Rate Of Cardiac Complications Research Articles

491. STEP BY STEP INTRATHORACIC HAND-SEWN ESOPHAGOGASTRIC ANASTOMOSIS DURING TOTALLY ROBOTIC MINIMALLY INVASIVE TWO-STAGE ESOPHAGECTOMY

Abstract Background In every esophagectomy, regardless of the approach, the creation of the anastomosis is a critical step. In minimally invasive esophagectomy, to avoid challenges of thoracoscopic suturing in the upper mediastinum most surgeons use stapling devices or even decide to do a cervical anastomosis. However, in robot-assisted minimally invasive esophagectomy, the surgeon benefits from increased dexterity that facilitates to perform a hand-sewn intrathoracic anastomosis. Methods A 67-year-old man with esophageal adenocarcinoma, staged as a T3N1 underwent neoadjuvant chemotherapy, followed by a fully robotic minimally invasive Ivor-Lewis esophagectomy (robotic surgery during both the abdominal and thoracic phase). For the thoracic phase, the patient was placed in left sided semi-prone position. An 8 mm robotic trocar is inserted in the 6th intercostal space for the camera. Two other 8mm robotic trocars were inserted in the 4th, 8th and a 12mm 10th intercostal space. The anastomosis was constructed at the level, just above the azygos vein. Results The esophagogastric anastomosis was performed with an end-to-end construction. A barbed 3.0 suture was used to close the posterior wall by a single-layer running hand-sewn technique. The esophagostomy and the gastrostomy were performed using vascular scissors. A 36Fr Faucher was placed to expose de inner layer during the esophagostomy. A second posterior continuous full-thickness layer was performed using barbed 3.0 suture. Finally, an anterior wall full-thickness layer was performed using the same suture. To protect the anastomosis an omental wrap was applied. Conclusions Totally robotic minimally invasive esophagectomy for the treatment of esophageal cancer is on the rise. It offers all the advances of minimally invasive techniques, like reduced rates of pulmonary and cardiac complications associated with open thoracotomy and shorter length of stay. Intrathoracic esophagogastric anastomosis still remains challenging and it is considered as the most difficult step of the procedure. Robotic transthoracic manual anastomosis has appeared to overcome this difficulties. https://www.dropbox.com/scl/fi/km4oo66hhnb00k45e7ecq/Stepbystepmanual.mp4?rlkey=eb074cf3sj796byijqza0zoq6&dl=0

Low psoas muscle index has a negative impact on survival after minimal invasive esophagectomy for cancer in European men

IntroductionSarcopenia, a key component of frailty in cancer patients, is associated with complicated procedures and worse survival after esophageal resection. The psoas muscle index (PMI) has been implicated as a possible sarcopenia imaging marker. This retrospective study aims to elucidate the effect of PMI and BMI in a cohort in Europe after totally minimally invasive esophagectomy for cancer. MethodsThe study included 318 consecutive adult patients (261 men and 57 women) who underwent minimally invasive esophagectomy for cancer between January 2016 and April 2021 in a German University Hospital. The PMI was measured at the third lumbar vertebra in the preoperative CT scan. The endpoints postoperative complication rates and survival rates were analysed and correlated with PMI and BMI according to gender. ResultsMale patients with low PMI (< 5.3 cm2/ m2) had a significantly higher rate of postoperative pulmonary and cardiac complications (p = 0.016, respectively p = 0.018). Low PMI and low BMI (<25 kg/m2) were associated with decreased survival rates in the univariate (p < 0.001) and multivariate analysis in male patients (p = 0.024, respectively 0.004). Having a low PMI (< 5.3 cm2/ m2) was significantly associated with worse overall survival in normal and underweight men (p < 0.001), but not in obese men with a BMI ≥ 25kg/m2 (p = 0.476). ConclusionPreoperative PMI and BMI are valid risk factors regarding postoperative survival after minimal invasive esophagectomy for cancer especially in a male European cohort.

Complications of Venous Thromboembolism Chemoprophylaxis in Lumbar Laminectomy With and Without Fusion.

The benefit of chemoprophylaxis (CPX) agents in preventing venous thromboembolism must be weighed against potential risks. Current literature regarding the efficacy of CPX after laminectomies with or without fusion is limited, with no clear consensus to inform guidelines. This study evaluated the association between CPX and surgical complications after lumbar laminectomy with and without fusion. Retrospective study of patients at a single large academic institution. The medical records of patients who underwent lumbar laminectomies with or without lumbar fusion from 2018 to 2020 were reviewed for demographics, surgical characteristics, CPX agents, postoperative complications, epidural hematomas, and wound drainage. Patients receiving CPX (n = 316) were compared with patients not receiving CPX (n = 316) via t test following propensity score matching, and patients on CPX were further stratified by fusion status. The CPX group had higher body mass index and American Society of Anesthesiologists grades. Rates of venous thromboembolism, epidural hematomas, infections, postoperative incision and drainage, transfusions, wound dehiscence, and reoperation were not associated with CPX. Moist dressings were more frequent, and average days of drain duration were longer with CPX. Overall postoperative complication rate and length of stay (LOS) were greater with CPX. The fusion subgroup had a lower Charlson Comorbidity Index, had a lower American Society of Anesthesiologists grade, was younger, had more women, and underwent more minimally invasive laminectomies. While estimated blood loss, operative times, and LOS were significantly greater in the fusion group, there was no difference in rate of intraoperative and postoperative complications. CPX after lumbar laminectomies with or without fusion was not associated with increased rates of epidural hematomas, wound complications, or reoperation. Patients receiving CPX had more postoperative cardiac complications, but it is possible that surgeons were more likely to prescribe CPX for higher-risk patients. They also had higher rates of ileus and moist dressings, greater LOS, and longer length of drain duration. Patients who underwent lumbar laminectomy with fusion on CPX tended to be lower risk yet incurred greater blood loss, operative times, LOS, cardiac complications, and hematomas/seromas than patients not undergoing fusion. This retrospective study compared surgical complications of lumbar laminectomies in patients who received chemoprophylaxis vs patients who did not. Chemoprophylaxis was not associated with increased rates of epidural hematomas, wound complications, or reoperation, but it was associated with higher rates of postoperative cardiac complications and ileus.

Assessment of fitness for open repair in patients with infrarenal abdominal aortic aneurysms

ObjectiveEndovascular aortic repair (EVAR) was originally designed as a treatment modality for patients with abdominal aortic aneurysms (AAAs) deemed unfit for open repair. However, the definition of “unfit for open repair” is largely subjective and heterogenous. The purpose of this study was to compare patients deemed unfit for open repair who underwent EVAR to a matched cohort who underwent open repair for infrarenal AAAs. MethodsThe Vascular Quality Initiative of the Society for Vascular Surgery was queried for patients who underwent EVAR and open infrarenal AAA repair from 2003 to 2022. Patients that underwent EVAR were included if they were deemed unfit for open repair by the operating surgeon. EVAR patients deemed unfit because of a hostile abdomen were excluded. Patients in both the open and EVAR datasets were excluded if their repair was deemed non-elective or if they had prior aortic surgery. EVAR patients were matched to a cohort of open patients. The primary outcome for this study was 1-year mortality. Secondary outcomes included 30-day mortality, major adverse cardiac events, pulmonary complications, non-home discharge, reinterventions, and 5-year survival. ResultsA total of 5310 EVAR patients were identified who were deemed unfit for open repair. Of those, 3028 EVAR patients (57.0%) were able to be matched 1:1 to a cohort of open patients. Open patients had higher rates of major adverse cardiac events (20.2% vs 4.4%; P < .001), pulmonary complications (12.8% vs 1.6%; P < .001), non-home discharges (28.5% vs 7.9%; P < .001), and 30-day mortality (4.5% vs 1.4%; P < .001). There were no differences in early survival, but open repair had better middle and late survival compared with EVAR over the course of 5 years. A total of 74 EVAR patients (2.4%) had reinterventions during the study period. EVAR patients that required interventions had higher 1-year (40.5% vs 7.3%; P < .001) and 5-year mortality (43.2% vs 14.1%; P < .001) compared with those that did not require reinterventions. EVAR patients who had reinterventions had higher 1-year (40.5% vs 6.3%; P < .001) and 5-year (43.2% vs 20.3%; P = .006) mortality compared with their matched open cohort. ConclusionsPatients undergoing EVAR for AAAs who are deemed unfit for open repair have better perioperative morbidity and mortality compared with open repair. However, patients who had an open repair had better middle and late survival over the course of 5 years. The categorization of unfitness for open surgery may be inaccurate and re-evaluation of this terminology/concept should be undertaken.

Comparative outcomes of open mesenteric bypass after a failed endovascular or open mesenteric revascularization for chronic mesenteric ischemia

IntroductionClinical practice guidelines have recommended an endovascular-first approach (ENDO) for the management of patients with chronic mesenteric ischemia (CMI), whereas an open mesenteric bypass (OMB) is proposed for subjects deemed to be poor ENDO candidates. However, the impact of a previous failed endovascular or open mesenteric reconstruction on a subsequent OMB is unknown. Accordingly, this study was designed to examine the results of a remedial OMB (R-OMB) after a failed ENDO or a primary OMB (P-OMB) for patients with recurrent CMI. MethodsAll patients who underwent an OMB from 2002 to 2022 at the University of Florida were reviewed. Outcomes after an R-OMB (ie, history of a failed ENDO or P-OMB) and P-OMB were compared. The primary end point was 30-day mortality, whereas secondary outcomes included complications, reintervention, and survival. The Kaplan-Meier methodology was used to estimate freedom from reintervention and all-cause mortality, whereas multivariable Cox proportional hazards modeling identified predictors of death. ResultsA total of 145 OMB procedures (R-OMB, n = 48 [33%]; P-OMB, n = 97 [67%]) were analyzed. A majority of R-OMB operations were performed for a failed stent (prior ENDO, n = 39 [81%]; prior OMB, n = 9 [19%]). R-OMB patients were generally younger (66 ± 9 years vs P-OMB, 69 ± 11 years; P = .09) and had lower incidence of smoking exposure (29% vs P-OMB, 48%; P = .07); however, there were no other differences in demographics or comorbidities. R-OMB was associated with less intraoperative transfusion (0.6 units vs P-OMB, 1.4 units; P = .01), but there were no differences in conduit choice or bypass configuration.The overall 30-day mortality and complication rates were 7% (n = 10/145) and 53% (n = 77/145), respectively, with no difference between the groups. Notably, R-OMB had decreased cardiac (6% vs P-OMB, 21%; P < .01) and bleeding complication rates (2% vs P-OMB, 15%; P = .01). The freedom from reintervention (1 and 5 years: R-OMB: 95% ± 4%, 83% ± 9% vs P-OMB: 97% ± 2%, 93% ± 5%, respectively; log-rank P = .21) and survival (1 and 5 years: R-OMB: 82% ± 6%, 68% ± 9% vs P-OMB: 84% ± 4%, 66% ± 7%; P = .91) were similar. Independent predictors of all-cause mortality included new postoperative hemodialysis requirement (hazard ratio [HR], 7.4, 95% confidence interval [CI], 3.1-17.3; P < .001), pulmonary (HR, 2.7, 95% CI, 1.4-5.3; P = .004) and cardiac (HR, 2.4, 95% CI, 1.1-5.1; P = .04) complications, and female sex (HR, 2.1, 95% CI, 1.03-4.8; P = .04). Notably, R-OMB was not a predictor of death. ConclusionsThe perioperative and longer-term outcomes for a remedial OMB after a failed intraluminal stent or previous open bypass appear to be comparable to a P-OMB. These findings support the recently updated clinical practice guideline recommendations for an endovascular-first approach to treating recurrent CMI due to the significant perioperative complication risk of OMB. However, among the subset of patients deemed ineligible for endoluminal reconstruction after failed mesenteric revascularization, R-OMB results appear to be acceptable and highlight the utility of this strategy in selected patients.

Predicting operative outcomes of total shoulder arthroplasty using the model for end-stage liver disease score

The aim of this study was to assess the efficacy of the Model for End-Stage Liver Disease (MELD) score in predicting postoperative complications following total shoulder arthroplasty (TSA). The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2019. The study population was subsequently classified into two categories: those with a MELD score ≥ 10 and those with a MELD score < 10. Atotal of 5265 patients undergoing TSA between 2015 and 2019 were included in this study. Among these, 4690 (89.1%) patients had a MELD score ≥ 10, while 575 (10.9%) patients had a MELD score < 10. Postoperative complications within 30 days of the TSA were collected. Multivariate logistic regression analysis was conducted to explore the correlation between a MELD score ≥ 10 and postoperative complications. The anchor based optimal cutoff was calculated by receiver operating characteristic analysis to determine the MELD score cutoff that most accurately predicts a specific complication. Youden's index (J) determined the optimal cutoff point calculation for the maximum sensitivity and specificity; these were deemed to be "acceptable" if the area under curve (AUC) was greater than 0.7 and "excellent" if greater than 0.8. Multivariate regression analysis found a MELD score ≥ 10 to be independently associated with higher rates of reoperation (OR, 2.08; P=.013), cardiac complications (OR, 3.37; P=.030), renal complications (OR, 7.72; P=.020), bleeding transfusions (OR, 3.23; P<.001), and nonhome discharge (OR, 1.75; P<.001). The receiver operating characteristic analysis showed that AUC for a MELD score cutoff of 7.61 as a predictor of renal complications was 0.87 (excellent) with sensitivity of 100.0% and specificity of 70.0%. AUC for a MELD score cutoff of 7.76 as a predictor of mortality was 0.76 (acceptable) with sensitivity of 81.8% and specificity of 71.0%. A MELD score ≥ 10 was correlated with high rates of reoperation, cardiac complications, renal complications, bleeding transfusions, and nonhome discharge following TSA. MELD score cutoffs of 7.61 and 7.76 were effective in predicting renal complications and mortality, respectively.

Chagas cardiomyopathy in Boston, Massachusetts: Identifying disease and improving management after community and hospital-based screening.

Limited data exist regarding cardiac manifestations of Chagas disease in migrants living in non-endemic regions. A retrospective cohort analysis of 109 patients with Chagas disease seen at Boston Medical Center (BMC) between January 2016 and January 2023 was performed. Patients were identified by screening and testing migrants from endemic regions at a community health center and BMC. Demographic, laboratory, and cardiac evaluation data were collected. Mean age of the 109 patients was 43 years (range 19-76); 61% were female. 79% (86/109) were diagnosed with Chagas disease via screening and 21% (23/109) were tested given symptoms or electrocardiogram abnormalities. Common symptoms included palpitations (25%, 27/109) and chest pain (17%, 18/109); 52% (57/109) were asymptomatic. Right bundle branch block (19%, 19/102), T-wave changes (18%, 18/102), and left anterior fascicular block (11%, 11/102) were the most common electrocardiogram abnormalities; 51% (52/102) had normal electrocardiograms. Cardiomyopathy stage was ascertained in 94 of 109 patients: 51% (48/94) were indeterminate stage A and 49% (46/94) had cardiac structural disease (stages B1-D). Clinical findings that required clinical intervention or change in management were found in 23% (25/109), and included cardiomyopathy, apical hypokinesis/aneurysm, stroke, atrial or ventricular arrhythmias, and apical thrombus. These data show high rates of cardiac complications in a cohort of migrants living with Chagas disease in a non-endemic setting. We demonstrate that Chagas disease diagnosis prompts cardiac evaluation which often identifies actionable cardiac disease and provides opportunities for prevention and treatment.

Functionally dependent status is an independent predictor for worse perioperative outcomes following craniotomy for aneurysmal subarachnoid hemorrhage.

Aneurysmal subarachnoid hemorrhage (aSAH) is a medical emergency, and functional status is often a predictor of adverse outcomes perioperatively. Patients with different functional statuses may have different perioperative outcomes during surgery for aSAH. This study retrospectively examines the effect of functional status on specific perioperative outcomes in patients receiving craniotomy for aSAH. Patients with aSAH who underwent neurosurgery were identified using International Classification of Diseases (ICD) codes (ICD10, I60; ICD9, 430) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2021. Subjects were stratified into two study groups: functionally dependent and functionally independent, based on their documented functional status on NSQIP. Significant preoperative differences were present between groups so a multivariable regression was performed between functionally dependent and independent patients. The 30-day perioperative outcomes of the two groups were compared. Perioperative outcomes included death, major adverse cardiovascular events (MACEs), cardiac complications, stroke, wound complications, renal complications, sepsis, clot formation, pulmonary complications, return to the operating room, operation time >4 h, length of stay longer than 7 days, discharge not to home, and bleeding. For aSAH patients receiving craniotomy repair, functionally dependent patients had significantly greater rates of MACE, cardiac complications, sepsis, pulmonary complications, and discharge not to home compared to functionally independent patients. This study shows specific perioperative variables influenced by dependent functional status when treating aSAH through craniotomy, thus leading to a more complicated postoperative course. Additional research is needed to confirm these findings among the specific variables that we analyzed.

Perceval sutureless bioprosthesis versus Trifecta sutured bioprosthesis for aortic valve replacement: immediate results of the Perfecta study.

The Perceval sutureless biological prosthesis for aortic valve replacement has been introduced with the rationale for shortening surgical, extracorporeal circulation and aortic cross-clamping times, in order to reduce postoperative complications. To evaluate early hemodynamic performance and immediate outcomes of implantation of the Perceval sutureless bioprosthesis in comparison with the St. Jude Trifecta sutured bioprosthesis for aortic valve replacement (Perfecta study). Between December 2014 and June 2023, 281 patients underwent St. Jude Trifecta implantation (n = 220, mean age: 75.2 ±6.5 years) and Perceval implantation, when indicated (n = 61, mean age: 77.9 ±5.1 years). Concomitant CABG was performed in 73 (33%) and in 27 (44%) patients, respectively. Extracorporeal circulation and cross-clamp times were significantly shorter in Perceval patients in all aortic valve replacements (61 ±23 and 49 ±18 minutes vs. 96 ±36 and 67 ±21 minutes), and in isolated procedures (54 ±10 and 43 ±8 minutes vs. 84 ±28 and 66 ±21 minutes) (p < 0.0001, for all comparisons). Operative mortality was absent and 2.7%, respectively (p = 0.2). Postoperatively, low output cardiac syndrome (0% vs. 4.5%) and total rate of major cardiac and non-cardiac related complications (6.6% vs. 18.6%) were significantly lower in Perceval patients (p = 0.01). Echocardiography at discharge in comparison with preoperatively showed a relevant and similar decrease of mean and peak trans-aortic valve gradients for the Trifecta prosthesis (11.6 ±4.3 vs. 50 ±15.2 mm Hg; 21.6 ±7.3 vs. 78.8 ±24 mm Hg) and for the Perceval prosthesis (12.6 ±4.8 vs. 52 ±12.5 mm Hg; 22.6 ±7.9 vs. 77.8 ±16 mm Hg) (p < 0.00001, for all comparisons). Better global cardiac function was observed in Perceval patients. Concomitant multi-vessel and left main coronary artery disease (p = 0.046; HR = 4.6) and chronic pulmonary disease (p = 0.006; HR = 5.6) were detected as independent predictors of death and postoperative major complications. Early hemodynamic performance appears to be satisfactory with the use of Trifecta sutured and Perceval sutureless bioprostheses. Perceval implantation allows reduction of surgical times, better preservation of myocardial contractile function and, consequently, reduction of the risk of postoperative complications.

Comparing clinical outcomes in bicuspid versus trileaflet aortic valve endocarditis

Abstract Background The incidence of bicuspid aortic valve infective endocarditis (BAV-IE) has been reported at 2% in contemporary BAV cohorts with an estimated risk of developing BAV-IE 11 times that of the general population with a trileaflet aortic valve (TAV). Purpose To characterise BAV-IE from a clinical and microbiological perspective and compare clinical outcomes with a cohort of individuals with trileaflet aortic valve infective endocarditis (TAV-IE). Methods The clinical records of all patients (&amp;gt;16 years old) admitted to a large tertiary referral centre in the United Kingdom between 2015 and 2022 with a definitive diagnosis of native aortic valve IE by Duke’s criteria were included. Clinical, echocardiographic and microbiological data were obtained. The primary outcomes were death or surgical aortic valve intervention during the indexed hospital admission. Secondary outcomes included the incidence of cardiac complications (e.g. aortic root abscess or fistula formation, IE affecting another valve or high degree atrioventricular block requiring temporary or permanent pacing). Extra-cardiac complications included embolic phenomena and thrombotic events. Results 83 patients were included (BAV-IE 34; TAV-IE 49). BAV-IE patients were significantly younger at presentation than TAV-IE patients (Table 1). There was no difference age-adjusted mortality rate between the two groups (mortality rate BAV-IE 0.20 (95% CI 0.08-0.54) versus TAV-IE 0.29 (95% CI 0.17-0.48). The rate of cardiac complications including aortic root abscess or fistula formation, and concomitant mitral valve endocarditis was greater in the BAV group, though not reaching statistical significance. Those in the BAV-IE group were more likely to develop at least moderate aortic regurgitation and have aortic valve intervention during the admission (70.6% (24/34) BAV-IE versus 46.9% (23/49) TAV-IE, p=0.03). Conclusion Despite an estimated prevalence of 1% in the general population, BAV accounted for 41% of all native AV IE cases at our institution. This study demonstrates that even in young, otherwise healthy individuals, BAV-IE has a poor prognosis with a high proportion developing structural complications. Age-adjusted mortality rates are similar to those with TAV-IE, who are often older with more co-morbidities. Though antibiotic prophylaxis is currently only recommended for those at the highest risk, these findings reinforce the importance of mitigating sources of infection in individuals with BAV. Prompt medical attention and treatment of suspected IE cases is of utmost importance as degeneration of a BAV and other cardiac complications, particularly aortic regurgitation, can rapidly develop.

Abstract 18363: Readmission &amp; Temporal Trends of Post LVAD Placement Complications in Patients With End-Stage Heart Failure

Introduction: 5-10% of heart failure (HF) patients progress to advanced stages. Left ventricular assist devices (LVADs) have emerged as a favored therapy for end-stage HF as destination therapy or as a bridge to heart transplantation. However, complications and provider expertise hinder its widespread use. Third generation LVAD was introduced in 2018 to enhance usability and reduce complications. We aim to investigate the temporal trends in post-LVAD complications with the latest generation LVAD vs the previous version. Methods: We utilized the 2016-2020 Nationwide Readmission Database to identify patients ≥ 18 years of age with advanced HF implanted with an LVAD. Variables were identified using International Classification of Diseases, Tenth revision codes. We compared 2 groups based on the implant year (2016-2018 and 2019-2020). The primary outcome was 30-day readmission (30-dr), while secondary outcomes were trends in complications, mortality rate, and healthcare cost. Multivariate analyses and descriptive bivariate analyses were performed. A p-value &lt;0.05 was considered statistically significant. Results: We identified 7,975 patients (21.3% females) of which 17.1 % (n = 1,214) were readmitted within 30 days. Readmission rates were 17.7% (n = 778) for 2016-2018 and 16.2% (n = 435) for 2019-2020 (adjusted Wald test, p = 0.26). The 2019-2020 group exhibited lower rates of cardiac device complications, vasopressor usage, cardiac tamponade, and peri-procedural circulatory complications than the 2016-2018 group (adjusted Wald test, p &lt; 0.05). No significant differences in mortality or LOS were observed between the two groups (adjusted Wald test, p &gt; 0.05). Healthcare costs were higher in the 2019-2020 group (mean $276,439 vs $315,332, adjusted Wald test, p = 0.01). Conclusions: Complications following LVAD placement continue to impede broader adoption for advanced HF. Nonetheless, advancements in newer LVAD generations and improved provider expertise hold promise for increased utilization. Our study indicates a decline in complications, including cardiac tamponade and post-procedural complications, which may be attributed to newer device innovations. Further research is necessary to explore this correlation in greater depth.

Increased 90-Day Mortality and Morbidity Among Patients Recovering From Elective Primary Arthroplasty During the COVID-19 Pandemic in New York City.

All elective procedures were stopped in March 2020 because of the coronavirus disease 2019 (COVID-19) pandemic. We report the 90-day mortality and complications of patients who underwent primary arthroplasty before the stopping of elective procedures at a single academic medical center. A retrospective cohort study was conducted including patients who underwent elective primary arthroplasty between December 2019 and mid-March 2020. Their 90-day postoperative mortality and medical complications were statistically compared with those of a historical cohort from the same operative period in 2019. The 2020 and 2019 cohorts included 372 and 410 patients, respectively. Except for the prevalence of diabetes, there was no significant difference between the two cohorts regarding baseline characteristics or preoperative health. The 2020 cohort had statistically significant higher rates of pneumonia (2.7% vs 0.7%; P=.03), readmission (9.1% vs 5.4%; P=.04), pulmonary embolism (1.6% vs 0.2%; P=.04), and 90-day mortality (1.1% vs 0%; P=.04). The 2020 cohort also had a trend for increased rates of deep venous thrombosis (1.1% vs 0.7%; P=.7) and cardiac complications (1.9% vs 0.5%; P=.07) and no change in emergency department visits (14.0% vs 11.7%; P=.3). There were 7 confirmed cases of COVID-19 in the 2020 cohort and 1 death. This study demonstrates that patients who underwent primary arthroplasty procedures at our institution close to the time of the first wave of the COVID-19 pandemic experienced a statistically significant increase in mortality, pneumonia, pulmonary embolism, and readmission compared with a historical cohort. As elective procedures have resumed during the ongoing pandemic, providers and patients should be aware of these increased risks. [Orthopedics. 2024;47(3):135-140.].

Adjusting the Split: Examining Complications After Emergency Exploratory Laparotomy in Older Adults

IntroductionOlder adults experience higher rates of complications after an emergency exploratory laparotomy (EEL). To better understand the shift to an aging population in the United States, identifying how age may influence these complications in older patients is important. The current standard age category for older adult patients is ≥65. We analyzed postlaparotomy complications using a lower age split. MethodsA retrospective analysis was done on patients who required an EEL from October 2015 to December 2019 at an academic medical center. Patient demographics and hospital course variables were collected. Differences in complications in patients aged ≥/<55 y and ≥/<65 y were measured using univariate and multivariable analyses. ResultsA total of 481 patients were reviewed. Both patient groups of ≥55 and ≥65 were typically male, White, had 3+ comorbidities, Medicare insurance, were retired, and presented in extremis to the emergency department. Patients aged ≥55 y had significant rates of pulmonary complications and inpatient mortality (odds ratio 2.2, 2.7, respectively). Patients aged ≥65 y had significant rates of genitourinary and cardiac complications (odds ratio 2.3, 1.8, respectively). ConclusionsPatients aged ≥55 y undergoing EEL had higher odds of experiencing pulmonary complications and death during their index hospitalizations, which was not present with the standard ≥/<65-y-old patient analysis. Those aged ≥65 y experienced index genitourinary and cardiac complications. The ≥/<55 age split has a unique set of complications that should be considered. Given the increased odds of inpatient mortality and types of complications in patients aged ≥55 y, the current age split for older adults should be reconsidered.

The rate of cardiac complications in patients receiving a 24-hour dose of 5-Fluorouracil

Background. Cardiotoxicity caused by fluoropyrimidines is an uncommon but potentially fatal complication. Its frequency has been 1.6 to 19% in previous studies. But there are no accurate statistics in Iran. The aim of this study was to determine the rate of cardiac complications of 5-fluorouracil (5-FU) infusion. Methods. This prospective study was conducted in patients with gastrointestinal cancers who underwent chemotherapy with regimens containing 24-hour infusion of 5-FU at Rohani Hospital of Babol. Patients with a history of radiation therapy to the chest or epigastrium or suffering from COVID-19 disease in the last 6 weeks were excluded from the study. Each patient was examined in 2 cycles of chemotherapy. In case of complications, cardiac examinations including examination, electrocardiogram, echocardiography and if necessary, coronary angiography were done. Data analysis was done with SPSS 26 software using descriptive indices and Fisher exact test (significance≤0.05). Results. In sixty one patients, 122 courses of chemotherapy were evaluated. Underlying cancer was colorectal cancer in 32 patients, stomach cancer in people. Eight patients (13.11%) had cardiac complication, in eleven chemotherapy cycles, included 7 cases of chest pain and one case of each of complications of myocardial infarction, pulmonary edema and pericarditis. Four out of 8 patients suffered from complications only in the first round, one only in the second round and three patients in both rounds of chemotherapy (P=0.004).The incidence rate of complications in patients without a history of heart disease was 8.7% and in patients with a history of heart disease 26.7%(P=0.073), in non-smokers 10% and in smokers 30%(P=0.084). It was 10.6% in non-diabetic patients and 21.4% in diabetic patients (P=0.294). Conclusion. Cardiac complications are common in 24-hour injection of 5-fluorouracil. A patient who has a heart complication once, might have a higher probability of having a complication in the next cycles. Practical Implications. Due to the high prevalence of cardiac complications of 24-hour floururacil infusion, especially in patients with a history of heart disease, careful cardiac monitoring during hospitalization is recommended.

Outcomes of thoracoabdominal aortic aneurysm repair in patients with a previous myocardial infarction

ObjectiveMany patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair have had a previous myocardial infarction (MI). To address the paucity of data regarding outcomes in such patients, we aimed to compare outcomes after open TAAA repair in patients with and without previous MI. MethodsFrom 1986 to 2022, we performed 3737 consecutive open TAAA repairs. Of these, 706 (18.9%) were in patients with previous MI. We used multivariable logistic regression to identify predictors of operative death. Propensity score matching analyzed preoperative and select operative variables to create matched groups of patients with or without a previous MI (n = 704 pairs). Late survival was determined by Kaplan–Meier analysis and compared by log rank test. ResultsOverall, operative mortality was 8.5% and the adverse event rate was 15.2%; these were elevated in patients with MI (11.0% vs 7.9% [P = .01] and 18.0% vs 14.6% [P = .02], respectively). In the propensity score–matching cohort, the MI group had a greater rate of cardiac complications (32.4% vs 25.4%; P = .005) and delayed paraparesis (5.1% vs 2.4%; P = .1); however, there was no difference in operative mortality (11.1% vs 10.9%; P = 1) or adverse event rate (18.0% vs 16.8%; P = .6). Overall, previous MI was not independently associated with operative mortality in multivariable analysis (P = .1). The matched MI group trended toward poorer 10-year survival (29.8% ± 1.9% non-MI vs 25.0% ± 1.8% MI; P = .051). ConclusionsAlthough previous MI was not associated with early mortality after TAAA repair, patients with a previous MI had greater rates of cardiac complications and delayed paraparesis. Patients with a previous MI also trended toward poorer survival.

Outcomes of anastomosis of mechanically prepared bowel vs. mechanically unprepared bowel in laparoscopic anterior resection in adult patients with rectal cancer

Introduction: The limited literature supporting the utilization of mechanical bowel preparation (MBP) for patients undergoing laparoscopic anterior resection of rectum (LAR) remains a notable issue. This study was conducted to examine the clinical consequences of anastomosis in rectal surgery with MBP compared to cases where MBP is not utilized (no-MBP) in the context of LAR.Methods: This is a retrospective comparative study conducted in the professorial surgical wards of Teaching Hospital Karapitiya (THK). Rectal cancer patients (n=306) participated in the study, including 151 MBP patients and 155 no-MBP patients where the postoperative complications and mortality rates were compared.Results: The anastomotic leakage rate was 2.6% (n=4) in the no-MBP group and 6.0% (n=9) in the MBP group, (p=0.143). Postoperative paralytic ileus rate was 18.5% (n=28) and 5.8% (n=9) in the MBP group and no-MBP group respectively displaying a statistically significant difference (p=0.001). Wound infection, pneumonia, urinary tract infection, and cardiac complication rates also were higher in the MBP group. Overall mortality rate was 1.3% (n=3) in no-MBP group and 2.0% (n=2) in MBP group. Conclusions: The evidence concludes that MBP increases post-operative complications. Therefore, prophylactic MBP in LAR has not been proven to benefit patients. However, further research is necessary to understand the comparative effects of MBP versus no preparation comprehensively.

Trends in cardiovascular complications of pregnancy: A nationwide inpatient sample analysis

BackgroundCardiovascular disease (CVD) is the leading cause of pregnancy-related mortality in the United States. Physiologic stress of pregnancy can induce several hemodynamic changes that contribute to an increased risk of cardiac complications in the peripartum period. There are ongoing efforts to improve cardiovascular mortality in pregnant patients. Understanding trends in cardiovascular complications during pregnancy may provide insight into improving care for high-risk pregnancies. MethodsWe retrospectively analyzed data from the National Inpatient Sample (NIS) Database and identified all inpatient hospitalizations for pregnancy and delivery. We then analyzed trends in the rates of cardiac complications in the pregnant patient. ResultsThere are concerning increases in trends of cardiac complications and comorbidities in pregnant people including: acute coronary syndrome, spontaneous coronary artery dissection, cardiogenic shock, pulmonary hypertension, chronic congestive heart failure, heart transplant, aortic syndromes, stroke, and pulmonary embolism. While the rates of STEMI have decreased, the incidence of peripartum cardiomyopathy has remained stable. ConclusionThere are concerning increases in certain cardiac complications during pregnancy. This is likely due to increasing age at the time of pregnancy and associated comorbidities.

Comparisons of drug-eluting balloon versus drug-eluting stent for the treatment of cancer patients presenting with acute myocardial infarction

BackgroundTreatment for cancer patients presenting with acute myocardial infarction (AMI) remains challenging. The objective of the study was to investigate the safety and efficiency of drug eluting balloon (DEB) versus drug eluting stent (DES) in this high-risk group.MethodsBetween 1st January 2017 and 1st January 2022, cancer patients admitted to Beijing Chaoyang Hospital with AMI were retrospectively enrolled. The primary endpoint was major adverse cardiovascular event (MACE). The secondary endpoints included major bleeding events, heart failure and cardiac complications.ResultsA total of 164 cancer patients presenting with AMI were included in the final analysis. Patients treated with DEB had a numerically lower rate of MACE than those treated with DES during a median follow-up of 21.8 months (22.9% vs. 37.1%, p = 0.23). Patients treated with DEB had a trend towards lower rate of major bleeding events than patients treated with DES (6.3% vs. 18.1%, HR 2.96, 95% CI [0.88, 9.92], p = 0.08). There were no significant differences between the two groups with regards to the rate of heart failure (4.2% vs. 9.5%, p = 0.32) and cardiac complications (0.0% vs. 2.6%, p = 0.56).ConclusionsThe present study demonstrated that in cancer patients with AMI, DEB had a trend towards lower rate of major bleeding events and a numerically lower rate of MACE compared with DES.Graphical

Social vulnerability is associated with higher risk-adjusted rates of postoperative complications in a broad surgical population

ObjectiveThe purpose of this study was to determine if an association between Social Vulnerability Index (SVI) and risk-adjusted complications exists in a broad spectrum of surgical patients. Summary background dataGrowing evidence supports the impact of social circumstances on surgical outcomes. SVI is a neighborhood-based measure accounting for sociodemographic factors putting communities at risk. MethodsThis was a multi-hospital, retrospective cohort study including a sample of patients within one healthcare system (2012–2017). Patient addresses were geocoded to determine census tract of residence and estimate SVI. Patients were grouped into low SVI (score<75) and high SVI (score≥75) cohorts. Perioperative variables and postoperative outcomes were tracked and compared using local ACS-NSQIP data. Multivariable logistic regression was performed to generate risk-adjusted odds ratios of postoperative complications in the high SVI cohort. ResultsOverall, 31,224 patients from five hospitals were included. Patients with high SVI were more likely to be racial minorities, have 12/18 medical comorbidities, have high ASA class, be functionally dependent, be treated at academic hospitals, and undergo emergency operations (all p ​< ​0.05). Patients with high SVI had significantly higher rates of 30-day mortality, overall morbidity, respiratory, cardiac and infectious complications, urinary tract infections, postoperative bleeding, non-home discharge, and unplanned readmissions (all p ​< ​0.05). After risk-adjustment, only the associations between high SVI and mortality and unplanned readmission became non-significant. ConclusionsHigh SVI was associated with multiple adverse outcomes even after risk adjustment for preoperative clinical factors. Targeted preventative interventions to mitigate risk of these specific complications should be considered in this high-risk population.

479. TRANSTHORACIC VERSUS TRANSABDOMINAL SURGICAL APPROACH FOR SIEWERT TYPE II ESOPHAGOGASTRIC JUNCTIONAL ADENOCARCINOMAS—A PROPENSITY SCORE-MATCHED ANALYSIS

Abstract Background Esophagogastric junctional(EGJ) adenocarcinoma is a complex type of cancer that varies in etiology and disease pattern depending on the tumor level. There is increasing evidence on the need for different surgical approaches for different Siewert types. The optimal surgical approach for Siewert type II cancer remains controversial. This study aims to compare the oncological and surgical safety of transthoracic and transabdominal approaches for type II cancers. Methods The study included patients who underwent resection for Siewert type II adenocarcinomas from 2003–2020 in a single tertiary center using transthoracic (TT) and transabdominal (TA) approaches with macroscopic tumor clearance. The TT approach referred to Lewis-Tanner esophagogastrectomy, while the TA approach included total gastrectomy and proximal gastrectomy. Data from a prospectively-managed database were analyzed to compare postoperative morbidity and mortality rates, lymph node harvest, completeness of resection and overall survival between the two groups. Propensity score matching (PSM) was used in further analyses. Results Excluding R2 resections, there were 54 patients in the TT and 45 (proximal gastrectomy:23) in the TA groups. cT stages were comparable. In TT group, median tumor length was 6 cm (vs. 3 cm,p = 0.000), 18.5% with esophageal extension of &amp;gt;4 cm above EGJ;75.9% had nodal metastases (vs. 47.7%, p = 0.004);20.4% underwent neoadjuvant therapy (vs. 6.8%, p = 0.057). Anastomotic leak and cardiopulmonary complication rates, R0 resection rates, nodal yield and positive lymph node ratios were comparable. Proximal margin was involved in 15.9% for TA (vs. 5.6%, p = 0.092). Overall median survival times were similar (TT vs. TA: 42vs.65 months, p = 0.557). PSM yielded 33 patients per group. Only one in TT group had &amp;gt;4 cm esophageal involvement. Cardiac complication rate in TT group was 23.6%(vs. 3.5%, p = 0.024). Conclusion After correcting for selection bias, positive lymph node ratio, resection margin and overall survival did not differ for the TT and TA approaches. Resection by the TT approach is associated with more cardiac complications. For Siewert type II tumors with limited thoracic esophageal extension, the TA approach is safe and should be sufficient.