multivariable regression was performed within each procedure group to model the odds of in-hospital mortality and hospital LOS with age, sex, insurance, zip-code median household income, and location as predictors. Baseline patient characteristics including gender, income, geography, and payer status were similar between CABG, AVR, and AVR/CABG. TAVR patients had a higher proportion of female sex and Medicare as the primary payer, with an overall greater age. Multivariable Cox proportional hazards regression found that higher income was strongly associated with decreased LOS following AVR and CABG, and moderately associated in TAVR and AVR/CABG. Private insurance was associated with a decreased LOS in patients undergoing CABG, AVR, TAVR, and AVR/CABG. Female sex and increased age were associated with increased odds of mortality in TAVR, CABG, and AVR/CABG. Private insurance was associated with a decreased odds of mortality in patients undergoing AVR. These findings reveal significant disparities in patient outcomes after routine cardiac operations that are associated with socioeconomic status. Patients who did not have private insurance or had lower incomes were found to be at risk for increased LOS. Women were at a higher risk of mortality for several operations, a finding which has been previously described elsewhere. Private insurance conveyed a decreased odds of mortality in patients undergoing AVR. This data set serves to highlight differences in healthcare outcomes based on a variety of socioeconomic, geographic, and other inherent factors. Additional research is needed to identify the mechanisms behind these disparities with the goal of providing equitable care to all patients.

Systems of Care Factors Should Be Considered in Regionalization of Congenital Cardiac Surgery

BackgroundRegionalization of care has been proposed to optimize outcomes in congenital cardiac surgery (CCS). We hypothesized that hospital infrastructure and systems of care factors could also be considered in regionalization efforts. MethodsObserved-to-expected (O/E) mortality ratio and hospital volumes were obtained between 2015 and 2018 from public reporting data. Using a resource dependence framework, we examined factors obtained from American Hospital Association, Children’s Hospital Association, and hospital websites. Linear regression models were estimated with volume only, then with hospital factors, stratified by procedural complexity. Robust regression models were reestimated to assess the impact of outliers. ResultsWe found wide variation in the volume of congenital cardiac surgeries performed (89-3920) and in the surgical outcomes (O/E ratio range, 0.3-3.1). Six outlier hospitals performed few high-complexity cases with high mortality. Univariate analysis including all cases indicated that higher volume predicted lower O/E ratio (β = −0.02; SE = 0.008; P = .011). However, this effect was driven by the most complex cases. Models stratified by The Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery category show that volume is a significant predictor only in category 5 cases (β = −1.707; SE = 0.663; P = .012). Robust univariate regression accounting for outliers found no effect of volume on O/E ratio (β = 0.005; SE = 0.002; P = .975). Elimination of outliers through robust multivariate regression decreased the volume-outcome relationship and found a modest relationship between health plan ownership and outcomes. ConclusionsSystems of care factors should be considered in addition to volume in designing regionalization in CCS. Patient-level data sets will better define these factors.

Abstract 9967: Outcomes of Cardiac Surgery in Patients With Systemic Lupus Erythematosus

Introduction: Patients with systemic lupus erythematosus (SLE) are at increased cardiovascular risk. Data about outcomes after cardiac surgery are scarce. Hypothesis: We sought to evaluate early and late outcomes after cardiac surgery for patients with SLE during a 27- year period at a single institution. Methods: A retrospective review of the institutional Society of Thoracic Surgeons (STS) database between 1993 and 2019 was performed. A total of 329 patients with SLE (median age, 62.4 years, and 68.4% females) had undergone cardiac surgery. Patients’ characteristics and outcomes were analyzed. A logistic regression model was used to assess factors associated with mortality. Results: Incidence of cardiac surgery in patients with SLE has steadily increased with time (0.8% from 1993-2000, 0.9% from 2001-2010, 1.4% from 2011-2019). Of 329 patients, 166 patients (50.5%) had valve surgery, 82 patients (24.9%) had coronary artery bypass grafting (CABG), 48 patients (14.6%) had CABG + valve surgery, and 24 patients (7.3%) had pericardiectomy or pericardial window +/- others procedures. Patients with SLE were more likely to be females, white, older, and have hypertension, diabetes, dyslipidemia, chronic kidney disease, prior myocardial infarction, and congestive heart failure. The requirement of corticosteroids occurred in 91% of patients. The status of surgery was urgent or emergent in 20% of patients. Operative mortality was 4.6% and length of hospital stay was 6.1 days [IQR, 5.1, 9.2]. Overall long-term survival at 1, 5, and 10 years was 89%, 73% and 52%, respectively (Figure). Older age, re-operative dialysis, chronic lung disease, prior cardiac surgery, and dialysis required after surgery were strongly associated with long-term mortality. Conclusion: Cardiac surgery in SLE patients can be performed with acceptable morbidity and mortality. These data are beneficial in risk stratification of patients with SLE referred for cardiac surgery.

Intraoperative Urine Oxygen in Cardiac Surgery and 12-Month Outcomes.

Key Points Low intraoperative urinary oxygen during cardiac surgery is associated with increased risk of poor 12-month outcomes.With decreasing urinary oxygen thresholds, the risk of poor 12-month outcomes increases.