Preoperative Risk Factors For Mortality Research Articles

Risk factors for in-hospital mortality after emergency colorectal surgery in octogenarians: results of a cohort study from a referral center

PurposeThe objective of this study was to investigate predictive factors of mortality in emergency colorectal surgery in octogenarian patients.MethodsIt is a retrospective cohort study conducted at a single-institution tertiary referral center. Consecutive patients who underwent emergency colorectal surgery between January 2015 and January 2020 were identified. The primary endpoint was 30-day mortality. Univariate and multivariate analyses were performed using a logistic regression model.ResultsA total of 111 patients were identified (43 men, 68 women). Mean age was 85.7 ± 3.7 years (80–96). Main diagnoses included complicated sigmoiditis in 38 patients (34.3%), cancer in 35 patients (31.5%), and ischemic colitis in 31 patients (27.9%). An ASA score of 3 or higher was observed in 88.3% of patients. The mean Charlson score was 5.9. The Possum score was 35.9% for mortality and 79.3% for morbidity. The 30-day mortality rate was 25.2%. Univariate analysis of preoperative risk factors for mortality shows that the history of valvular heart disease (p = 0.008), intensive care unit provenance (p = 0.003), preoperative sepsis (p < 0.001), diagnosis of ischemic colitis (p = 0.012), creatinine (p = 0.006) and lactate levels (p = 0.01) were significantly associated with 30-day mortality, and patients coming from home had a lower 30-day mortality rate (p = 0.018). Intraoperative variables associated with 30-day mortality included ileostomy creation (p = 0.022) and temporary laparostomy (p = 0.004). At multivariate analysis, only lactate (p = 0.032) and creatinine levels (p = 0.027) were found to be independent predictors of 30-day mortality, home provenance was an independent protective factor (p = 0.004). Mean follow-up was 3.4 years. Survival at 1 and 3 years was 57.6 and 47.7%.ConclusionEmergency colorectal surgery is challenging. However, age should not be a contraindication. The 30-day mortality rate (25.2%) is one of the lowest in the literature. Hyperlactatemia (> 2mmol/L) and creatinine levels appear to be independent predictors of mortality.

Incidence and risk factors analysis for mortality after total knee arthroplasty based on a large national database in Korea

This study aimed to analyze the rates and risk factors of postoperative mortality among 560,954 patients who underwent total knee arthroplasty (TKA) in Korea. The National Health Insurance Service-Health Screening database was used to analyze 560,954 patients who underwent TKA between 2005 and 2018. In-hospital, ninety-day, and one-year postoperative mortality, and their association with patient’s demographic factors and various comorbidities (ie., cerebrovascular disease, congestive heart failure, and myocardial infarction) were assessed. In-hospital, ninety-day and one-year mortality rates after TKA were similar from 2005 to 2018. The risk of in-hospital mortality increased with comorbidities like cerebrovascular disease (hazard ratio [HR] = 1.401; 95% confidence interval [CI] = 1.064–1.844), congestive heart failure (HR = 2.004; 95% CI = 1.394 to 2.881), myocardial infarction (HR = 2.111; 95% CI = 1.115 to 3.998), and renal disease (HR = 2.641; 95% CI = 1.348–5.173). These co-morbidities were also independent predictors of ninety-day and one-year mortality. Male sex and old age were independent predictors for ninety-day and one-year mortality. And malignancy was risk factor for one-year mortality. The common preoperative risk factors for mortality in all periods were male sex, old age, cerebrovascular disease, congestive heart failure, myocardial infarction, and renal disease. Malignancy was identified as risk factor for one-year mortality. Patients with these comorbidities should be provided better perioperative care.

Sex Differences in Ascending Aortic and Arch Surgery: A Propensity-Matched Comparison of 1153 Pairs

BackgroundWe investigated the relationship of sex with clinical outcomes after proximal aortic (ascending and arch) operations, and whether sex-specific preoperative factors are associated with mortality. MethodsOf 3745 patients who underwent elective, urgent, and emergency proximal aortic operations over a 30-year period, 1153 pairs of men and women were propensity-matched, and their early and long-term outcomes were compared. Kaplan-Meier survival analysis was used to estimate late survival. ResultsWomen and men had similar operative mortality (9.1% vs 8.8%, P = .8), stroke (5.7% vs 5.6%, P = .9), and renal failure rates (7.0% vs 6.6%, P = .7). Thirty-day mortality was 7.5% vs 5.6% (P = .06), respectively. Results were less favorable for women than for men regarding respiratory failure (34.3% vs 29.2%, P=0.008) and intensive care unit length of stay (9.11 ± 11.9 vs 7.87 ± 12.48 days; P = .023). Long-term survival was not significantly different between women and men: 66.3% (95% confidence interval [CI] 62.8%-69.5%) vs 67.1% (95% CI 63.6%-70.4%) at 5 years, and 45.9% (95% CI 41.76%-50.0%) vs 46.2% (95% CI 41.7%-50.6%) at 10 years (P = .4). Preoperative factors including diabetes, prior stroke, prior renal insufficiency, and peripheral vascular disease were associated with operative mortality in men, whereas chronic obstructive pulmonary disease was the main risk factor in women. ConclusionsNo differences were seen between the sexes in life-changing adverse outcomes after ascending aortic and arch procedures, although specific preoperative variables were associated with specific adverse events. Recognizing differences in preoperative risk factors for mortality between the sexes may facilitate targeted preoperative assessment, preparation, and counseling.

A preoperative mortality risk assessment model for Stanford type A acute aortic dissection

BackgroundAcute aortic dissection type A is a life-threatening disease required emergency surgery during acute phase. Different clinical manifestations, laboratory tests, and imaging features of patients with acute aortic dissection type A are the risk factors of preoperative mortality. This study aims to establish a simple and effective preoperative mortality risk assessment model for patients with acute aortic dissection type A.MethodsA total of 673 Chinese patients with acute aortic dissection type A who were admitted to our hospital were retrospectively included. All patients were unable to receive surgically treatment within 3 days from the onset of disease. The patients included were divided into the survivor and deceased groups, and the endpoint event was preoperative death. Multivariable analysis was used to investigate predictors of preoperative mortality and to develop a prediction model.ResultsAmong the 673 patients, 527 patients survived (78.31%) and 146 patients died (21.69%). The developmental dataset had 505 patients, calibration by Hosmer Lemeshow was significant (χ2 = 3.260, df = 8, P = 0.917) and discrimination by area under ROC curve was 0.8448 (95% CI 0.8007–0.8888). The validation dataset had 168 patients, calibration was significant (χ2 = 5.500, df = 8, P = 0.703) and the area under the ROC curve was 0.8086 (95% CI 0.7291–0.8881). The following independent variables increased preoperative mortality: age (OR = 1.008, P = 0.510), abrupt chest pain (OR = 3.534, P < 0.001), lactic in arterial blood gas ≥ 3 mmol/L (OR = 3.636, P < 0.001), inotropic support (OR = 8.615, P < 0.001), electrocardiographic myocardial ischemia (OR = 3.300, P = 0.001), innominate artery involvement (OR = 1.625, P = 0.104), right common carotid artery involvement (OR = 3.487, P = 0.001), superior mesenteric artery involvement (OR = 2.651, P = 0.001), false lumen / true lumen of ascending aorta ≥ 0.75 (OR = 2.221, P = 0.007). Our data suggest that a simple and effective preoperative death risk assessment model has been established.ConclusionsUsing a simple and effective risk assessment model can help clinicians quickly identify high-risk patients and make appropriate medical decisions.

Safety and Feasibility of Thoracoscopic Lung Resection for Non-Small-Cell Lung Cancer in Octogenarians.

Octogenarians comprise an increasing proportion of patients presenting with non-small-cell lung cancer (NSCLC). This study examines postoperative morbidity and mortality, and long-term survival in octogenarians undergoing thoracoscopic anatomic lung resection for NSCLC, compared with younger cohorts. We conducted a retrospective review of our institutional Society of Thoracic Surgeons General Thoracic Surgery Database of all patients ≥60 years old undergoing elective lobectomy or segmentectomy for pathologic stage I, II, and IIIA NSCLC between 2009 and 2018. Results were compared between octogenarians (n = 71) to 2 younger cohorts of 60- to 69-year-olds (n = 359) and 70- to 79-year-olds (n = 308). Long-term survival among octogenarians was graphically summarized using the Kaplan-Meier method. Cox regression analysis was used to identify preoperative risk factors for mortality. A greater proportion of octogenarians required intensive care unit admission and discharge to extended-care facilities; however, postoperative length of stay was similar between groups. Among postoperative complications, arrhythmia and renal failure were more likely in the older cohort. Compared to the youngest cohort, in-hospital and 30-day mortality were highest among octogenarians. Overall survival among octogenarians at 1, 3, and 5 years was 87.3%, 61.8%, and 50.5%, respectively. On multivariable Cox regression analysis of baseline demographic variables, presence of stroke (hazard ratio [HR] = 28.5, 95% confidence interval [CI]: 6.1 to 132.7, P < 0.001) and coronary artery disease (HR = 2.5, 95% CI: 1.2 to 5.3, P = 0.02) were significant predictors of overall mortality among octogenarians. Thoracoscopic resection can be performed with favorable early postoperative outcomes among octogenarians. Long-term survival, although comparable to their healthy peers, is worse than those of younger cohorts. Further study into preoperative risk stratification and alternative therapies among octogenarians is needed.

Higher incidence of perivalvular abscess determines perioperative clinical outcome in patients undergoing surgery for prosthetic valve endocarditis

BackgroundCardiac surgery for prosthetic valve endocarditis (PVE) is associated with substantial mortality. We aimed to analyze 30-day and 1-year outcome in patients undergoing surgery for PVE and sought to identify preoperative risk factors for mortality with special regard to perivalvular infection.MethodsWe retrospectively analyzed data of 418 patients undergoing valve surgery for infective endocarditis between January 2009 and July 2018. After 1:1 propensity matching 158 patients (79 PVE/79 NVE) were analyzed with regard to postoperative 30-day and 1-year outcomes. Univariate and multivariable analyses were performed to identify potential risk factors for mortality.Results315 patients (75.4%) underwent surgery for NVE and 103 (24.6%) for PVE. After propensity matching groups were comparable with regard to preoperative characteristics, clinical presentation and microbiological findings, except a higher incidence of perivalvular infection in patients with PVE (51.9%) compared to NVE (26.6%) (p = 0.001), longer cardiopulmonary bypass (166 [76–130] vs. 97 [71–125] min; p < 0.001) and crossclamp time (95 [71–125] vs. 68 [55–85] min; p < 0.001). Matched patients with PVE showed a 4-fold increased 30-day mortality (20.3%) in comparison with NVE patients (5.1%) (p = 0.004) and 2-fold increased 1-year mortality (PVE 29.1% vs. NVE 13.9%; p = 0.020). Multivariable analysis revealed perivalvular abscess, sepsis, preoperative AKI and PVE as independent risk factors for mortality. Patients with perivalvular abscess had a significantly higher 30-day mortality (17.7%) compared to patients without perivalvular abscess (8.0%) (p = 0.003) and a higher rate of perioperative complications (need for postoperative pacemaker implantation, postoperative cerebrovascular events, postoperative AKI). However, perivalvular abscess did not influence 1-year mortality (20.9% vs. 22.3%; p = 0.806), or long-term complications such as readmission rate or relapse of IE.ConclusionsPatients undergoing surgery for PVE had a significantly higher 30-day and 1-year mortality compared to NVE. After propensity-matching 30-day mortality was still 4-fold increased in PVE compared to NVE.Patients with perivalvular abscess showed a significantly higher 30-day mortality and perioperative complications, whereas perivalvular abscess seems to have no relevant impact on 1-year mortality, the rate of readmission or relapse of IE.

Computed tomography findings and preoperative risk factors for mortality of total anomalous pulmonary venous connection

Detailed preoperative imaging of total anomalous pulmonary venous connection (TAPVC) is critical to ensuring adequate surgical planning and preoperative decision making. The purpose of this study was to describe the computed tomography findings of TAPVC and identify morphologic death risk factors. We conducted a retrospective study included 70 patients with TAPVC between May 2014 and June 2017 in Hunan Children’s Hospital. All available clinical data and computed tomography imaging were reviewed, and survival time was followed-up. Life Tables analysis was used to estimate survival rates. Patient survival was described with Kaplan–Meier curves. Cox Regression model was used to test the potential risk factors. TAPVC was subdivided into four types. Of 70 cases, 42 (60%) had supracardiac, 13 (18.6%) had cardiac, 8 (11.4%) had infracardiac, and 7 (10%) had mixed type. Pulmonary venous obstruction (PVO) was found in 30 (42.9%) of 70 patients in this group. Of all concurrent abnormalities, atrial septal defect (ASD) was the most common (98.6%), followed by patent ductus arteriosus (PDA; 31, 44.3%), and persistent left superior vena cava (PLSVC; 5, 7.1%). 1, 3, 6 and 12-month survival rates were 76, 61, 49, and 38% respectively. Risk factors for mortality in multivariable analysis comprised PVO, McGoon index (MGI), and mode of delivery. Various concurrent abnormalities and great morphological heterogeneity were observed in patients with TAPVC. Patients with TAPVC had a highest mortality in the neonatal period. PVO, smaller MGI and caesarean are important predictors for mortality.

Escala de riesgo Aristóteles como factor predictor de mortalidad en el cierre quirúrgico de persistencia de ductus arterioso en prematuros

Introduction and objectivesPatent ductus arteriosus is a very common diagnosis in pre-term infants. Surgical closure is a therapeutic option. An attempt is made to identify pre-operative risk factors for mortality, and the usefulness of the Aristotle score to predict mortality. MethodA retrospective analysis was conducted on all patients under 1500g birth weight undergoing surgical closure at our hospital between January 2008 and December 2013. Perioperative data were collected, and a logistic regression model was used for analysis. ResultsOf the 100 patients reviewed, 59 were male infants, and the mean gestational age and birth weight was 26.1±1.8 weeks and 823.5±191.9g, respectively. The mean Aristotle Comprehensive Complexity Score was 14.02±2.48. The median age at surgery was 15.5 days, and 19 (19%) patients died while in hospital.In the multivariate analysis for mortality, patients with a higher Aristotle Comprehensive Complexity Score (OR 2.8 (95% confidence interval, 1.73-4.59); P=.0001) had a higher mortality. Among the risk factors, the Aristotle Comprehensive Complexity Score showed the largest area under curve (0.904) in the receiver-operating curve analysis. The group with a greater than or equal to 15 score had a higher risk of mortality. ConclusionsMortality associated with surgical closure of patent ductus arteriosus is related to prematurity status of the patient not to surgery itself. Aristotle Comprehensive Complexity Score is the most useful independent predictor of mortality. The patient group with greater than or equal to 15 score had an increased risk of in-hospital mortality. In this selected sub-group, a conservative treatment might be the best option.

Preoperative prognostic factors for severe diffuse secondary peritonitis: a retrospective study.

The aim of this study was to analyse preoperative risk factors for mortality or intensive care unit admission to describe severe peritonitis. This was a single academic centre retrospective study of consecutive adult patients operated for diffuse secondary peritonitis between 2012 and 2013. Patients with appendicitis or cholecystitis were excluded. Independent risk factors were identified using binary and ordinal logistic regression. A total of 223 patients were analysed. Overall 30-day mortality was 14.5%. Postoperatively, 32.3% of patients were admitted into the intensive care unit (ICU). Independent risk factors for severe peritonitis were septic shock (odds ratio (OR) 37.94, 95% confidence interval (CI) 14.52-99.13), chronic kidney insufficiency (OR 5.98 (95% CI 1.56-22.86), severe sepsis (OR 4.80, 95% CI 2.10-10.65) and cardiovascular disease (OR 2.58, 95% CI 1.22-5.47). Patients lacking these factors had no mortality. ICU admission was refused in 24 (10.8%) patients with 70.8% mortality. In a subgroup of patients without treatment limitations (n = 190), independent risk factors for weighted outcome of ICU admission or mortality were septic shock (OR 11.89, 95% CI 4.98-28.40), severe sepsis (OR 5.56, 95% CI 2.39-12.89), metastatic malignant disease or lymphoma (OR 3.11, 95% CI 1.34-7.20) and corticosteroid use (OR 2.98, 95% CI 1.18-7.51). When receiving full level of care, patients with preoperative organ dysfunctions in this subgroup had 8.2% 30-day mortality. Preoperative organ dysfunctions, chronic kidney insufficiency and cardiovascular disease are the most important risk factors for severe peritonitis. Without these risk factors, patients had no mortality.

Survival, Neurologic Injury, and Kidney Function after Surgery for Acute Type A Aortic Dissection.

To analyze survival, neurologic injury, and kidney function after acute type A aortic dissection. A total of 445 patients undergoing surgery for acute type A aortic dissection were analyzed. Evaluation according to risk factors for mortality, neurologic injury, and kidney function was performed. Overall 1-, 5-, and 10-year survival rates were 82.8 ± 1.8%, 73.6 ± 2.4%, and 59.3 ± 3.9, respectively. Independent preoperative risk factors for mortality were preexisting renal impairment (p = 0.001), reduced left ventricular ejection fraction (p < 0.001), and age (p < 0.001). Perioperative risk factors were prolonged cross-clamp (p < 0.001) and cerebral perfusion time (p = 0.001). Risk factors for renal failure were preexisting renal impairment (p < 0.001), prolonged cross-clamp time (p < 0.001), cerebral perfusion time (p < 0.001), and age (p = 0.022). Risk factors for neurologic injury were cross-clamp time (p = 0.038), cerebral perfusion time (p = 0.007), and age (p = 0.045). In addition to classic risk factors, survival after type A aortic dissection is affected by preexisting renal impairment. Preexisting renal impairment is predictive of postoperative renal failure. Therefore treatment and prevention strategies for renal failure during the acute and long-term course after acute type A aortic dissection are warranted.

Analysis of pre-operative variables for identifying patients who might benefit from upfront cytoreductive nephrectomy for metastatic renal cell carcinoma in the targeted therapy era.

The aim of the study is to identify pre-operative variables for selection of patients who would benefit from upfront cytoreductive nephrectomy for metastatic renal cell carcinoma. We reviewed the medical records of 171 patients who were presented with synchronous metastatic renal cell carcinoma and who had received no systemic therapy before enrollment. Of these, 96 underwent cytoreductive nephrectomy followed by targeted therapy (cytoreductive nephrectomy group) and 75 treated with targeted therapy alone (non-cytoreductive nephrectomy group). A Cox proportional hazards regression model was used to estimate the prognostic significance of pre-operative characteristics predicting overall survival in the cytoreductive nephrectomy group. The significant variables were designated as pre-operative factors to identify patients who would benefit from cytoreductive nephrectomy. The median overall survival was 19.9 and 11.7 months in the cytoreductive nephrectomy and non-cytoreductive nephrectomy groups (P < 0.001). Karnofsky performance status (<80; hazard ratio 9.497, P < 0.001), hemoglobin (less than lower limit of normal; hazard ratio 1.913, P = 0.025), neutrophils (greater than upper limit of normal; hazard ratio 6.533, P < 0.001) and clinical N stage (N2; HR 2.714, P = 0.001) were independent pre-operative risk factors of mortality. Only those patients with risk factor <2 who had undergone upfront cytoreductive nephrectomy had a better median overall survival than patients who received targeted therapy alone (28.2 vs. 18.4 months, P = 0.018). Four pre-operative risk factors (Karnofsky performance status, hemoglobin, neutrophils and clinical N stage) were identified as suitable for selection of patients who would not benefit from undergoing cytoreductive nephrectomy.

The Aristotle Score Predicts Mortality After Surgery of Patent Ductus Arteriosus in Preterm Infants

Outcomes after surgical ligation of patent ductus arteriosus (PDA) in preterm infants are often complicated by prematurity associated comorbidities. The Aristotle comprehensive complexity score (ACCS) has been proposed as a useful tool for complexity adjustment in the analysis of outcome after congenital heart surgery. The aims of this study were to define preoperative risk factors for mortality and to demonstrate the usefulness of ACCS to predict mortality after surgical ligation of PDA in the preterm. Included were 49 preterm babies (≤35 weeks of gestation) who had surgical ligation of PDA between May 2009 and July 2012. Median gestational age was 27.6 weeks (range, 23 to 35 weeks) and median birth weight was 1,040 g (range, 520 to 2,280 g). Median age at operation was 15 days (range, 4 to 44 days) and median weight was 1,120 g (range, 400 to 2,880 g). Initial oral ibuprofen was ineffective in 24 patients and contraindicated in 25. All surgical ligations were done at bedside in the neonatal intensive care unit. Preoperative clinical and laboratory profiles were reviewed and ACCS was derived. Eight of 49 patients (16.3%) died at a median of 14 days (range, 2 to 73 days) after PDA ligation. Patients who had contraindications for oral ibuprofen (odds ratio [OR] 8.94; p=0.049), coagulopathy (OR 12.13; p=0.025), renal dysfunction (OR 28.88; p=0.003), intraventricular hemorrhage greater than grade II or seizure (OR 34.00; p=0.002), and ACCS points (OR 29.594; p<0.05) were significantly associated with an increased risk for mortality. Among the risk factors, ACCS showed the largest area under curve (0.991) by receiver-operating characteristic curve analysis. Optimal cutoff value of ACCS for mortality were 15 or greater, with sensitivity of 87.5%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 97.6%. The ACCS, especially for procedure-independent complexity factors, is a useful tool to predict mortality after ligation of PDA in preterm infants.

Factors that predict clinical outcome after colectomy for fulminant &amp;lt;i&amp;gt;Clostridium difficile&amp;lt;/i&amp;gt; colitis

Background: Historically, the incidence of C. difficile-associated colitis has increased significantly over the last decade. Of these patients, approximately 10% - 20% will ultimately require colectomy due to fulminant disease and progression to toxic colitis. Despite operative intervention, the mortality for this population remains high (35% - 80%). This study evaluates for preoperative risk factors for mortality. Methods: Retrospective medical record review of 47 patients who underwent emergent colectomy for fulminant C. ddifficile colitis over a five-year period at three teaching hospitals in New York City. Results: Forty-seven patients with Clostridium difficile colitis underwent colectomy from January 2003 to December 2008. The mean age was 66 years with 31 (67%) male and 16 (34%) female. The 30-day mortality was 34% (16/47 patients). Thirty-eight (81%) underwent subtotal colectomy, six (13%) Hartmann resection, two (4%) right hemicolectomy, and one (2%) underwent left colectomy. Univariate analysis showed that age (71.6 vs. 67.5 years; p = 0.402), white blood cell count (35,500 vs. 27,700/mm3; p = 0.271), and use of vaso-pressors in the pre-operative period *p = 0.440) were not statistically predictive of postoperative mortality. Conversely, preoperative serum lactate level (4.3 vs. 2.1 mmol/L p + 0.009) was statistically greater in the postoperative mortality group. Conclusion: In the setting of fulminant C. difficile colitis, serum lactate levels can help predict postoperative outcome following emergent colectomy and should be closely followed to facilitate the decision to proceed with surgery.

Outcomes for endocarditis surgery in North America: A simplified risk scoring system

Operation for infective endocarditis is associated with the highest mortality of any valve disease, with overall rates of in-hospital mortality exceeding 20%. The Society of Thoracic Surgeons Adult Cardiac Surgery Database was examined to develop a simple risk scoring system and identify areas for quality improvement. From 2002 through 2008, 19,543 operations were performed for infective endocarditis. Logistic regression analysis related baseline characteristics to both operative mortality and a composite of mortality and major morbidity within 30 days. Points were assigned to each risk factor, and estimated risk was obtained by averaging events for all patients having the same number of points. Overall unadjusted mortality was 8.2%, and complications occurred in 53%. Significant preoperative risk factors for mortality (associated points) were as follows: emergency, salvage status, or cardiogenic shock (17), preoperative hemodialysis, renal failure, or creatinine level less than 2.0 (12), preoperative inotropic or balloon pump support (10), active (vs treated) endocarditis (10), multiple valve involvement (9), insulin-dependent diabetes (8), arrhythmia (8), previous cardiac surgery (7), urgent status without cardiogenic shock (6), non-insulin-dependent diabetes (6), hypertension (5), and chronic lung disease (5), with a C statistic of 0.7578 (all P < .001). Risk-adjusted mortality and major morbidity were unchanged over the course of the study. In the entire data set, mortality was better if "any valve" was repaired (odds ratio = 0.76; P = .0023). Operative mortality for surgically treated infective endocarditis is substantially lower than reported in-hospital mortality rates for infective endocarditis. The described risk scoring system will inform clinical decision-making in these complex patients.

Gender and 30-day outcome in patients undergoing endovascular aneurysm repair (EVAR): An analysis using the ACS NSQIP dataset

Prior studies have demonstrated higher in-hospital mortality in women undergoing open abdominal aortic aneurysm repair. The current study evaluates the relationship between gender and 30-day outcomes for endovascular aneurysm repair (EVAR) in a multicenter, contemporary patient population. Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant use file that underwent EVAR of abdominal aortic aneurysm (AAA) from 2005 to 2007 were identified by CPT codes. Outcomes analyzed were 30-day mortality, morbidity (one or more of 21 complications defined by the ACS NSQIP protocol), length of hospital stay, and six complication subgroups. Preoperative risk factors, intraoperative variables, and outcomes were compared across genders using chi(2) (binary and categorical variables) and t tests (continuous variables). The relationship of gender to outcomes was further evaluated using multivariate logistic regressions to adjust for pre- and intraoperative risk variables. In 3662 EVAR patients, 647 (17.7%) were women and 3015 (82.3%) men with mean ages of 75.1 +/- 9.0 and 73.7 +/- 8.5 years (P < .001). Tube graft (360, 9.8%); bifurcated, one docking limb (1624, 44.3%); bifurcated, two docking limbs (1294, 35.3%); unibody (218, 5.9%); and aorto-uni-iliac/femoral (166, 4.4%) repairs were performed. Tube and aorto-uni-iliac/femoral grafts were more common in women (21.4% vs 12.8%, P < .001) than men, as were femoral/femoral crossovers (3.9% vs 1.8%, P = .011) and iliac or brachial exposures (2.8% vs 1.0%, P = .009). Overall morbidity and mortality were 11.9% and 2.1%, respectively. Mortality in women was significantly higher (3.4% vs 2.1%, P = .014), as was morbidity (17.8% vs 10.6%, P < .001). Of thirteen independent preoperative risk factors for mortality or morbidity, women had a higher incidence in five: emergent operation, functional dependence, recent weight loss, underweight status or morbid obesity, and severe chronic obstructive pulmonary disease (COPD). After adjustment for these variables, the odds ratio (OR) for mortality in women vs men was 1.52 (95% confidence interval [CI] 0.85-2.69, P = .157); OR for morbidity was 1.65 (95% CI 1.28-2.14, P < .001). Female gender was also found to be an independent risk factor for length of stay (Beta 0.7 days, 95% CI 0.2-1.2, P = .006), infectious complications (OR 1.49, 95% CI 1.10-2.03, P = .011), wound complications (OR 1.80, 95% CI 1.12-2.90, P = .015) and postoperative transfusion (OR 2.92, 95% CI 1.39-6.13, P = .002). Mortality and morbidity were higher in women than men undergoing EVAR. Multivariate analysis showed that the increased risk of mortality was related to women presenting more emergently, more debilitated (recent weight loss and functional dependence), and requiring iliac or brachial exposure. After adjustment for multiple preoperative and operative factors, women remained at significantly higher risk for the development of a broad range of complications and increased length of stay.

Preoperative risk factors for mortality after relaparotomy: analysis of 254 patients

The aim of this work was to analyze preoperative mortality risk factors after relaparotomy for abdominal surgery in a unit of General Surgery at a University Hospital. A total of 314 relaparotomies in 254 patients were performed between February 2004 and February 2008. We analyzed data about past medical history, first operation, as well as clinical and biochemical parameters previous to reoperation. Indications for relaparotomy were peritonitis, bleeding, abscess, exploratory laparotomy, and evisceration. Overall mortality was 22%. Mortality of the patients with a single relaparotomy was 20% vs. 44% if they were reoperated upon twice. Mortality was associated with age, past history of cardiovascular disease, active neoplasm, previous treatment with platelet anti-aggregant drugs, first surgery American Society of Anesthesia score, and the presence of an anastomosis. Preoperative data associated with mortality were the number of systemic inflammatory response syndrome criteria, suture dehiscense, ileus, positive blood cultures, mechanical ventilation, artificial nutrition, antibiotics or vasoactive drugs, tachycardia, and abnormal body temperature. High white blood cell count or bilirrubin levels and low albumin or prothrombin time were also associated with mortality. Multivariate logistic regression analysis isolated age (P = 0.02), abnormal body temperature (P = 0.02), and the need of mechanical ventilation (P = 0.004) as independent preoperative variables predictive for mortality after relaparotomy. Advanced age, the presence of either fever or hypothermia, and the need of mechanical ventilation are preoperative risk factors associated with mortality after relaparotomy and should be considered when planning reintervention.

Adult Congenital Heart Surgery: Adult or Pediatric Facility? Adult or Pediatric Surgeon?

One of the current controversies in the field of adult congenital heart disease is whether patients should be cared for at an adult or pediatric facility and by an adult or pediatric heart surgeon. After transitioning our program from the children's hospital to the adult hospital, we analyzed our experience with each system. Between 2000 and 2007, 303 operations were performed on adults (age >or= 18 years) with congenital heart disease. One hundred eighty-five operations were performed in an adult hospital and 118 in a pediatric hospital. Forty-six operations were performed by an adult heart surgeon and 257 by a congenital heart surgeon. Mean age, coexisting medical problems, and preoperative risk factors were higher in both the adult hospital group and adult surgeon group compared with the respective pediatric groups. Mortality was similar at the adult and pediatric hospitals (4.3% versus 5.1%), but was markedly higher in the adult surgeon group compared with the pediatric surgeon group (15.2% versus 2.7%; p = 0.0008). By multivariate analysis, risk factors for mortality included older age at the time of surgery (p = 0.028), surgery performed at a children's hospital (p = 0.013), and surgery performed by an adult heart surgeon (p = 0.0004). Congenital heart surgery can be performed in adults with reasonable morbidity and mortality. Caring for an anticipated aging adult congenital population with increasingly numerous coexisting medical problems and risk factors is best facilitated in an adult hospital setting. Also, when surgery becomes necessary, these adult patients are best served by a congenital heart surgeon.

Preoperative Risk Factors for Mortality After Biventricular Assist Device Implantation

Background A right ventricular assist device is a treatment option for patients with severe right ventricular failure after left ventricular assist device (LVAD) implantation. Recognition of risk factors for mortality after biventricular assist device (BiVAD) implantation is important for patient selection and optimal outcomes. Methods We reviewed our experiences between 1991 and 2005 in 44 patients who were supported by both an LVAD and a right ventricular assist device. Results Thirteen patients (30%) survived until heart transplantation, and 31 patients (70%) died while on support. The multivariate analysis shows that post-LVAD extracorporeal membrane oxygenation and worsening renal function are associated with the highest postoperative mortality. The univariate analysis also included previous thoracic surgery and ischemic cardiomyopathy as potential preoperative indicators for poor outcome after BiVAD implants. No differences were observed in the rates for the need of preoperative support with a ventilator, an intra-aortic balloon pump, or extracorporeal membrane oxygenation, or in the rates of postoperative complications between survivors and nonsurvivors. Conclusions BiVAD implantation remains one of the challenges in treating severe heart failure. Previous cardiac surgery, elevated creatinine, and post-LVAD extracorporeal membrane oxygenation were risk factors for mortality after BiVAD implantation. Dialated Cardiomyopathy on the other hand was associated with a more favorable outcome.

Preoperative Risk Factors for Mortality after Biventricular Assist Device Implantation

Preoperative Risk Factors for Mortality after Biventricular Assist Device Implantation

Predicting Operative Mortality After Surgery for Ischemic Cardiomyopathy

Ischemic cardiomyopathy accounts for as many as 70% of cases of heart failure with no clear algorithm for the treatment. We assessed the operative risks and mortality of various surgical options: coronary artery bypass grafting (CABG), CABG and mitral valve repair (CABG/MVR), and left ventricular remodeling (LVR) with or without CABG. We hypothesized that additional procedures increased the operative risk. We determined whether preoperative variables (eg, urgency of operation) impacted the surgical outcome. A retrospective analysis of University of Virginia patients from January 2000 until September 2006 was undertaken. Patients with CABG and an ejection fraction less than 35%, ischemic mitral regurgitation by operative characterization, and patients with LVR were identified. The Society of Thoracic Surgeons database risks, complications, and outcomes as well as degree of revascularization, quality of targets, and type of additional procedures were analyzed. Incomplete revascularization was defined as a planned bypass not performed. Poor targets were defined as per the operative note. In all, 382 patients were identified (220 CABG, 97 CABG/MVR, and 65 LVR). The overall operative mortality was 7.9%. Mortality was 9.1% for CABG, 8.2% for CABG/MVR, and 3.1% for LVR. Preoperative risk factors for mortality included diabetes mellitus (p = 0.05), previous cerebrovascular disease (p = 0.05), and chronic renal dysfunction (p = 0.03). Patients with emergency operations had a significantly increased mortality (p < 0.001) as did patients with intra-aortic balloon pumps (p = 0.015). Additional procedures such as MVR or LVR did not add to the operative risk of CABG for ischemic cardiomyopathy. Only preoperative comorbidities and emergency operations increased operative mortality.