Predictors Of Operative Mortality Research Articles

Clinical outcomes of combined aortic root replacement with mitral valve surgery

This study was undertaken to examine the operative mortality and morbidity and late outcomes in patients who required combined aortic root replacement with mitral valve surgery. These combined procedures were performed in 123 patients with a mean age of 51 +/- 16 years; 67% were men. The aortic root pathology was an aneurysm in 76 patients and other disorders in 47 patients. The mitral valve pathology was degenerative disease in 62 patients and other diseases in 61 patients. Sixty-four patients (52%) underwent previous cardiac surgery. The aortic valve was preserved in 21 patients, and the mitral valve was preserved in 67 patients; the remaining patients underwent valve replacement. In addition, 57 patients underwent other procedures. The mean follow-up was 4.9 +/- 4.3 years and complete. The operative mortality rate was 6.5% (8 patients), and late mortality was 9.7% (12 patients). Reexploration of the mediastinum for bleeding (15%) and implantation of permanent pacemaker (18%) were the most common postoperative complications. Urgent surgery and functional class IV were predictors of operative mortality by univariate analysis. Survival at 1, 5, and 10 years was 90.9% +/- 2.6%, 86.1% +/- 3.3%, and 79.3 +/- 4.9%, respectively. Six patients required reoperation. Freedom from reoperation at 1, 5, and 10 years was 100%, 96.4% +/- 2.5%, and 85.7% +/- 6.4%, respectively. At the latest follow-up, 98 patients were alive and free from reoperation; 92 patients were in functional classes 1 and 2, and 88 patients were free from any cardiac or valve-related complication. Aortic root replacement combined with mitral valve surgery is a complex operation associated with high morbidity, but the operative mortality is reasonably low and the long-term outcomes are gratifying.

Abstract 2062: Predictors Of Outcome In Low Flow, Low Gradient Aortic Stenosis. Result Of The Multicenter Topas Study

Background: Patients with low flow aortic stenosis (AS) have a poor prognosis and a high operative mortality. Dobutamine stress echocardiography (DSE) has been used to assess LV contractile reserve and determine the “actual” severity of the stenosis. Recently, we proposed the projected aortic valve area at a normal flow rate (AVA proj ) to better differentiate true-severe from pseudo-severe AS. The objective of this study was to identify the independent predictors of survival in low flow, low gradient AS. Methods and results: 101 patients with low flow, low gradient AS (AVA≤1.2cm 2 , LV Ejection Fraction (LVEF) ≤40% and mean gradient (MG) ≤40 mmHg) underwent DSE and an assessment of functional capacity using the Duke Activity Status Index (DASI). A subgroup of 74 patients underwent a 6-minute walk test (6MWT). Overall survival was 70±5% at 1 year and 61±5% at 2 years. On univariate analysis, predictors of mortality were 6MWT ≤320m (p<0.0001), DASI ≤20 (p=0.0001), rest AVA ≤1cm 2 p=(0.006), peak DSE LVEF (LVEF peak ) ≤35% (p=0.02), AVA proj ≤1.2cm 2 (p=0.04). After adjusting for age, gender, and the type of treatment (surgical vs. medical), significant predictors of mortality were DASI ≤20 (HR: 1.79, 95%CI: 1.28 –2.53 p=0.0006) and AVA proj ≤1.2cm 2 (HR:1.64, 95%CI: 1.04 –2.87 p=0.03). In the subgroup of patients undergoing a 6MWT (n=74), independent predictors of mortality were: 6MWT ≤320m (HR: 2.49, 95%CI: 1.55– 4.30 p<0.0001), AVA proj ≤1.2cm 2 (HR: 2.07, 95%CI: 1.18 – 4.08 p=0.01), and LVEF peak ≤35% (HR: 1.64, 95%CI: 1.10 –2.51 p=0.016). In the subset of patients undergoing valve replacement (n=44), unvariate predictors of operative mortality (18%) were: 6MWT ≤180m (OR: 9.8, 95%CI: 3.7–35, p=0.0002), DASI ≤15 (OR: 3.21, 95%CI: 1.67– 6.48, p=0.011) and LVEF peak ≤20% (HR:5.83, 95%CI: 2.6 –16.7 p=0.001). Conclusion: In low flow, low gradient AS, the most significant risk factors for poor outcome were: Impaired functional capacity documented by a reduced DASI or 6MWT, More severe valve stenosis as documented by a smaller AVA proj , and Reduced peak stress LVEF, a composite accounting for resting LV function and contractile reserve. This new knowledge may assist in predicting the prognosis of patients with low flow AS and improve operative risk stratification.

Abstract 3172: Impact of Prosthesis-Patient Mismatch on Long-Term Survival After Aortic Valve Replacement

Background: We recently reported that Prosthesis-Patient Mismatch (PPM) is an independent predictor of operative mortality in patients undergoing aortic valve replacement (AVR). The objective of this study was to evaluate the impact of PPM on late postoperative survival. Methods and Results: Between 1992 and 2005, 2653 patients (age: 68±10 years; 61% of males) underwent AVR in our institution. Patients who died at the time of operation or within 30 days were excluded from this study. The projected indexed effective orifice area (EOAi) was derived from the published normal in vivo EOA values for each model and size of prosthesis and PPM was classified as severe if the EOAi was ≤0.65 cm 2 /m 2 , moderate if it was > 0.65 cm 2 /m 2 and ≤ 0.85 cm 2 /m 2 , or not clinically significant if >0.85 cm 2 /m 2 . PPM was severe in 40 patients (2%), moderate in 797 (31%), and not significant in 1739 (67%). Patients with severe PPM had higher proportion of female gender (67% vs. 38%; P=0.0002) and hypertension (68% vs. 55%, p=0.02) and larger body surface (1.86±0.25 vs. 1.77±0.20, p=0.02). For patients with severe PPM, 5-year survival rate (74±8%) and 10-year survival rate (40±10%) were significantly (p=0.008) less than for patients with moderate PPM (5-yr: 81±2% and 10-yr: 57±3%) or no significant PPM (5-yr: 84±1% and 10-yr: 61±2%). On multivariate analysis after adjustment for other predictors of outcome, severe PPM was associated with increased overall mortality (Hazard ratio 1.38, [95% Confidence Interval 1.04 –1.75]; (p=0.02) Conclusion: In our previous study, we reported that severe PPM is a powerful risk factor for operative mortality. The results of the present study now suggest that severe PPM is also an independent predictor of long-term mortality. Hence, for the patients who are identified to be at risk of severe PPM at the time of operation, every effort should be made to implant a prosthesis with a larger EOA. Funded by: Canadian Institutes of Health Research

Results of Coronary Bypass and Valve Operations for Mitral Valve Regurgitation

Combined coronary bypass grafting and valve procedures for mitral valve regurgitation result in poor outcomes, but the impact of the etiology of valve regurgitation on operative and long-term outcomes is not well defined. A retrospective analysis of 468 patients who had combined coronary bypass grafting and valve operations for mitral regurgitation showed that 78% had valve repairs and 22% had replacements for ischemic (45%) or degenerative (55%) disease. Predictors of operative mortality were ischemic mitral regurgitation, failure to use the internal mammary artery for grafting, severe coronary disease, acute myocardial infarction, low ejection fraction, advanced heart failure, emergency operation, and mitral valve replacement. The 5-year survival rates for propensity-matched patients with ischemic or degenerative disease were similar (66%). Low ejection fraction (< 35%), advanced age (> 67 years), valve replacement surgery, residual mitral regurgitation, and severe coronary artery disease were predictors of poor long-term outcome. Although the operative outcomes of ischemic mitral regurgitation were poor compared to those of degenerative disease, the long-term survival was similar in both groups of propensity-matched patients. Left ventricular remodeling, an optimal valve procedure without residual mitral regurgitation, and left ventricular function are more important determinants of long-term outcome than the etiology of valve regurgitation.

Surgical therapy for ischemic heart failure: Single-center experience with surgical anterior ventricular restoration

Our objectives were (1) to report operative and long-term mortality in patients submitted to anterior surgical ventricular restoration, (2) to report changes in clinical and cardiac status induced by surgical ventricular restoration, and (3) to report predictors of death in a large cohort of patients operated on at San Donato Hospital, Milan, Italy. A total of 1161 consecutive patients (83% men, 62 +/- 10 years) had anterior surgical ventricular restoration with or without coronary artery bypass grafting and with or without mitral repair/replacement. A complete echocardiographic study was performed in 488 of 1161 patients operated on between January 1998 and October 2005 (study group). The indication for surgery was heart failure in 60% of patients, angina, and/or a combination of the two. Thirty-day cardiac mortality was 4.7% (55/1161) in the overall group and 4.9% (24/488) in the study group. Determinants of hospital mortality were mitral valve regurgitation and need for a mitral valve repair/replacement. Mitral regurgitation (>2+) associated with a New York Heart Association class greater than II and with diastolic dysfunction (early-to-late diastolic filling pressure >2) further increases mortality risk. Global systolic function improved postoperatively: ejection fraction improved from 33% +/- 9% to 40% +/- 10% (P < .001); end-diastolic and end-systolic volumes decreased from 211 +/- 73 to 142 +/- 50 and 145 +/- 64 to 88 +/- 40 mL, respectively (P < .001) early after surgery. New York Heart Association functional class improved from 2.7 +/- 0.9 to 1.6 +/- 0.7 (P < .001) late after surgery. Long-term survival in the overall population was 63% at 120 months. Surgical ventricular restoration for ischemic heart failure reduces ventricular volumes, improves cardiac function and functional status, carries an acceptable operative mortality, and results in good long-term survival. Predictors of operative mortality are mitral regurgitation of 2+ or more, New York Heart Association class greater than II, and diastolic dysfunction (early-to-late diastolic filling pressure >2).

Impact of Perfusion Strategy on Neurologic Recovery in Acute Type A Aortic Dissection

The optimal perfusion strategy during surgery of acute type A aortic dissection is controversial. The purpose of this study was to determine the impact of retrograde cerebral perfusion during hypothermic circulatory arrest on short-term and long-term outcome in this specific patient population. Between 1984 and 2005, 175 consecutive patients underwent repair of an acute type A dissection. Three different surgical approaches were used: aortic cross-clamping without hypothermic circulatory arrest in 50 (29%), hypothermic circulatory arrest alone in 69 (39%), and hypothermic circulatory arrest with supplemental retrograde cerebral perfusion in 56 (32%). Operative mortality was 18% +/- 3% (+/- 70% confidence interval), and adverse outcomes (death or cerebrovascular accident) occurred in 21% +/- 3% of patients (p = 0.97 between groups). Multivariate analysis identified valve replacement (p = 0.04), preoperative flow complications (p = 0.03), and non-Marfan syndrome (p = 0.04) as predictors of operative mortality. Intraoperative dissection (p < 0.001) and history of cerebrovascular disease (p = 0.02) were predictors for permanent neurologic deficit, and retrograde cerebral perfusion was shown to have a protective effect on transient neurologic deficits (p = 0.008). Kaplan-Meier survival was 75% +/- 3% at 1 year (131 patients at risk), 63% +/- 4% at 5 years (87 patients at risk), and 49% +/- 4% at 10 years (48 patients at risk) and was independent of surgical approach (p = 0.37). Long-term survival was diminished with increased age (p < 0.001), earlier operative year (p < 0.001), and coronary artery disease (p = 0.02). The current investigation suggests improved neurologic recovery with circulatory arrest and supplemental retrograde cerebral perfusion. Operative mortality and long-term survival were comparable among groups.

Predictors of operative mortality and cardiopulmonary morbidity in the National Emphysema Treatment Trial

Predictors of operative mortality and cardiopulmonary morbidity in the National Emphysema Treatment Trial

Predictors of operative mortality and cardiopulmonary morbidity in the National Emphysema Treatment Trial

Predictors of operative mortality and cardiopulmonary morbidity in the National Emphysema Treatment Trial

The performance of the EuroSCORE and the Society of Thoracic Surgeons mortality risk score: the gender factor

The purpose of this study was to explore potential differences in the performance of the EuroSCORE and the STS mortality risk score in the prediction of operative mortality following cardiac surgery with special focus on the impact of gender. We retrospectively reviewed 3125 consecutive cases of coronary artery bypass surgery performed at our institution between 2001 and 2004. STS and EuroSCORE (logistic [E-log] and additive [E-add]) operative mortality risk scores were calculated for each patient and stratified by gender (female: n=692; male: n=2433). Mortality risk scores were compared between the STS and EuroSCORE using C-statistics and likelihood ratios (LR). Stratified by gender, the E-log and E-add correlated well with the STS (female: r=0.77, 0.78, P<0.001; male: r=0.78, 0.79, P<0.001). Using C-statistics generated from logistic regression, both EuroSCORE models correctly modeled operative mortality compared to the STS. Among male patients, the EuroSCORE C-statistic (E-log, 0.808; E-add, 0.809; STS, 0.796) performed more comparable to the STS than female patients (E-log, 0.853; E-add, 0.855; STS, 0.827). Our results suggest that both the STS risk scores and the EuroSCORE are good predictors for operative mortality with slight advantage for the STS risk score. Combined with the ease of use, we conclude that the EuroSCORE is another viable, bedside instrument for surgeons looking for a preoperative assessment of mortality risk, particularly in female patients undergoing cardiac surgery.

1039 The impact of using different measures of relative wall thickness on assessment of left ventricular geometry in asymptomatic aortic stenosis. A SEAS substudy

in men/women), RWT and midwall shortening were evaluated in 1728 patients (39% women, aged 67±10 years) with asymptomatic AS, re- cruited in the Simvastatin Ezetimibe in Aortic Stenosis (SEAS) study. RWT was defined as the ratio of either posterior wall thickness (RWTp, concentric geometry if ≥0.43), or the average of posterior and septal wall thickness (RWTm, concentric geometry if ≥0.45) to LV radius. Both variables were also normalized for age using previously published regression coefficients (RWTpa and RWTma, concentric geometry if ≥0.40 and 0.41, respectively). Results: Average peak transaortic velocity was 3.09±0.54 m/sec. Compared to RWTp and RWTm, use of RWTpa and RWTma reclassified LV geometry in 2.8% and 3.5% of patients (Table 1). Compared to RWTp, use of RWTm reclassified LV geometry in 11.2% of patients (183 from eccentric to concen- tric and 11 from concentric to eccentric geometry) (p<0.01). Compared to those who maintained eccentric or concentric geometry, respectively, pa- tients reclassified to concentric geometry by RWTm included more hyper- tensive patients, had larger LV mass and wall thicknesses and lower midwall shortening (all p<0.05), while patients reclassified to eccentric geometry did not differ in clinical characteristics, but had lower LV septal thickness and higher midwall shortening (both p<0.01). Conclusions: Use of age-normalized RWT modestly reclassified LV geom- etry in this elderly population. However, in patients with asymptomatic AS, defining RWT from average septal and posterior wall thickness compared to posterior wall thickness alone, considerably increased both prevalence of concentric geometry and associated midwall dysfunction. ), with low gradient-low EF (LVEF £35%, GDT £30 mm Hg) and who had aortic valvular replacement (AVR) were prospectively enrolled. Preoperative contractile reserve (CR) during dobutamine infusion was defined by an increase in stroke volume of ≥20% compared with baseline values. CR was present in 35 patients (Group I, 76%) and absent in 11 patients (Group II, 24%). In the overall sample, operative mortality was 17%. Operative mortality was 8.5% in group I compared with 45% in group II (p=0.013). In univariate analysis, lack of CR (p=0.013), three-vessel coronary artery disease (p=0.02) and GDT £20 mm Hg (p=0.02) were associated with operative mortality. In- dependent predictors of operative mortality were GDT £20 mmHg (odds ra- tio=11; 95% CI, 1.2 to 107.6; p=0.03), lack of contractile reserve (odds ratio =10; 95% CI, 1.2 to 81.6; p=0.034) and three vessels coronary artery disease (odds ratio =11; 95% CI, 1.2 to 107.6; p=0.034). All patients without CR and with GDT £20 mmHg (n=3) died in the perioperative period. Conclusions: These data further support in patients with low GDT-low EF AS the value of very low gradient (±20 mm Hg) at rest and of CR on DSH for preoperative risk stratification. Patients with GDT £20 mm Hg and lack of CR have an extremely high operative mortality.

THE PERFORMANCE OF THE EUROSCORE AND THE SOCIETY OF THORACIC SURGEONS MORTALITY RISK SCORE: THE GENDER FACTOR

PURPOSE: Recently, different scoring systems to assess operative risk were adopted by cardiac surgeons. The EuroSCORE and the Society of Thoracic Surgeons Mortality Risk (STS) Score are widely used and validated among US patient populations. The study aim is to explore potential differences in the performance of the EuroSCORE and the STS Scores in the prediction of operative mortality following coronary artery bypass surgery cardiac surgery (CABG) with special focus on the impact of gender.

Outcomes of cardiac surgery in the elderly

The elderly represent a rapidly growing and substantially under-treated sector in industrialized countries, with coronary artery disease and degenerative aortic stenosis rampant. The proportion of elderly patients undergoing cardiac surgery is rising steadily and outcomes continue to improve with the refinement of operative techniques and perioperative care. Advanced risk stratification models, such as the logistic European System for Cardiac Operative Risk Evaluation now offer validated prediction of operative mortality in these high-risk patients. Current trends towards off-pump coronary artery surgery, hybrid revascularization and mitral repair may have advantages in the elderly, who often have more diffuse cardiovascular disease and a lower tolerance to intervention. Recent advances may also provide surgical options for the emerging epidemics of cardiovascular disease affecting the elderly, atrial fibrillation and heart failure.

Clinical outcomes of surgery of mitral valve regurgitation and coronary artery bypass grafting

The impact of etiology of associated mitral valve regurgitation and a valve procedure on operative and long-term outcomes after coronary bypass grafting surgery is yet to be clearly defined. Results of combined coronary artery bypass grafting and valve procedures for mitral valve regurgitation were retrospectively analyzed in 468 patients. The regurgitation was of ischemic in 45%, degenerative in 55% and 78% valve repairs, 22% valve replacements were performed. Severe coronary artery disease, acute myocardial infarction, low ejection fraction, ischemic mitral regurgitation, advanced heart failure symptoms, failure to use internal mammary artery, valve replacement surgery, and emergency operations are predictors of operative mortality. The 5-year survivals for propensity-matched patients of ischemic and degenerative disease were similar (66%), but 67% vs. 83%, respectively, for unmatched patients. Low ejection fraction (<35%), advanced age (>67 years), valve replacement surgery, residual mitral regurgitation, and severe coronary artery disease were predictors of poor long-term survival. Left ventricular remodeling processes, optimal valve procedure without residual mitral regurgitation and left ventricular function are important determinants of long-term outcome than the etiology of valve regurgitation.

Predictors of operative death after oesophagectomy for carcinoma

Oesophagectomy for carcinoma provides a chance of cure but carries significant risk. This study defined risk factors for death after oesophageal resection for malignant disease. Between 1990 and 2003, 773 oesophagectomies for oesophageal cancer were performed. Continuous variables were categorized into quartiles for analysis. Predictors of operative mortality were identified by univariate and multiple logistic regression analysis. The operative mortality rate was 4.8 per cent (37 of 773). In univariate analysis, advanced age, reduced forced expiratory volume in 1 s (FEV1), reduced forced vital capacity, presence of diabetes and tumour located in the upper third of the oesophagus were associated with a higher mortality rate. Multivariate analysis identified age (highest relative to lowest quartile, odds ratio (OR) 4.87 (95 per cent confidence interval (c.i.) 1.35 to 17.55); P = 0.009), tumour position (upper third relative to other locations, OR 4.23 (95 per cent c.i. 1.06 to 16.86); P = 0.041) and FEV1 (lowest relative to highest quartile, OR 4.72 (95 per cent c.i. 1.01 to 21.99); P = 0.018) as independent predictors of death. Advanced age, impaired preoperative respiratory function and a tumour high in the oesophagus are associated with a significantly increased risk of death after oesophagectomy for carcinoma.

Is early anticoagulation with warfarin necessary after bioprosthetic aortic valve replacement?

Freedom from anticoagulation is the principal advantage of bioprosthesis; however, the American Heart Association/American College of Cardiology and the American College of Chest Physicians guidelines recommend early anticoagulation with heparin, followed by warfarin for 3 months after bioprosthetic aortic valve replacement. We examined neurologic events within 90 days of bioprosthetic aortic valve replacement at our institution. Between 1993 and 2000, 1151 patients underwent bioprosthetic aortic valve replacement with (641) or without (510) associated coronary artery bypass. By surgeon preference, 624 had early postoperative anticoagulation (AC+) and 527 did not (AC-). In the AC- group, 410 patients (78%) received antiplatelet therapy. Groups were similar with respect to gender (female, 36% AC+ vs 40% AC-, P = .21), hypertension (64% AC+ vs 61%, P = .27), and prior stroke (7.6% AC+ vs 8.5% AC-, P = .54). The AC+ group was slightly younger than the AC- group (median, 76 years vs 78 years, P = .006). Operative mortality was 4.1% with 43 (3.7%) cerebrovascular events within 90 days. Excluding 18 deficits apparent upon emergence from anesthesia, we found that postoperative cerebrovascular accident occurred in 2.4% of AC+ and 1.9% AC- patients. By multivariable analysis, the only predictor of operative mortality was hypertension ( P < .0001). Postoperative cerebrovascular accident was unrelated to warfarin use ( P = .32). The incidence of mediastinal bleeding requiring reexploration was similar (5.0% vs 7.4%), as were other bleeding complications in the first 90 days (1.1% vs 0.8%). No variables were predictive of bleeding by multivariate analysis. Although these data do not address the role of antiplatelet agents, early anticoagulation with warfarin after bioprosthetic aortic valve replacement did not appear to protect against neurologic events.

1236 Prognostic evaluation of hepatocellular carcinoma: a comparative analysis of four different staging systems in anti-HCV patients with liver cirrhosis

Background: The advances in immunotherapy, along with a liberalization of eligibility criteria have contributed significantly to the ever increasing demand for donor organs. In an attempt to expand the donor pool, transplant programs are now accepting older donors as well as donors from more remote areas. The purpose of this study is to determine the effect of donor age and organ ischemic time on survival following orthotopic heart transplantation (OHT).From April 1981 to December 1996 372 adult patients underwent OHT at the University of Western Ontario. Cox proportional hazards models were used to identify predictors of outcome. Variables affecting survival were then entered into a stepwise logistic regression model to develop probability models for 30-day- and 1-year-mortality.The mean age of the recipient population was 45.6 ± 12.3 years (range 18–64 years: 54 ≤ 30; 237 were 31–55; 91 > 56 years). The majority (329 patients, 86.1%) were male and the most common indications for OHT were ischemic (n = 180) and idiopathic (n = 171) cardiomyopathy. Total ischemic time (TIT) was 202.4 ± 84.5 minutes (range 47–457 minutes). In 86 donors TIT was under 2 hours while it was between 2 and 4 hours in 168, and more than 4 hours in 128 donors. Actuarial survival was 80%, 73%, and 55% at 1, 5, and 10 years respectively. By Cox proportional hazards models, recipient status (Status I–II vs III–IV; risk ratio 1.75; p = 0.003) and donor age, examined as either a continuous or categorical variable ([age < 35 vs ≥ 35; risk ratio 1.98; p < 0.001], [age < 50 vs ≥ 50; risk ratio 2.20; p < 0.001], [age < 35 vs 35–49 versus ≥ 50; risk ratio 1.83; p < 0.001]), were the only predictors of operative mortality. In this analysis, total graft ischemic time had no effect on survival. However, using the Kaplan-Meier method followed by Mantel-Cox logrank analysis, ischemic time did have a significant effect on survival if donor age was >50 years (p = 0.009). By stepwise logistic regression analysis, a probability model for survival was then developed based on donor age, the interaction between donor age and ischemic time, and patient status.Improvements in myocardial preservation and peri-operative management may allow for the safe utilization of donor organs with prolonged ischemic times. Older donors are associated with decreased peri-operative and long-term survival following OHT, particularly if graft ischemic time exceeds 240 minutes and if these donor hearts are transplanted into urgent (Status III–IV) recipients.

Risk factors for mortality after the Norwood procedure.

Recent studies have suggested that survival following the Norwood procedure is influenced by anatomy and is worse for patients with hypoplastic left heart syndrome (HLHS), particularly aortic atresia (AA), as compared to other forms of functional single ventricle and systemic outflow tract obstruction. The current study was undertaken to evaluate our recent experience with the Norwood procedure and to evaluate potential predictors of operative and 1-year mortality. A retrospective study of risk factors for operative and 1-year mortality in 158 patients undergoing the Norwood procedure between January 1, 1998 and June 30, 2001. HLHS was present in 102 patients (70 with AA) and other forms of functional single ventricle with systemic outflow tract obstruction in the remaining 56. Operative survival was 77% (122/158), 78% for patients with HLHS and 75% for patients with other diagnoses. Multivariable analysis identified birth weight (odds ratio (OR) 0.18/kg, 95% confidence limit (CL) 0.08-0.42, P<0.001), associated cardiac anomalies (OR 4.45, 95% CL 1.50-13.2, P=0.001), total support time (OR 1.02/min, 95% CL 1.01-1.03, P=0.004), and extracorporeal membrane oxygenation (ECMO) or ventricular assist device (VAD) support (OR 17.8, 95% CL 4.40-71.0, P<0.001) as predictors of operative mortality. The anatomic diagnosis (HLHS versus non-HLHS) was not a predictor of mortality, P=0.6). The Kaplan-Meier survival estimate at 1 year was 66% (95% CL 58-73%) and was not different for patients with HLHS compared to non-HLHS, P=0.5. For patients who have survived the Norwood procedure, survival to 1 year was 86% (95% CL 78-91%). Presence of an extra-cardiac anomaly or genetic syndrome (OR 2.70, 95% CL 0.98-7.41%, P=0.05) and presence of an additional cardiac defect (OR 3.99, 95% CL 1.67-9.57, P=0.002) were predictors of worse survival in the first year of life. The Norwood procedure is currently being applied to a heterogeneous group of patients. Operative and 1-year survival are equivalent for patients with HLHS and those with other cardiac defects. The presence of additional cardiac or extra-cardiac anomalies are predictors of poor outcome.

Prediction of operative mortality after valve replacement surgery

Prediction of operative mortality after valve replacement surgery

Perioperative Factors as Predictors of Operative Mortality and Morbidity in Pneumonectomy

Pneumonectomy for lung cancer is associated with significant morbidity and mortality. Risk factors for the morbidity and mortality have been reported, but consistent conclusive data are undetermined. Current accepted 30-day mortality rates for pneumonectomy range from 7 to 11 per cent. The objective of this study is to determine whether various perioperative factors can serve as predictors of morbidity and mortality in pneumonectomy patients and to review outcome data on patients undergoing pneumonectomy for lung cancer. A total of 105 patients undergoing pneumonectomy for lung cancer from 1988 through 1998 are studied in a retrospective chart review. The main outcome measure is the 30-day operative mortality and morbidity. Complications occurring in 10 per cent or more of the patients included atrial fibrillation (33.3%), respiratory failure (23.8%), pneumonia (21.9%), and bronchopleural fistula (12.4%). The 30-day mortality rate was 10.5 per cent (11 deaths). By Fisher's exact test for Chi-square only three statistically significant mortality factors were identified: respiratory failure (P < 0.021), sepsis (P < 0.008), and male sex (P < 0.031); respiratory failure, sepsis, and sex were predictors of death. Significant correlation could not be made to predict postoperative morbidity. Overall long-term clinical outcome for pneumonectomy as lung cancer treatment was poor. Clinical judgment remains an essential factor when considering pneumonectomy as an option for lung cancer treatment.

Prediction of operative mortality after valve replacement surgery

OBJECTIVESWe sought to develop national benchmarks for valve replacement surgery by developing statistical risk models of operative mortality.BACKGROUNDNational risk models for coronary artery bypass graft surgery (CABG) have gained widespread acceptance, but there are no similar models for valve replacement surgery.METHODSThe Society of Thoracic Surgeons National Cardiac Surgery Database was used to identify risk factors associated with valve surgery from 1994 through 1997. The population was drawn from 49,073 patients undergoing isolated aortic valve replacement (AVR) or mitral valve replacement (MVR) and from 43,463 patients undergoing CABG combined with AVR or MVR. Two multivariable risk models were developed: one for isolated AVR or MVR and one for CABG plus AVR or CABG plus MVR.RESULTSOperative mortality rates for AVR, MVR, combined CABG/AVR and combined CABG/MVR were 4.00%, 6.04%, 6.80% and 13.29%, respectively. The strongest independent risk factors were emergency/salvage procedures, recent infarction, reoperations and renal failure. The c-indexes were 0.77 and 0.74 for the isolated valve replacement and combined CABG/valve replacement models, respectively. These models retained their predictive accuracy when applied to a prospective patient population undergoing operation from 1998 to 1999. The Hosmer-Lemeshow goodness-of-fit statistic was 10.6 (p = 0.225) for the isolated valve replacement model and 12.2 (p = 0.141) for the CABG/valve replacement model.CONCLUSIONSStatistical models have been developed to accurately predict operative mortality after valve replacement surgery. These models can be used to enhance quality by providing a national benchmark for valve replacement surgery.