Preoperative Beta-blocker Use Research Articles

Preoperative beta blockers and other drugs in relation to anastomotic leakage after anterior resection for rectal cancer.

Previous research has indicated that preoperative beta blocker therapy is associated with a decreased risk of complications after surgery for rectal cancer. This is thought to arise because of the anti-inflammatory activity of the drug. These results need to be reproduced and analyses extended to other drugs with such properties, as this information might be useful in clinical decision-making. The main aim of this work was to replicate previous findings of beta blocker use as a prognostic marker for postoperative leakage. We also investigated whether drug exposure might induce anastomotic leaks. This is a retrospective multicentre cohort study, comprising 1126 patients who underwent anterior resection for rectal cancer between 2014 and 2018. The use of any preoperative beta blocker was treated as the primary exposure, while anastomotic leakage within 12 months of surgery was the outcome. Secondary exposures comprised angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins and metformin. Using multivariable regression, we performed a replication analysis with a predictive aim for beta blockers only, while adjustment for confounding was done in more causally oriented analyses for all drugs. We estimated incidence rate ratio (IRR) and relative risk (RR) with 95% confidence intervals (CIs). Anastomotic leakage occurred in 20.6% of patients. Preoperative beta blockers were used by 22.7% of the cohort, while the leak distribution was almost identical between exposure groups. In the main replication analysis, no association could be detected (IRR 0.95, 95% CI 0.68-1.33). In the causally oriented analyses, only metformin affected the risk of leakage (RR 1.59, 95% Cl 1.31-1.92). While previous research has suggested that preoperative beta blocker use could be prognostic of anastomotic leakage, this study could not detect any such association. On the contrary, our results indicate that preoperative beta blocker use neither predicts nor causes anastomotic leakage after anterior resection for rectal cancer.

Association of Metabolic Syndrome with Stroke, Myocardial Infarction, and Other Postoperative Complications Following Carotid Endarterectomy: A Multicenter, Retrospective Cohort Study

Metabolic Syndrome (MetS) is a constellation of hypertension, insulin resistance, obesity, and dyslipidemia, and is known to increase the risk of postoperative morbidity. This study aimed to assess the impact of MetS on stroke, myocardial infarction (MI), mortality, and other complications following carotid endarterectomy (CEA). We analyzed data from the National Surgical Quality Improvement Program. Patients undergoing elective CEA between 2011 and 2020 were included. Patients with American Society of Anesthesiologists status 5, preoperative length of stay >1 day, ventilator dependence, admission from non-home location, and ipsilateral internal carotid artery stenosis of <50% or 100% were excluded. A composite cardiovascular outcome for postoperative stroke, MI, and mortality was generated. Multivariable binary logistic regression analyses were used to assess the association of MetS with the composite outcome and other perioperative complications. We included 25,226 patients (3613, 14.3% with MetS). MetS was associated with postoperative stroke, unplanned readmission, and prolonged length of stay (LOS) on bivariate analysis. On multivariable analysis, MetS was significantly associated with the composite cardiovascular outcome (1.320 [1.061-1.642]), stroke (1.387 [1.039-1.852]), unplanned readmission (1.399 [1.210-1.619]), and prolonged LOS (1.378 [1.024-1.853]). Other clinicodemographic factors associated with the cardiovascular outcome included Black race, smoking status, anemia, leukocytosis, physiologic risk factors, symptomatic disease, preoperative beta blocker use, and operative time ≥150 minutes. MetS is associated with cardiovascular complications, stroke, prolonged LOS, and unplanned readmissions following CEA. Surgeons should provide optimized care to this high-risk population and strive to reduce operative durations.

Medicare Patients with Symptomatic Carotid Disease Requiring Carotid Revascularization Are Likely to Have Delayed Access: An Analysis of a Multicenter Surgical Data

The Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease recommends carotid revascularization as soon as the patient is neurologically stable after 48 hours and before 14 days of symptom onset in patients with recent stroke. In the United States, insurance status has been demonstrated to play a role in wait times for surgical care. There are no large-scale studies that assess the effect of patient primary insurance status on time to surgery in patients with symptomatic carotid disease. We utilized the Vascular Quality Initiative (VQI) database to evaluate our hypothesis that insurance status is associated with waiting times before surgery in patients with symptomatic carotid disease. All patients who underwent carotid revascularization in the VQI dataset from 2010 to 2022 were included. Patients with incomplete or missing outcomes data, Modified Rankin score of >2 and asymptomatic were excluded. Primary outcome was time between onset of symptomatic carotid disease and intervention. Categorical variables were compared using χ2 test and one-way analysis of variance for continuous variables. Multivariable logistic regression was used to assess the association between insurance status and waiting time to surgery while adjusting for potential confounders. The study consisted of 11,973 patients who had carotid revascularization within 14 days of symptoms (early cohort) and 21,253 patients in the late cohort (after 14 days). Patients in the late cohort were older (70.1 ± 9.8 vs 69.8 ± 10.5; P = .02), less likely to undergo carotid endarterectomy (85.9% vs 88.4%; P < .01), and more likely to have an elective procedure (90.3% vs 44.3%; P < .01). Fig 1 shows the distribution of insurance coverage among the study cohort. After adjusting for potential confounders, compared to Medicare, recipients of other insurer types had lower odds of experiencing delayed surgery: Medicare Advantage (adjusted odds ratio [aOR], 0.89; 95% confidence interval [CI], 0.80-0.99; P = .03), commercial (aOR, 0.84; 95% CI, 0.78-0.90; P < .001), military/Department of Veterans Affairs (aOR, 0.67; 95% CI, 0.54-0.84; P < .001), and self-pay (aOR, 0.54; 95% CI, 0.45-0.65; P < .001). Medicaid patients had similar delay (aOR, 0.90; 95% CI, 0.78-1.03; P = .14) and non-US insurance had longer delay to surgery (aOR, 1.48; 95% CI, 1.13-1.95; P = .005), in comparison to Medicare patients (Fig 2). Symptomatic carotid patients on Medicare and Medicaid are more likely to receive delayed revascularization procedures compared to patient with commercial insurance. Future studies are needed to investigate and potentially mitigate the underlying causes for the delay and the overall health implications of such a delay on the long-term outcomes of these patients.Fig 2Adjusted odds of receiving late carotid revascularization in symptomatic patients requiring surgery: comparing other major insurance providers with Medicare. *Model adjusted for urgency of procedure, prior coronary artery disease, prior carotid endarterectomy/coronary artery stenting, preoperative beta-blocker use, prior congestive heart failure, type of procedure (carotid endarterectomy, transcarotid artery revascularization, transfemoral carotid artery stenting), age, race, body mass index, preoperative creatinine levels, preoperative hemoglobin concentration, preoperative dysrhythmia, previous major amputation, preoperative functional status, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, and degree of stenosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract WP180: Gender-specific Risk Of Stroke In Patients With Peripheral Artery Disease

Objective: Peripheral artery disease (PAD) is a common atherosclerotic disease associated with increased morbidity and mortality. We conducted a retrospective review to investigate the role of gender in influencing the incidence of stroke after surgery for PAD. Methods: We conducted a retrospective review using data from the Vascular Quality Initiative database for patients who underwent supra-inguinal and infra-inguinal surgery between 2010 and 2020. The relationship between gender and 30-day post-operative outcomes was calculated as an odds ratio; the threshold of significance was p =0.05 for univariate and multivariable analysis. Gender-based influence of age and adjusted probability of stroke was plotted using Sigma Plot. Results: A total of 79,981 patients were included based on our eligibility criteria, 34% of which were female. Although only 0.6% of patients experienced stroke, risk of stroke was significantly higher in female patients ( p &lt;0.001). Female patients were more commonly hypertensive ( p =0.007) and diabetic ( p =0.003), while also presenting decreased pre-operative use of statin ( p &lt;0.001) and aspirin ( p &lt;0.001) as compared to males. Additional predictors of post-operative stroke include age &gt; 65 years ( p =0.015), hypertension ( p =0.002), and pre-operative use of beta blockers ( p &lt;0.001). Overall, females had higher risk of all-cause morbidity ( p =0.004), stroke ( p &lt;0.001), mortality ( p &lt;0.001), and major adverse cardiovascular events ( p &lt;0.001), while males had increased risk of returning to the operating room ( p =0.006). Regression analysis revealed a significantly stronger bearing of high age on probability of post-operative stroke in women ( p &lt;0.001). Conclusion: Our data suggests that incidence of post-operative stroke and other cardiovascular complications is influenced by gender in surgery of PAD. Future research investigating underlying gender-based mechanisms is necessary to personalize treatment in patients with PAD.

Lack of Association Between Perioperative Medication and Postoperative Delirium in Hip Fracture Patients in an Orthogeriatric Care Pathway.

Units for perioperative geriatric care are playing a growing role in the care of older patients after hip fracture surgery. Postoperative delirium is one of the most common complications after hip fracture, but no study has assessed the impact of therapeutics received during a dedicated orthogeriatric care pathway on its incidence. Our main objective was to assess the association between drugs used in emergency, operating, and recovery departments and postoperative delirium during the acute stay. Retrospective cohort study. All patients ≥70years old admitted for hip fracture to the emergency department and hospitalized in our unit for perioperative geriatric care after hip fracture surgery under general anesthesia between July 2009 and December 2019 in an academic hospital in Paris. Demographic, clinical, and biological data and all medications administered pre-, peri-, and postoperatively were prospectively collected by 3 geriatricians. Postoperative delirium in the unit for perioperative geriatric care was assessed by using the confusion assessment method scale. Logistic regression analysis was used to assess variables independently associated with postoperative delirium. A total of 490 patients were included [mean (SD) age 87 (6) years]; 215 (44%) had postoperative delirium. The occurrence was not associated with therapeutics administered during the dedicated orthogeriatric care pathway. Probability of postoperative delirium was associated with advanced age [>90years, odds ratio (OR) 2.03, 95% confidence interval (CI) 1.07-3.89], dementia (OR 3.51, 95% CI 2.14--5.82), depression (OR 1.85, 95% CI 1.14-3.01), and preoperative use of beta-blockers (OR 1.75, 95% CI 1.10-2.79). No emergency or anesthetic drugs were significantly associated with postoperative delirium. Further studies are needed to demonstrate a possible causal link between preoperative use of beta-blockers and postoperative delirium.

Incidence and predictive factors associated with hemodynamic instability among adult surgical patients in the post-anesthesia care unit, 2021: A prospective follow up study

BackgroundHemodynamic instability, which is an independent predictor of long-term patient morbidity and duration of stay in the hospital, is a risk for patients in the post-anesthesia care unit. Multiple factors contribute to the development of postoperative hemodynamic instability. Prevention and treatment of these factors may reduce patients' hemodynamic instability, and its associated morbidity and mortality. ObjectiveThe aim of this study was to determine the incidence and factors associated with hemodynamic instability among adult surgical patients in the post-anesthesia care unit. MethodAn institution-based prospective follow up study was conducted from April 20, 2021 to June 28, 2021. Four hundred and seventeen (417) adult surgical patients were involved in this study. Descriptive and analytic statistics were used to describe our results. Both the bivariable and multivariable logistic regression with crude odds ratio and adjusted odds ratio were used with a 95% confidence interval to evaluate the strength of association. In multivariable regression, a p-value < 0.05 was considered as statistically significant. ResultThe overall incidence of hemodynamic instability was 59.47% (CI: 0.55, 0.64). The incidence of tachycardia, bradycardia, hypotension, and hypertension were 27.34%, 21.82%, 13.67%, and 15.35% respectively. Preoperative use of beta-blockers, ASA class III, procedure longer than 4 h, intraoperative hemodynamic instability, and regional anesthesia were significantly associated with hemodynamic instability in the post-anesthesia care unit. Conclusion and recommendationThe incidence of hemodynamic instability in the post anesthesia care unit was high. Preoperative use of beta-blockers, intraoperative hemodynamic instability, and prolonged duration of procedures were predictors of hemodynamic instability after operation. Early detection and management of these perioperative risk factors is necessary to reduce hemodynamic instability in the post-anesthesia care unit.

The association between the type of anesthesia and hemodynamic instability during pheochromocytoma surgery: a retrospective cohort study.

Pheochromocytoma often carries a risk for perioperative hemodynamic instability (HDI). The aim of this study is to evaluate the risk factors of intraoperative HDI during minimally invasive posterior retroperitoneal adrenalectomy (PRA) for pheochromocytoma. This retrospective study analyzed the prospectively collected data of 172 patients who underwent laparoscopic PRA or robotic PRA for pheochromocytoma between January 2014 and December 2020 at a single tertiary center. The patients were divided into two groups according to the intraoperative hypertensive event of systolic blood pressure (> 160mmHg). The clinical manifestations and perioperative hemodynamic conditions were analysed. In the multivariate logistic regression analysis, the tumor size (> 3.4cm) [OR 3.14, 95% confidence intervals (CI) (1.48-6.64), p = 0.003], type of preoperative alpha-blocker (selective type) [OR 3.9, 95% CI (1.52-10.02), p = 0.005], preoperative use of beta-blockers [OR 3.94, 95% CI (1.07-14.49), p = 0.039] and type of anesthesia [total intravenous anesthesia (TIVA) vs. balanced anesthesia (BA)] [OR 2.57, 95% CI (1.23-5.38), p = 0.012] were determined as independent risk factors of intraoperative hypertensive events during minimally invasive adrenalectomy. The type of anesthesia was independently associated with intraoperative HDI along with larger tumor size, type of preoperative alpha-blocker and the use of preoperative beta-blockers. TIVA increased the risk of intraoperative hypertensive events compared with BA. Thus, the consideration of the type of anesthesia prior to adrenal surgery for pheochromocytoma along with the use of preoperative non-selective alpha-blockers may be beneficial in minimizing the risk of intraoperative HDI.

Preoperative beta-blocker in ventricular dysfunction patients: need a more granular quality metric

BackgroundThe use of preoperative beta-blockers has been accepted as a quality standard for patients undergoing coronary artery bypass graft (CABG) surgery. However, conflicting results from recent studies have raised questions concerning the effectiveness of this quality metric. We sought to determine the influence of preoperative beta-blocker administration before CABG in patients with left ventricular dysfunction.MethodsThe authors analyzed all cases of isolated CABGs in patients with left ventricular ejection fraction less than 50%, performed between 2012 January and 2017 June, at 94 centres recorded in the China Heart Failure Surgery Registry database. In addition to the use of multivariate regression models, a 1–1 propensity scores matched analysis was performed.ResultsOf 6116 eligible patients, 61.7% received a preoperative beta-blocker. No difference in operative mortality was found between two cohorts (3.7% for the non-beta-blockers group vs. 3.0% for the beta-blocker group; adjusted odds ratio [OR] 0.82 [95% CI 0.58–1.15]). Few differences in the incidence of other postoperative clinical end points were observed as a function of preoperative beta-blockers except in stroke (0.7% for the non-beta-blocker group vs. 0.3 for the beta-blocker group; adjusted OR 0.39 [95% CI 0.16–0.96]). Results of propensity-matched analyses were broadly consistent.ConclusionsIn this study, the administration of beta-blockers before CABG was not associated with improved operative mortality and complications except the incidence of postoperative stroke in patients with left ventricular dysfunction. A more granular quality metric which would guide the use of beta-blockers should be developed.

Anesthetic implications and role of preoperative beta blockade in esophageal substitution with stomach in pediatric surgical patients

BackgroundThere is a paucity of literature on the anesthetic management of pediatric esophageal substitution using the stomach. We did a retrospective analysis of all such cases done at our institution. We analyzed the patient’s demography, indication, and type of surgery, co-morbid conditions, anesthesia techniques, duration of postoperative ventilation, hospital stay, complications, and mortality. The use of beta-blockers and their effect on the incidence of intraoperative and postoperative tachycardia in gastric pull-up patients was also analyzed.ResultsThirty-four cases of gastric substitution of the esophagus in children were done over 19-year period; gastric pull-up was done in 28 patients and a gastric tube was made in 6 patients. General anesthesia was given to all; a thoracic epidural for pain was sited in 25 patients. Twenty-eight patients were ventilated postoperatively; the mean duration of ventilation is 54 h. Significant intraoperative tachycardia was observed in 85.7% of patients without beta-blocker as compared to 23.8% patients with beta-blocker (p = 0.004). Postoperatively, tachycardia was absent in patients receiving beta-blocker and present in 71.4% of patients not receiving beta-blockers (p < 0.001). Overall mortality was 8.8% but mortality due to cardiac arrhythmia was 42.9% in the patients not receiving beta-blockers (p = 0.001).ConclusionsA thorough preoperative preparation, control of tachyarrhythmias, postoperative ventilation, and pain management is recommended for a favorable outcome. In addition, our paper supports the preoperative use of beta-blockers in reducing the incidence of fatal tachyarrhythmias associated with gastric pull-up surgery without any serious adverse effects.Level of evidenceLevel III

Long-term Use of Preoperative Beta-Blockers Is Associated With Reduced Postoperative Stroke After Thoracic Endovascular Aneurysm Repair

Thoracic endovascular aortic repair (TEVAR) has been established as the treatment of choice for a range of thoracic aortic pathologies. Beta-blockers represent a possible perioperative treatment option to improve TEVAR outcomes due to their role in management of aortic aneurysm, dissection, and Marfan syndrome. We investigated the effect of preoperative beta-blocker usage on outcomes of TEVAR using the Vascular Quality Initiative database.

26141 The risk of Mohs surgery complications in patients with preoperative beta-blocker use

Background: Beta (β) blockers are commonly used to lower blood pressure. Dermal fibroblasts, which express β2 receptors, play a major role in wound healing. It is unclear whether patients who undergo Mohs micrographic surgery (MMS) while on β-blockers are at increased risk of postoperative complications compared with those not on β-blockers.

Perioperative Risk Factors Predisposing to Atrial Fibrillation After CABG Surgery.

To detect perioperative risk factors for atrial fibrillation (AF) after coronary artery bypass graft (CABG) and to assess the impact of AF on outcome and postoperative complications. We undertook a prospective observational study of 1000 consecutive patients who underwent isolated CABG in Cairo University hospitals and other centers from March 2019 to November 2020. Patients were subsequently divided into 2 groups depending on the occurrence of postoperative AF. Preoperative, intraoperative, and postoperative risk factors were recorded for all patients, as well as postoperative mortality, complications, and hospital and intensive care unit (ICU) lengths of stay. Postoperative atrial fibrillation (POAF) occurred in 78 patients (7.8%), with significant risk factors of age (P = .001), low ejection fraction (P = .001), absence of preoperative beta-blocker use (P = .001), and presence of right coronary artery lesion (P = .003). The intraoperative significant risk factor was the absence of total coronary revascularization (P = .001). Postoperative significant risk factors were electrolyte imbalance (P = .001) and postoperative inotropes (P = .02). Patients with postoperative AF had increased risk of mortality (P = .001) and longer ICU (P = .001) and hospital (P = .001) stays. The risk of POAF can be decreased by modifying perioperative adjustable risk factors, namely routinely using preoperative beta-blockers (unless contraindicated), achieving total coronary revascularization, avoiding postoperative electrolyte imbalance, and avoiding unnecessary use of inotropic support.

Abstract 12820: Beta Blocker Use and Peri-operative Outcomes in Cancer Patients Receiving Immunotherapy

Introduction: The impact of beta blocker use on surgical outcomes of cancer patients receiving immunotherapy is unknown. Hypothesis: Beta blocker use is associated with lower post-operative mortality in cancer patients on immunotherapy. Methods: We used an institutional Advanced Cohort Explorer to identify all patients who underwent any surgical procedure less than 90 days after receiving immunotherapy. Data on the procedure performed as well as the post-operative outcome were collected and analyzed per the pre-operative beta blocker use status. Results: A total of 233 patients underwent surgery between 09/2011-06/2019. Mean age was 64.7 years (range: 16-92). The most common cancer diagnoses were lung (48, 44.4%), melanoma (49, 45.4%) and kidney (11, 10.2%). Immunotherapy medications were pembrolizumab ( 127, 54.5%), nivolumab (51, 21.9%), ipilimumab (43, 18.5%), atezolizumab (11, 4.7%) and avelumab (1, 0.43%). Pre-operative beta blocker use was documented in 140 (60.1%) patients. Most common surgical procedures were skin resection (75, 32.1%), wound repair (47, 20.2%), vascular procedures (36, 15.5%), urethral procedures 16 (6.9%) and sentinel lymph node biopsies (10, 4.3%). The 30-day mortality rate was 10.3% (24 deaths). In a multi-variable logistic regression analysis, pre-operative use of beta blockers was associated with a lower risk of death within 30 days from surgery (OR 0.34, CI 0.13-0.87, P=0.024). 30-day mortality rates were higher in patients undergoing vascular (50%, 17 of 34) versus non-vascular (3.5%, 7 of 199) procedures (P&lt;0.0001) in a Chi Square test. Conclusions: Beta blocker use is associated with a lower 30-day mortality rate after surgical procedures in cancer patients treated with immunotherapy. Further investigation is warranted.

PREOPERATIVE PREDICTIVE VALUE OF ECHOCARDIOGRAPHIC CHARACTERISTICS AND CARDIOVASCULAR RISK FACTORS IN POSTOPERATIVE ATRIAL FIBRILLATION

Objective: Postoperative atrial fibrillation (POAF) is the most common arrhythmia in patients after isolated coronary artery bypass grafting (CABG).With a reported incidence between 10% and 40%, it is associated with an increased morbidity, mortality and prolonged hospitalization which is very often followed by an increased hospital-related complications and costs.The aim of this study was to identify significant preoperative predictors for non-valvular POAF in patients undergoing CABG. Design and method: Retrospective study included 226 consecutive patients revascularized at Clinic of Cardiac Surgery, Clinical Center of Serbia, during the four months’ period. Patients were divided in two groups: on-pump (N: 176) and off-pump (N: 50). In both groups, we investigated the association of demographic characteristics (gender, age), echocardiographic characteristics (left ventricular systolic function, preoperative size of the left atrium and left ventricle) and cardiovascular risk factors (arterial hypertension, diabetes, hyperlipidemia) with the occurrence of non-valvular POAF, using the Logistic regression analysis. Exclusion criteria were severe MR and preoperative AF. Results: The incidence of POAF was 23.45% (on-pump: 22.2%, off-pump: 28%; p > 0.05). There were statistically significant differences between two study groups considering: left ventricular systolic function (X2 = 12,896; p < 0,001), preoperative size of the left atrium (X2 = 13,046; p < 0,001) and left ventricle (EDD:t = 3,439; p = 0,001, ESD: t = 3,162; p = 0,002) and presence of diabetes mellitus (X2 = 6,841; p = 0,009). In the off-pump group, an independent preoperative predictor of POAF was preoperative size of left atrium (OR 34.000; 95% CI 1.479–781.787; p: 0.027). Paradoxically, an independent inverse relationship of preoperative arterial hypertension and the risk of POAF was documented in the on-pump group(OR 0.088; 95% CI 0.009–0.874; p: 0.038), most likely due to the more frequent preoperative use of beta-blockers in patients with a history of hypertension. Conclusions: We found that patients with very enlarged left atrium (>5 cm) had significantly higher risk of POAF. Independent preoperative predictors for POAF are preoperative size of left atrium in off-pump and arterial hypertension in on-pump revascularized patients.

PREOPERATIVE PREDICTIVE VALUE OF HYPERTENSION, ECHOCARDIOGRAPHIC CHARACTERISTICS AND OTHER CARDIOVASCULAR RISK FACTORS IN POSTOPERATIVE ATRIAL FIBRILLATION

Objective: Postoperative atrial fibrillation (POAF) is the most common arrhythmia in patients after isolated coronary artery bypass grafting (CABG). The incidence is between 10% and 40%, and is associated with an increased morbidity, mortality and prolonged hospitalization. The aim of this study was to identify significant preoperative predictors for non-valvular POAF in patients undergoing CABG. Design and method: We included 226 consecutive patients, revascularized at Cardiac Surgery Clinic, Clinical Center of Serbia, during the four months’ period. Patients were divided in two groups: on-pump (N: 176) and off-pump (N: 50). In both groups, we investigated the association of demographic characteristics (gender, age), echocardiographic characteristics (left ventricular systolic function, preoperative size of the left atrium and left ventricle) and cardiovascular risk factors (arterial hypertension, diabetes, hyperlipidemia) with the occurrence of non-valvular POAF, using the logistic regression analysis. Exclusion criteria were severe MR and preoperative AF. Results: The incidence of POAF was 23.45% (on-pump: 22.2%, off-pump: 28%; p > 0.05). There were statistically significant differences between two study groups considering: left ventricular systolic function (p < 0,001), preoperative size of the left atrium (p < 0,001) and left ventricle (p = 0,001, ESD: p = 0,002) and presence of diabetes mellitus (p = 0,009). In the off-pump group, an independent preoperative predictor of POAF was preoperative size of left atrium (p: 0.027). Paradoxically, an independent inverse relationship of preoperative arterial hypertension and the risk of POAF was documented in the on-pump group (p: 0.038), most likely due to the more frequent preoperative use of beta-blockers in patients with a history of hypertension. Conclusions: We found that patients with very enlarged left atrium (>5 cm) had significantly higher risk of POAF. Independent preoperative predictors for POAF are preoperative size of left atrium in off-pump and arterial hypertension in on-pump revascularized patients.

Professional Society Leadership in Health Care Quality: The Society of Thoracic Surgeons Experience

The STS quality program is overseen by the STS Council on Quality, Research, and Patient Safety, which has four components. The Workforce on Research Development, in collaboration with the STS Research Center, coordinates clinical research based on the STS National Database, all of which is focused on improving clinical outcomes. The Workforce on Evidence Based Surgery develops clinical practice guidelines and expert consensus documents to foster the use of best practices. The Workforce on Patient Safety disseminates high-reliability practices from within and outside health care to improve the safety of cardiothoracic surgical care. The Workforce on National Databases consists of four subspecialty registries (adult cardiac, congenital cardiac, general thoracic, mechanical circulatory support [Intermacs and Pedimacs]) and multiple functionally oriented task forces (Quality Measurement, Quality Initiatives, Public Reporting, Informatics, Patient-Reported Outcomes, and Aortic Surgery). Between 1998 and 2016, the rates of coronary artery bypass grafting surgery adverse outcomes decreased substantially, including operative mortality (-31.3%), renal failure (-56.3%), stroke (-43.5%), reoperation (-65.7%), and sternal infection (-50.0%). Comparable increases in process measure compliance included internal mammary artery use (32%), preoperative beta-blocker use (83.1%), discharge antiplatelet drugs (22.9%), discharge antilipid drugs (78.6%), and discharge beta-blockers (54.1%). The STS quality program has achieved remarkable, continuing improvements in patient safety and quality over several decades. The components of this program can be replicated by other health care professional societies to advance quality and safety for their patient populations.

Predictors and Impact of Vasoplegia after Continuous-Flow Left Ventricular Assist Device Implantation

Purpose We identified the impact of vasoplegia after left ventricular assist device (LVAD) on postoperative outcomes and predictors of postoperative vasoplegia. Methods Retrospective review of 624 patients who had continuous flow LVAD implantation from 2005-2017 at our institution. Mild, moderate, or severe vasoplegia was determined with the vasoactive score (VS) [dopamine+100 x epinephrine + 100 x norepinephrine + 10000 x vasopressin] (U/kg/min), with a VS of 28 being severe. Mean VS was calculated at 0-6 hrs, 6-12 hrs, and 12-24 hrs postoperatively. Results Mean age was similar for vasoplegic and non-vasoplgic patients (Table 1). Vasoplegia was observed in 134 (21.5%) patients. Reoperation for bleeding and 30-day mortality were higher in vasoplegic patients (Table 1). VS at 12-24 hrs had a greater association with 30-day mortality compared to VS at 0-6 or 6-12 hrs (AUC 0.72 vs 0.69 vs 0.65; p creatinine , prolonged cardiopulmonary bypass time, preoperative beta blocker use and preoperative mechanical circulatory support . Conclusion Moderate to severe vasoplegia at 12 to 24 hrs postoperatively is associated with significantly worse survival after CF-LVAD implantation. Modifiable risk factors identified in this study should be optimized to reduce risk of vasoplegia.

Early Carotid Endarterectomy after Acute Stroke Yields Excellent Outcomes: An Analysis of the Procedure-Targeted ACS-NSQIP

Recurrent ischemic events have been associated with delayed carotid endarterectomy (CEA) for patients who present with acute strokes. As such, earlier intervention has been advocated to preserve cerebral function and expedient rehabilitation. We sought to determine the differences in 30-day postoperative major adverse clinical events (MACEs) for patients who undergo early (≤7days) and delayed (>7days) CEA after acute stroke. Our sample consisted of patients captured in the CEA-targeted American College of Surgeons National Surgical Quality Improvement Program data set between 2011 and 2015. The primary outcome was 30-day postoperative MACEs (death, stroke, or myocardial infarction [MI]). Differences in postoperative MACEs were determined between early and delayed CEA treatment. In addition, multivariable analyses were done to determine the association between various patient factors and postoperative complications after CEA for patients who presented with acute strokes. A total of 3,427 patients were identified who underwent CEA for acute stroke in the CEA-targeted files between 2011 and 2015. Overall, perioperative rates of 30-day death, stroke, or MI were 1.30% (n=43), 2.74% (n=94), and 0.96% (n=33), respectively. There were no differences in 30-day postoperative death, stroke, or MI for early or delayed CEA after acute strokes. On multivariable analysis, independent predictors for postoperative MACEs in patients with acute stroke were age ≥80 years (OR 2.41; 95% CI [1.15-5.06]), preoperative beta-blocker use (OR 2.11; 95% CI [1.13-3.93]), and operative time>150min (OR 2.39; 95% CI [0.82-4.98]). There are no differences in postoperative 30-day death, stroke, or MI in early and delayed CEA after an acute stroke. These results substantiate the recommendation for early (<7days) CEA after acute strokes.

Relationship between perioperative thyroid function and acute kidney injury after thyroidectomy

Thyroid dysfunction may alter kidney function via direct renal effects and systemic haemodynamic effects, but information on the effect of thyroid function on postoperative acute kidney injury (AKI) following thyroidectomy remains scarce. We reviewed the medical records of 486 patients who underwent thyroidectomy between January 2010 and December 2014. Thyroid function was evaluated based on the free thyroxine or thyroid stimulating hormone levels. The presence of postoperative AKI was determined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. AKI developed in 24 (4.9%) patients after thyroidectomy. There was no association between preoperative thyroid function and postoperative AKI. Patients with postoperative hypothyroidism showed a higher incidence of AKI than patients with normal thyroid function or hyperthyroidism (19.4%, 6.7%, and 0%, respectively; P = 0.044). Multivariable logistic regression analysis showed that male sex (OR, 4.45; 95% CI, 1.80–11.82; P = 0.002), preoperative use of beta-blockers (OR, 4.81; 95% CI, 1.24–16.50; P = 0.016), low preoperative serum albumin levels (OR, 0.29; 95% CI, 0.11–0.76; P = 0.011), and colloid administration (OR, 5.18; 95% CI, 1.42–18.15; P = 0.011) were associated with postoperative AKI. Our results showed that postoperative hypothyroidism might increase the incidence of AKI after thyroidectomy.

CABG and Preoperative use of Beta-Blockers in Patients with Stable Angina are Associated with Better Cardiovascular Survival.

ObjectiveIn contrast to unstable angina, optimal therapy in patients with stable angina is debated. Our aim was to evaluate the outcomes of patients with stable angina scheduled for isolated coronary artery bypass grafts and the effect of preoperative use of beta-blockers. Overall and cardiovascular survivals were our primary outcome. Operative mortality and postoperative complications along with subgroup analysis of diabetic patients were our secondary outcomes.MethodsRetrospective evaluation of patients with stable angina scheduled for isolated coronary artery bypass grafts was included. Pre- and postoperative variables were extracted from the institution database. Survival was obtained from the National Registry.ResultsWe included 282 patients with stable angina, with a mean age of 65.6±9.5 years. 26.6% were female and 38.7% had diabetes. Three-vessel disease was present in 76.6% of patients. Previous beta-blocker treatment was evident in 69.9% of patients. 10-year overall survival in the whole population was 60.5% (95% confidence interval [CI]: 50.3-70.7%). Operative mortality during the study period was 3.5%. Patients with preoperative use of beta-blocker therapy had better overall survival (9.0 years, 95%CI: 8.6-9.5) than those without treatment (7.9 years, 95%CI: 7.1-8.8 years; P=0.048). Predictors for overall survival were: hypertension, diabetes, and age. Predictors for cardiovascular survival in diabetic patients were: beta-blocker use, gender, and age.ConclusionCoronary artery bypass grafts surgery in patients with stable angina carries low operative mortality, postoperative complications, and excellent long-term cardiovascular survival. The preoperative use of beta-blockers in diabetic patients is associated with better cardiovascular survival after coronary artery bypass grafts.