Society Of Thoracic Surgeons Predicted Risk Research Articles

A Coronary-Friendly Device Mitigating Risk of Coronary Obstruction in Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) induced coronary artery obstruction (CAO) is a rare but devastating complication. Current preventive strategies need additional procedures and may be associated with adverse events. This study aimed to evaluate the early safety and efficacy of stand-alone TAVR using the J-Valve (Jianshi JieCheng Medical Technology Co. Ltd, Shanghai, China) in patients at potential high risk for CAO. CAO was defined as coronary ostia obstruction requiring intervention. Patients at potential high risk for CAO were identified retrospectively from 673 consecutive patients who underwent TAVR from January 2015 to July 2021 at Zhongshan Hospital, Fudan University. Procedural results and early outcomes were evaluated according to Valve Academic Research Consortium-3 definitions. A total of 20 consecutive patients (age 72 ± 9 years; 85% female;) were included. The Society of Thoracic Surgeons-Predicted Risk of Mortality was 5% (interquartile range, 4 to 10%). All patients (100%) had at least 2 classical risk factors for CAO by pre-procedural computed tomography analysis, and 90% patients had native aortic valve diseases. TAVR was successful in 95% of cases, with only 1 patient requiring second device implantation. Early safety at 30 days was achieved in all cases without death. All patients were free from CAO, stroke or emergency reintervention. Post-procedural mean aortic valve gradient was 7 (interquartile range, 4, 12) mmHg, and none/trace or mild aortic regurgitation was present in all patients. Stand-alone TAVR using the J-Valve may mitigate the risk of TAVR-induced CAO.

Impact of Transcatheter Aortic Valve Implantation on Severe Gastrointestinal Bleeding in Patients With Aortic Stenosis

To investigate the effectiveness of transcatheter aortic valve implantation (TAVI) for resolving gastrointestinal bleeding (GIB) in patients with severe GIB and severe aortic stenosis. This was an observational study of consecutive TAVI procedures from 2011 to 2018, identified through a prospectively maintained institutional database. Patients with severe GIB defined as abnormal hemoglobin/hematocrit and overt bleeding or positive fecal occult blood test. Groups were compared for differences in baseline clinical and procedural characteristics and post-TAVI outcomes. A total of 1,192 patients who underwent TAVI were identified, of which 164 patients (13.8%) were found to have had severe GIB. Society of Thoracic Surgeons-Predicted Risk of Mortality scores were higher in the severe GIB group than in the non-GIB group (8.8 ± 5.3 vs 7.6 ± 4.5, p=0.002). The 30-day mortality was similar across each group (p >0.05), with overall 30-day mortality being 3.2% (38 of 1,192) for the entire cohort. Of the 164 TAVIs with severe GIB, 130 (79.3%) had resolution of their GIB after their TAVI. Patients without resolution of their GIB had higher aortic valve mean pressure gradients after their TAVI (15.0 ± 5.3 vs 9.0 ± 4.3). In conclusion, TAVI was associated with substantial reductions in severe GIB. Despite higher baseline risk, patients with severe GIB achieved similar outcomes, including 30-day mortality, compared with patients without GIB. TAVI may be a safe and effective treatment for patients with severe aortic stenosis and severe GIB, whereas persistently high transvalvular pressure gradients after TAVI may be related to the likelihood of recurrent GIB.

Evaluation of the safety and efficacy of transcatheter aortic valve replacement with domestic prostheses for patients with severely stenotic bicuspid aortic valve

Objective: To evaluate the safety and efficacy of transcatheter aortic valve replacement (TAVR) with domestic prostheses in patients with severely stenotic bicuspid aortic valve (BAV). Methods: This study was a prospective single-center non-randomized controlled study. Patients with symptomatic severe aortic stenosis (AS), who underwent TAVR with domestic prostheses at the First Affiliated Hospital of Air Force Medical University from January 2016 to April 2020 were consecutively included in our study. Patients were divided into BAV group and tricuspid aortic valve (TAV) group according to the aortic valve morphology. Baseline characteristics, procedural outcomes were compared between the two groups, and the primary endpoint was one-month all-cause mortality. Results: A total of 100 patients aged (69.8±8.9) years were enrolled, including 71 (71%) males. There were 51 cases in BAV group and 49 cases in TAV group. Compared with TAV group, patient in the BAV group was younger ((67.1±8.6) years vs. (72.7±8.4) years, P=0.002) and had larger ascending aortic diameter at proximal part ((39.7±5.7) mm vs. (36.0±4.2) mm, P<0.001), lower Society of Thoracic Surgeons-Predicted Risk of Mortality (STS-PROM) score (3.1 (1.9, 5.4) % vs. 5.9 (2.6, 12.3) %, P=0.002). In BAV group and TAV group, the incidence of 2nd prosthesis implantation was 15.7% (8/51) and 18.4% (9/49) (P=0.721), the incidence of moderate or severe paravalvular regurgitation was 2.0% (1/51) and 0 (P=1.000), the rate of device success was 82.4% (42/51) and 81.6% (40/49) (P=0.925), respectively. One-month all-cause mortality was 2.0% (1/51) and 10.2% (5/49) (P=0.108), respectively. Echocardiography showed that postprocedural mean pressure gradient (PGmean) was higher in the BAV group (13.0 (10.0, 16.0) mmHg vs. 9.0 (7.0, 14.0) mmHg, P=0.003) (1 mmHg=0.133 kPa), but the PGmean decrease post procedure as compared with that before TAVR was similar between the two groups ((36.7±16.6) mmHg vs. (36.2±17.5) mmHg, P=0.893). Conclusion: Favorable safety and efficacy are evidenced in patients with severely stenotic BAV undergoing TAVR with domestic prostheses.

Midterm outcomes with a sutureless aortic bioprosthesis in a prospective multicenter cohort study

ObjectiveThe objective of this study was to report midterm clinical outcomes with a self-expandable sutureless aortic valve. MethodsBetween 2010 and 2013, 658 patients at 25 European institutions received the Perceval sutureless valve (LivaNova Plc, London, United Kingdom). Mean follow-up was 3.8 years; late cumulative follow-up was 2325.2 patient-years. ResultsThe mean age of the population was 78.3 ± 5.6 years and 40.0% (n = 263) were 80 years of age or older; mean Society of Thoracic Surgeons-Predicted Risk of Mortality score was 7.2 ± 7.4. Concomitant procedures were performed in 31.5% (n = 207) of patients. Overall duration of cardiopulmonary bypass time was 64.8 ± 25.2 minutes and aortic cross-clamping time was 40.7 ± 18.1 minutes. Thirty-day all-cause mortality was 3.7% (23 patients), with an observed:expected ratio of 0.51. Overall survival was 91.6% at 1 year, 88.5% at 2 years, and 72.7% at 5 years. Peak and mean gradients remained stable during follow-up, and were 17.8 ± 11.3 mm Hg and 9.0 ± 6.3 mm Hg, respectively, at 5 years. Preoperatively, 33.4% of those who received the Perceval valve (n = 210) were in New York Heart Association functional class I or II versus 93.1% (n = 242) at 5 years. ConclusionsThis series, representing, to our knowledge, the longest follow-up with sutureless technology in a prospective, multicenter study, shows that aortic replacement using sutureless valves is associated with low mortality and morbidity and good hemodynamic performance.

Longitudinal outcomes of dialysis-dependent patients undergoing isolated coronary artery bypass grafting.

Dialysis-dependent patients have a higher risk of short-term morbidity and mortality following cardiac surgery. However, longitudinal survival and readmissions in this patient population after isolated coronary artery bypass grafting (CABG) are lacking in the literature. All patients undergoing isolated CABG from 2011 to 2017 were included. Perioperative data were retrospectively extracted from a prospectively maintained cardiac surgical database with a primary focus on longitudinal mortality and readmissions. The total study population consisted of 6874 nondialysis-dependent patients and 174 patients with dialysis dependence. Patients in the dialysis-dependent group presented a higher risk of morbidity and mortality as reflected in the Society of Thoracic Surgeons-Predicted Risk of Morbidity and Mortality (STS-PROM) (8.4% ± 9.7% vs 2.3% ± 3.9%; P < 0.001). Operative (30-day) mortality was significantly higher in the dialysis group (8.6% vs 2.3%; P < 0.001). Unadjusted outcomes yielded 30-day (92% vs 98%; P < 0.001), 1-year (80% vs 94%; P < 0.001), and 5-year (38% vs 84%; P < 0.001) survival that was significantly worse for the dialysis group. Freedom from readmission at 30 days (93% vs 87%; P = 0.005), 1 year (78% vs 56%; P < 0.001), and 5 years (62% vs 39%; P < 0.001) was significantly better for the nondialysis cohort. Dialysis dependence was an independent predictor of mortality at 30 days (hazard ratio [HR], 3.86; 95% confidence interval [CI], 2.96, 5.03; P < 0.001), 1 year (HR, 3.20; 95% CI, 2.14, 2.79; P < 0.001), and 5 years (HR, 4.02; 95% CI, 3.07, 5.26; P < 0.001) despite risk adjustment. Dialysis-dependent patients have significantly elevated operative risk, which translates to worse short- and long-term survival following isolated CABG. The need for dialysis alone is an independent predictor of both mortality and readmission in the midterm.

Valve Hemodynamics and Clinical Outcomes After Transcatheter Aortic Valve Replacement for a Small Aortic Annulus.

The hemodynamics and outcomes in patients with a small aortic annulus (SAA) after transcatheter aortic valve replacement (TAVR) with a second-generation transcatheter heart valve remain unclear. We investigated whether TAVR with a Sapien XT (Edwards Lifesciences, Irvine, California) influences postprocedural valve hemodynamics and long-term outcome in high-risk SAA patients compared with surgical aortic valve replacement (SAVR).We retrospectively identified 94 SAA patients who underwent aortic valve replacement (TAVR = 35 and SAVR = 59). SAA was defined as an aortic annulus diameter ≤ 20 mm, measured by preprocedural transesophageal echocardiography.The mean age was 80.2 years. The mean Society of Thoracic Surgeons-Predicted Risk of Mortality was 6.8%. The post-procedural peak transvalvular velocity and mean pressure gradient were significantly lower in the TAVR cohort than in the SAVR cohort, whereas the postprocedural aortic valve area was significantly higher in the TAVR cohort. Severe prosthesis-patient mismatch (PPM) occurred less frequently after TAVR than SAVR (TAVR 2.9% versus SAVR 22.0%, P = 0.01). The two-year mortality in SAA patients was similar between the two groups.TAVR with a Sapien XT in SAA patients improved the valve hemodynamics and reduced the incidence of PPM compared with SAVR. TAVR patients had a similar 2-year mortality despite higher risk baseline characteristics. To avoid PPM and the consequent poor outcomes, TAVR can be considered an alternative option to SAVR in high surgical risk patients with SAA.

Malnutrition and Mortality in Frail and Non-Frail Older Adults Undergoing Aortic Valve Replacement.

Older adults undergoing aortic valve replacement (AVR) are at risk for malnutrition. The association between preprocedural nutritional status and midterm mortality has yet to be determined. The FRAILTY-AVR (Frailty in Aortic Valve Replacement) prospective multicenter cohort study was conducted between 2012 and 2017 in 14 centers in 3 countries. Patients ≥70 years of age who underwent transcatheter or surgical AVR were eligible. The Mini Nutritional Assessment-Short Form was assessed by trained observers preprocedure, with scores ≤7 of 14 considered malnourished and 8 to 11 of 14 considered at risk for malnutrition. The Short Performance Physical Battery was simultaneously assessed to measure physical frailty, with scores ≤5 of 12 considered severely frail and 6 to 8 of 12 considered mildly frail. The primary outcome was 1-year all-cause mortality, and the secondary outcome was 30-day composite mortality or major morbidity. Multivariable regression models were used to adjust for potential confounders. There were 1158 patients (727 transcatheter AVR and 431 surgical AVR), with 41.5% females, a mean age of 81.3 years, a mean body mass index of 27.5 kg/m2, and a mean Society of Thoracic Surgeons-Predicted Risk of Mortality of 5.1%. Overall, 8.7% of patients were classified as malnourished and 32.8% were at risk for malnutrition. Mini Nutritional Assessment-Short Form scores were modestly correlated with Short Performance Physical Battery scores (Spearman R=0.31, P<0.001). There were 126 deaths in the transcatheter AVR group (19.1 per 100 patient-years) and 30 deaths in the surgical AVR group (7.5 per 100 patient-years). Malnourished patients had a nearly 3-fold higher crude risk of 1-year mortality compared with those with normal nutritional status (28% versus 10%, P<0.001). After adjustment for frailty, Society of Thoracic Surgeons-Predicted Risk of Mortality, and procedure type, preprocedural nutritional status was a significant predictor of 1-year mortality (odds ratio, 1.08 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.01-1.16) and of the 30-day composite safety end point (odds ratio, 1.06 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.001-1.12). Preprocedural nutritional status is associated with mortality in older adults undergoing AVR. Clinical trials are needed to determine whether pre- and postprocedural nutritional interventions can improve clinical outcomes in these vulnerable patients.

Use of extracorporeal membrane oxygenation in complicated transcatheter aortic valve replacement.

Although transcatheter aortic valve replacement (TAVR) is an excellent alternative procedure for high-risk patients with severe symptomatic aortic stenosis, it is often associated with life-threatening complications. We report on the emergency or elective use of veno-arterial extracorporeal membrane oxygenation (ECMO) to manage these complications. Between December 2013 and February 2016, 46 patients underwent TAVR at our institution. Of these, 4 patients required emergency ECMO support and another 3 patients were electively placed on ECMO support at the start of the procedure. The mean age of the ECMO patients was 87.3 ± 3.6years and all were female. The Society of Thoracic Surgeons-predicted risk of mortality score in these patients was 12.2 ± 6.2%. TAVR with ECMO was completed through the transapical approach in 6 patients, and the transfemoral approach in 1 patient. The arterial access route for ECMO was the femoral artery in 5, the external iliac artery in 1, and the subclavian artery in 1. Indications for the use of emergency ECMO were hemodynamic instability in 2, cardiogenic shock in 2, while indications for elective ECMO were severe pulmonary hypertension, impaired left ventricular function and a combination of these. There was no 30-day mortality, and the 1-year survival rate was 83.3% with no significant difference compared to patients without ECMO support. The use of ECMO in very high-risk patients undergoing TAVR may increase safety and contribute to excellent outcomes. Although ECMO support is rarely needed in TAVR, a well-prepared treatment strategy by the heart team is mandatory.

Revascularization heart team recommendations as an adjunct to appropriate use criteria for coronary revascularization in patients with complex coronary artery disease.

To evaluate how a comprehensive evidence-based clinical review by a multidisciplinary revascularization heart team on treatment decisions for revascularization in patients with complex coronary artery disease using SYNTAX scores combined with Society of Thoracic Surgeons-derived clinical variables can be additive to the utilization of Appropriate Use Criteria for coronary revascularization. Decision-making regarding the use of revascularization for coronary artery disease has come under major scrutiny due to inappropriate overuse of revascularization. There is little data in routine clinical practice evaluating how a structured, multidisciplinary heart team approach may be used in combination with the Appropriate Use Criteria for revascularization. From May 1, 2012 to January 1, 2015, multidisciplinary revascularization heart team meetings were convened to discuss evidence-based management of 301 patients with complex coronary artery disease. Heart team recommendations were adjudicated with the Appropriate Use Criteria for coronary revascularization for each clinical scenario using the Society for Cardiovascular Angiography and Interventions' Quality Improvement Toolkit (SCAI-QIT) Appropriate Use Criteria App. Concordance of the Heart Team to Appropriate Use Criteria had a 99.3% appropriate primary indication for coronary revascularization. Among patients who underwent percutaneous revascularization, 34.9% had an inappropriate or uncertain indication as recommended by the Heart Team. Patients with uncertain or inappropriate percutaneous coronary interventions had significantly higher SYNTAX score (27.3 ± 6.6; 28.5 ± 5.5; 19.2 ± 6; P < 0.0001) and Society of Thoracic Surgeons-Predicted Risk of Mortality (6.1% ± 4.7%; 8.1% ± 6.3%; 3.7% ± 4.1%; P < 0.0081) compared to appropriate indications, frequently had concomitant forms of advanced comorbidities and frailty in the setting of symptomatic coronary artery disease. A formal, multidisciplinary revascularization heart team can provide proper validation for clinical decisions and should be considered in combination with the Appropriate Use Criteria for coronary revascularization to formulate revascularization strategies for individuals in a patient-centered fashion. © 2015 Wiley Periodicals, Inc.

Prediction of Costs and Length of Stay in Coronary Artery Bypass Grafting

Although more than 200,000 bypass operations are performed in the United States annually, few data exist on the predictors of costs and resource use for this procedure. Questions related to clinical outcomes, costs, and resource use in coronary artery bypass grafting (CABG) were addressed. In a multiinstitutional statewide database, patient level data from 42,839 patients undergoing isolated CABG were combined with cost data. After adjustment for cost-to-charge ratios and inflation, the association of length of stay and costs with the Society ofThoracic Surgeons-Predicted Risk of Mortality (STS-PROM) was analyzed. Patients were randomly divided into development (60%) and validation (40%) cohorts. Regression models were developed to analyze the impact of patient characteristics, comorbidities, and adverse events on postoperative length of stay and total costs. Postoperative length of stay and total direct costs for CABG averaged 6.9 days and $38,847. Length of stay and costs increased from 5.4 days and $33,275 in the lowest-risk decile (mean STS-PROM of 0.6%) to 13.8 days and $69,122 in the highest-risk decile (mean STS-PROM 19%). Compared with adverse events, patient characteristics had little impact on length of stay and costs. onvalidation, the models that combined preoperative and postoperative variables explained variance better (R(2)=0.51 for length of stay; R(2)= 0.47 for costs) and were better calibrated than the preoperative models (R(2)= 0.10 for length of stay; R(2)= 0.14 for costs). The STS-PROM and preoperative regression models are useful for preoperative prediction of costs and length of stay for groups of patients, case-mix adjustment in hospital benchmarking, and pay for performance measures. The combined preoperative and postoperative models identify incremental costs and length of stay associated with adverse events and are more suitable for prioritizing quality improvement efforts.

Postoperative Atrial Fibrillation Significantly Increases Mortality, Hospital Readmission, and Hospital Costs

New-onset postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery. However, the magnitude of POAF on length of stay, resource utilization, and readmission rates remains an area of clinical interest. The purpose of this study was to examine the risk-adjusted impact of POAF on measures of mortality, hospital resources, and costs among multiple centers. A total of 49,264 patient records from a multi-institutional Society of Thoracic Surgeons (STS) certified database for cardiac operations (2001 to 2012) were extracted and stratified by the presence of POAF (19%) versus non-POAF (81%). The influence of POAF on outcomes was assessed by hierarchic regression modeling, adjusted for calculated STS predictive risk indices. Mean age was 64±11 years, and median STS predicted risk of mortality for patients who developed POAF were incrementally higher (2% vs 1%, p<0.001) compared with non-POAF patients. The rate of POAF was highest among those undergoing aortic valve replacement+coronary artery bypass grafting, aortic valve, and mitral valve replacement operations. The POAF patients had a higher unadjusted incidence of mortality, morbidity, hospital readmission, longer intensive care unit (ICU) and postoperative length of stay, and higher hospital costs. After risk adjustment, POAF was associated with a twofold increase in the odds of mortality (adjusted odds ratio=2.04, p<0.001), greater hospital resource utilization, and increased costs; POAF was associated with 48 additional ICU hours (p<0.001), 3 additional hospital days (p<0.001), and $3,000 (p<0.001) and $9,000 (p<0.001) of increased ICU and total hospital-related costs, respectively. New onset POAF is associated with increased risk-adjusted mortality, hospital costs, and readmission rates. Protocols to reduce the incidence of POAF have the potential to significantly impact patient outcomes and the delivery of high-quality, cost-effective patient care.

Surgical Care Improvement Project measure for postoperative glucose control should not be used as a measure of quality after cardiac surgery

The current Surgical Care Improvement Project (SCIP) measure for controlled postoperative 6-am glycemic control after cardiac surgery identifies those with blood glucose levels of ≤200 mg/dL. The purpose of the present study was to evaluate the effect of achieving this SCIP measure on risk-adjusted postoperative cardiac surgical outcomes. The data were analyzed for all cardiac surgery patients from a single institution (June 2010 to August 2012). The patients were categorized by the postoperative 6-am glucose levels into 2 SCIP measure cohorts: SCIP (≤200 mg/dL) versus non-SCIP (>200 mg/dL). Propensity-matched cohort comparisons and multiple regression analyses assessed the associations between SCIP measure compliance and the risk-adjusted outcomes. Of 1703 patients, 1527 (90%) achieved SCIP measure glycemic control. Preoperative diabetes was more common among the non-SCIP patients (P<.001); the median Society of Thoracic Surgeons-predicted mortality (P=.14) was similar between the 2 groups. No significant differences were observed in major morbidity, mortality, or resource usage among the propensity-matched cohorts. After adjustment for Society of Thoracic Surgeons-predicted risk, non-SCIP status was not associated with increased mortality (P=.44), composite major morbidity (P=.16), major sternal complications (P=.68), total intensive care unit duration (P=.70), or postoperative length of stay (P=.27). Similar risk-adjusted results were estimated for patients undergoing isolated coronary artery bypass grafting. Achieving the SCIP measure for controlled postoperative 6-am blood glucose levels ≤200 mg/dL after cardiac surgery was not associated with improved risk-adjusted mortality, morbidity, or hospital resource usage. These data suggest that this metric might not be a valid measure of postoperative cardiac surgical quality.

Preoperative Beta-Blocker Use Should Not Be a Quality Metric for Coronary Artery Bypass Grafting

Preoperative beta-blockade for coronary artery bypass grafting (CABG) has become an accepted hospital quality metric. However, single-institution reports regarding the benefits of beta-blocker (ß-blocker) use are conflicting. The purpose of this study was to evaluate the associations between preoperative beta-blocker use and outcomes within a large, regional cohort. Patient records from a statewide, multi-institutional Society of Thoracic Surgeons (STS) certified database for isolated CABG operations (2001 to 2011) were extracted and stratified by preoperative ß-blocker use. The influence of preoperative ß-blockers on risk-adjusted outcomes was assessed by hierarchical regression modeling with adjustment for preoperative risk using calculated STS predictive risk indices. A total of 43,747 (age, 63 years; ß-blocker 80% versus non ß-blocker 20%) patients were included. Median STS predicted risk of mortality scores for ß-blocker patients were incrementally lower (1.2% vs 1.4%, p < 0.001). Non ß-blocker patients more frequently developed pneumonia (3.5% vs 2.8%, p = 0.001), while ß-blocker patients surprisingly had greater intraoperative blood usage (16% vs 11%, p < 0.001). There was no difference in unadjusted mortality (ß-blocker: 1.9% vs non ß-blocker: 2.2%, p = 0.15). After risk adjustment, preoperative ß-blocker use was not associated with mortality (p = 0.63), morbidity, length of stay (p = 0.79), or hospital readmission (p = 0.97). Preoperative ß-blocker use is not associated with risk-adjusted mortality, several measures of morbidity, or hospital resource utilization after CABG operations. Thus, these data suggest that the routine use of preoperative ß-blockers for CABG operations should not be used as a measure of surgical quality.

Conventional Aortic Valve Replacement for Elderly Patients in the Current Era

Because of the rising expectation of prolonged life in the general population and the recent recognition of undertreated aortic valve disease in the elderly, updating the available results of aortic valve surgery is imperative, especially considering the rapid evolution of the transcatheter valve implantation procedure. Between 1997 and 2010, 308 patients aged 70 years or older underwent aortic valve replacement (AVR) for aortic stenosis (AS). Short- and long-term results were analyzed and risk factors for long-term mortality were determined. Mean age was 78.5 years and 124 patients were aged 80 or older. Concomitant coronary artery bypass grafting (CABG) was performed in 46% of the cases. Mean left ventricular ejection fraction (LVEF) was 52%. Overall observed and expected operative mortality using the Society of Thoracic Surgeons-Predicted Risk of Mortality score was 3.9% and 4.8%, respectively. Overall survival rates at 1, 5, and 10 years were 88.6%, 71.6%, and 31.8%, respectively. Predictors of long-term mortality included diabetes; preoperative shock; LVEF ≤ 40%; New York Heart Association functional class III or IV; and age. Short- and long-term results of conventional AVR in the elderly prove it to be durable and, especially in relatively low-risk patients and patients who require concomitant CABG, operative mortality is reasonably low. Conventional AVR ± CABG remains the gold standard for elderly patients with AS.

The use of spirometry testing prior to cardiac surgery may impact the Society of Thoracic Surgeons risk prediction score: A prospective study in a cohort of patients at high risk for chronic lung disease

Chronic lung disease is a significant comorbidity in patients undergoing cardiac surgery. Chronic lung disease is currently being classified and reported to the Society of Thoracic Surgeons database by using either clinical interview or spirometric testing. We sought to compare the chronic lung disease classification captured by the 2 methods. We performed a prospectively designed study in which patients presenting for cardiac surgery, excluding emergent patients, were screened for a history of asthma, a history of 10 or more pack-years of smoking, a persistent cough, and the use of oxygen. Each selected patient underwent spirometry. The presence and severity of chronic lung disease was coded per Society of Thoracic Surgeons guidelines by using the 2 methods of clinical report and spirometric results. The chronic lung disease classifications were compared, and differences were determined by using concordance and discordance rates. The results were then used to construct Society of Thoracic Surgeons-predicted risk models. The discordant rate was 39.1%, with underestimation of the severity of chronic lung disease in 94% of misclassified patients. This affected the Society of Thoracic Surgeons-predicted risk models for prolonged ventilation, morbidity/mortality, and mortality by increasing the predicted risk when spirometry was used for morbidity/mortality by an average of 1.5 +/- 1.2 percentage points (P < .001) and prolonged ventilation time by an average of 1.3 +/- 1.4 percentage points (P < .001). The use of patient history for symptoms, medication, and/or oxygen use as the only method to determine chronic lung disease for this subgroup of patients led to underreporting of chronic lung disease and underestimation of the risk for adverse outcomes. Therefore data submission to the Society of Thoracic Surgeons database should be designed to capture and correct for potential bias in the definition of chronic lung disease because the rate of spirometry in different centers in defining chronic lung disease is not regulated.

Contemporary surgical or percutaneous management of severe aortic stenosis in the elderly

To assess patient characteristics, therapeutic options, and their results in patients referred to a tertiary centre with on-site capabilities for surgical and percutaneous valvular interventions for the management of severe symptomatic aortic stenosis (AS). Sixty-six consecutive patients >70 years (83 +/- 6 years) were referred for severe AS. Their mortality risk predicted by the logistic European System for Cardiac Operative Risk Evaluation and the Society of Thoracic Surgeons-Predicted Risk of Mortality scores were on average 20 +/- 14% and 17 +/- 7%, respectively. Thirty-nine patients (59%) were considered at high-risk for surgery or inoperable after multidisciplinary evaluation: 12 (31%) underwent a transfemoral aortic valve implantation and 27 were considered unsuitable and treated medically (n = 16) or with valvuloplasty (n = 7), or were re-directed towards surgery (n = 4). The 27 other patients underwent valve replacement. In-hospital mortality was 9% (6 of 66). There were three hospital deaths in patients treated percutaneously, two in those treated medically, and one after surgery. At 6 months, 10% (6 of 60) of the survivors died: two after valvuloplasty and four after medical treatment. A large proportion of elderly patients referred for management of severe AS have a high-risk profile. The availability of percutaneous valvular interventions increases the number of those who are offered interventions.