Surgeons Adult Cardiac Surgery Database Research Articles

Effect of Skeletonization of Bilateral Internal Thoracic Arteries on Deep Sternal Wound Infections

Bilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Primary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching. We analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P= .129) and 23% (P= .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P= .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories. The observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization.

Reoperation After Transcatheter Aortic Valve Replacement: An Analysis of the Society of Thoracic Surgeons Database

ObjectivesThis study sought to report the largest series of patients receiving a surgical reoperation after transcatheter aortic valve replacement (TAVR) using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. BackgroundTAVR has become an effective means of treating aortic stenosis. As TAVR is used in progressively lower-risk cohorts, management of device failure will become increasingly important. MethodsThe STS Adult Cardiac Surgery Database was queried for patients with a history of prior TAVR undergoing surgical aortic valve replacement from 2011 to 2015. Observed-to-expected (O/E) mortality ratios were determined to facilitate comparison across reoperative indications and timing from index TAVR procedure. ResultsA total of 123 patients met inclusion criteria (median age 77 years) with an STS Predicted Risk of Mortality of 4%, 4% to 8%, and >8% in 17%, 24%, and 59%, respectively. Median time to reoperation was 2.5 (interquartile range: 0.7 to 13.0) months, and the operative mortality rate was 17.1%. Common indications for reoperation included early TAVR device failures such as paravalvular leak (15%), structural prosthetic deterioration (11%), failed repair (11%), sizing or position issues (11%), and prosthetic valve endocarditis (10%). All pre-operative risk categories were associated with an increased O/E mortality ratio (Predicted Risk of Mortality <4%: O/E 5.5; 4% to 8%: O/E 1.7; >8%: O/E 1.2). ConclusionsSAVR following early failure of TAVR, while rare, is associated with worse-than-expected outcomes as compared with similar patients initially undergoing SAVR. Continued experience with this developing technology is needed to reduce the incidence of early TAVR failure and further define optimal treatment of failed TAVR prostheses.

The Evolving Burden of Drug Use Associated Infective Endocarditis in the United States

The rise in the number of valve operations performed for infective endocarditis (IE) due to drug use is an important manifestation of the opioid epidemic. This study characterized national trends and outcomes of valve surgery for drug use-associated IE (DU-IE). Adults undergoing valve surgery for active IE in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database between July 2011 and June 2018 were stratified as DU-IE and non-DU-IE. Trends and clinical profiles were analyzed. Early outcomes were assessed. The association of DU-IE with outcomes was analyzed with multivariable regression, adjusting for STS Valve Risk model covariates. There were 34,905 valve operations performed for IE, of which 33.7% were for DU-IE. DU-IE operations increased 2.7-fold during the study period. There was considerable regional variability in DU-IE operations, ranging from 28% to 58% of all IE surgeries in 2018, with highest rates observed in East South Central and South Atlantic regions. DU-IE patients were younger and had fewer cardiovascular comorbidities. Risk-adjusted major morbidity and in-hospital mortality were significantly higher in the DU-IE group. Redo valve procedures in DU-IE patients were associated with worse outcomes, compared with those receiving a first valve operation. Operations for DU-IE have increased sharply in the United States during the last several years, exhibiting substantial regional variability. DU-IE patients have unique clinical profiles, and worse risk-adjusted outcomes. This demonstrates the significant impact of the opioid epidemic on endocarditis surgeries and punctuates the urgent need for multidisciplinary regional and national efforts to reverse this trend.

Impact of Transcatheter Aortic Valve Replacement on Risk Profiles of Surgical Aortic Valve Replacement Patients

BackgroundThe advent of transcatheter aortic valve replacement (TAVR) has changed which patients undergo surgical aortic valve replacement (SAVR). We sought to understand the impact of TAVR on the characteristics of SAVR patients in the United States. MethodsA cohort of 2959 patients who underwent isolated SAVR at 11 US hospitals that perform both TAVR and SAVR from 2013 through 2017 were grouped by the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database version (v)2.73 (2011–2014), v2.81 (2014–2017), and v2.9 (2017) to assess temporal trends in patient characteristics. ResultsOver time, SAVR patients were younger with fewer preoperative comorbidities. There was a significant decrease in median STS predicted risk of mortality (PROM) score (2.0 vs. 1.8 vs. 1.3, p < 0.001, in v2.73 vs. v2.81 vs. v2.9). Specifically, there were fewer high-risk (STS PROM > 8%: 4.3% vs. 4.7% vs. 1.2%, p = 0.03) and intermediate-risk (STS PROM 4% to 8%: 16.3% vs. 11.7% vs. 4.3%, p < 0.001) patients. The proportion of patients with bicuspid aortic valve disease increased significantly (11.2% vs. 26.9% vs. 36.6%, p < 0.001). There were no differences in operative mortality (1.9% vs. 2.1% vs. 1.4%, p = 0.75). ConclusionsThe introduction of TAVR has already impacted the demographics, clinical characteristics and risk profiles of patients undergoing SAVR in the US. Now that TAVR is approved for low-risk patients, SAVR is likely to be reserved for younger patients who are willing to receive a mechanical valve and for patients with aortopathy, coronary artery disease, or concomitant mitral or tricuspid pathology.

Cardiac Surgery and Postoperative Renal Allograft Failure

Although cardiac surgery among renal allograft recipients is relatively safe, less is known about the impact of cardiac surgery on the functioning renal allograft. This study assessed postoperative renal failure among renal transplant recipients undergoing cardiac surgery. The study population was identified by matching medical record numbers from the United Network for Organ Sharing Kidney Transplant Database to a cardiovascular surgery database and The Society of Thoracic Surgeons Adult Cardiac Surgery Database for the authors' institution from January 1992 through August2018. One hundred seventy-nine renal transplant recipients with a functioning allograft underwent cardiac surgery a mean of 6.4 ± 5.6 years after renal transplantation. Thirty (17.6%) of the 170 patients either died or had allograft failure during the first postoperative year. Receiver-operating characteristics curve analysis using Cox regression demonstrated an optimal cutoff point for preoperative serum creatinine predicting postoperative allograft loss is 1.9 mg/dL (hazard ratio 3; 95% confidence interval, 1.5 to 6.9) with a model C statistic of 0.642. The current study affirms findings in the literature that cardiac surgery in renal transplant recipients carries acceptable perioperative morbidity and mortality. Renal transplant recipients who underwent cardiac surgery had a constant hazard of renal allograft loss similar to that of the general transplant population. A preoperative serum creatinine value greater than 1.9 mg/dL increases the risk for long-term renal allograft loss after cardiac surgery.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2020 Update on Outcomes and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive database in cardiac surgery and one of the most respected clinical data registries in health care. It is widely acknowledged for accurately benchmarking risk-adjusted outcomes and serving as the foundation for quality measurement and improvement activities in cardiac surgery. In addition, the database is a valuable resource for novel research. The advent of the database's fourth decade in operation is being heralded with major revisions to its functionality, ease of use, and value to multiple stakeholders. This report is the fifth in a series of annual reports that provides updated national outcomes, volume trends, and database-related developments, as well as a summary of research performed in the past year using data from this valuable repository on quality and performance improvement.

Transfusion in Elective Aortic Root Replacement: Analysis of the STS Adult Cardiac Surgery Database

Data on blood use in proximal aortic surgery is limited. This study sought to establish quality benchmarks in the pattern of transfusion during elective aortic root replacement. The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried to identify all patients who underwent primary elective aortic root replacement between July 2014 and June 2017. Multivariable negative binomial regressions were used to determine whether perioperative transfusion was associated with demographic or procedural factors. Multivariable logistic regression analysis was performed for clinical outcomes. Of 5559 patients analyzed, 38.95% (n= 2165) received no blood products. Patients who had a valve-sparing root replacement were less likely to undergo transfusion than those who received composite roots (bioprosthetic or mechanical valves) or homografts. The 30-day mortality for all patients was 2.57% (n= 143). Transfusion was associated with an increased risk of death at 30 days (odds ratio [OR], 1.833; P= .012), more frequent reoperation for bleeding (OR, 1.766; P< .001), prolonged ventilation (OR, 1.935; P < .001), a longer postoperative hospital stay (OR, 1.056; P < .001), and a higher incidence of new dialysis-dependent renal failure (OR, 2.088; P= .003). There was no correlation between institutional case volume and transfusion practice. Elective aortic root replacement can be performed with acceptable requirements for blood products. Composite root replacement has a greater likelihood of transfusion than does a valve-sparing procedure. Transfusion is independently associated with more complications after elective aortic root surgery, including 30-day mortality.

Anticoagulation and amiodarone for new atrial fibrillation after coronary artery bypass grafting: Prescription patterns and 30-day outcomes in the United States and Canada

ObjectiveWe sought to elucidate national practice patterns regarding anticoagulation and antiarrhythmic medication use at discharge and examine short-term patient outcomes. MethodsIn this retrospective cohort study, we analyzed the data of patients from the Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 2011 to June 2018 who underwent first-time isolated coronary artery bypass graft surgery (CABG) and developed new post-CABG atrial fibrillation (AF) without significant complications. In total, 166,747 patients met study criteria. We examined 30-day outcomes. ResultsIn total, 166,747 patients were analyzed and divided into 4 groups based on discharge medications: amiodarone with or without anticoagulation, anticoagulation alone, and neither. Demographic characteristics were similar among the 4 groups. In total, 25.7% of patients were discharged on anticoagulation with an average CHA2DS2-VASc score of 3.2 ± 1.3. Anticoagulation use at discharge was not associated with lower 30-day stroke readmissions (adjusted odds ratio [AOR], 0.87; 95% confidence interval [CI], 0.65-1.16; P = .35). Adjusted 30-day readmissions for major bleeding were significantly more common in anticoagulated patients (AOR, 4.30; 95% CI, 3.69-5.03; P < .0001). Among those discharged off anticoagulation, there was no significant difference in adjusted 30-day stroke rates based on amiodarone use at discharge (AOR, 1.19; 95% CI, 0.85-1.66; P = .31). ConclusionsPost-CABG anticoagulation for new AF is associated with increased bleeding and no difference in stroke at 30 days. Prospective randomized studies are needed to formalize safe and efficacious short- and long-term management strategies.

Concomitant carotid endarterectomy and cardiac surgery does not decrease postoperative stroke rates

ObjectiveThe timing of operative revascularization for patients with concomitant carotid artery stenosis and coronary artery disease remains controversial. We examined the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database to evaluate the association of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) with postoperative outcomes. MethodsAll patients undergoing CABG with known carotid stenosis of >80% were identified from 2011 to 2016. Individuals were stratified by use of cardiopulmonary bypass and whether a concomitant CEA was performed at the time of CABG. Multivariate logistic regression was used to model the probability of combined CABG and CEA. The resulting propensity scores were used to match individuals on the basis of clinical and operative characteristics to evaluate primary (30-day mortality and in-hospital transient ischemic attack and stroke) and secondary (STS morbidity composite events and length of stay) end points, with P < .05 required to declare statistical significance. ResultsAfter propensity score matching, 994 off-pump CABG patients (497 CABG only and 497 CABG-CEA) and 5952 on-pump CABG patients (2976 CABG only and 2976 CABG-CEA) were identified. For patients who received on-pump operations, those undergoing CABG-CEA had no observed difference in rate of in-hospital stroke (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.72-1.21; P = .6), higher incidence of STS morbidity composite events (OR, 1.15, 95% CI, 1.01-1.31; P = .03), longer length of stay (7.0 [interquartile range, 5.0-9.0] days vs 6.0 [interquartile range, 5.0-9.0] days; P < .005), and no observed difference in 30-day mortality (OR, 1.28; 95% CI, 0.97-1.69; P = .08) compared with those undergoing CABG only. For off-pump procedures, CABG-CEA patients had no observed difference in rate of in-hospital stroke (OR, 0.80; 95% CI, 0.37-1.69; P = .56) compared with those undergoing CABG only. ConclusionsWhereas the differences are relatively small, these data suggest that a combined CABG-CEA approach is unlikely to provide significant stroke reduction benefit compared with CABG only. However, comparison with staged approaches merits further investigation.

Association of postoperative complications and outcomes following coronary artery bypass grafting

The long-term effects of postoperative complications following coronary artery bypass grafting (CABG) are unknown. Medicare-linked records from the Society of Thoracic Surgeons Adult Cardiac Surgery Database were queried for isolated CABG records from 2007 through 2012. Unadjusted and adjusted associations between individual postoperative complications and both mortality and all-cause rehospitalization were evaluated to 7 years using Cox proportional-hazards models and cumulative incidence functions. Because of nonproportional hazards, associations are presented as early (0 to 90 days) and late (90 days to 7 years). Of the 294,533 isolated CABG patients who had records linked to Medicare for long-term follow-up (median age, 73 years; 30% female), 120,721 (41%) experienced at least 1 of the complications of interest, including new-onset atrial fibrillation (30.0%), prolonged ventilation (12.3%), renal failure (4.5%), reoperation (3.5%), stroke (1.9%), and sternal wound infection (0.4%). Each of the 6 postoperative complications was associated with a significantly increased risk of mortality and rehospitalization to 7 years despite adjustment for baseline characteristics and the presence of multiple complications. Although the predominant effect of postoperative complications was observed in the first 90 days, the increased risk-adjusted hazard for death and rehospitalization continued through 7 years. Postoperative complications are associated with an increased risk of both early and late mortality and all-cause rehospitalization, particularly during the "value" window within 90 days of CABG. These findings underscore the need to develop avoidance strategies as well as cost-adjustment methods for each of these complications.

Impact of Substance Use Disorder on Midterm Mortality After Valve Surgery for Endocarditis

Fueled by the burgeoning opioid epidemic, valve surgeries for substance use disorder-related infective endocarditis (SUD-IE) are increasing. The impact of substance use disorder on postvalve replacement morbidity needs further investigation. We queried The Society of Thoracic Surgeons Adult Cardiac Surgery Database for all valve surgeries for infective endocarditis at Tufts Medical Center (2002-2016) and collected demographic and disease-related data, including timing of mortality subclassified as short-term (<6 months including operative), midterm (6 months to 5 years), and extended-term (>5 years). Patients with documentation of illicit drug use before the operation were considered to have SUD-IE. Deaths were confirmed through review of medical record and matching with the Massachusetts Vital Statistics Database. We performed univariate and multivariate proportional hazard regressions examining the impact of substance use disorder mortality in people who received a valve replacement. In the cohort of 228 patients, 80 (35%) had SUD-IE. Eight-six people (38%) died, and overall mortality was higher in people with SUD-IE compared with non-SUD-IE (48% vs 32%, P= .025). SUD-IE was associated with a higher risk of overall mortality (adjusted hazard ratio, 2.41; 95% confidence interval, 1.38-4.20; P= .002). Although the difference between short-term or extended-term mortality wasnot significant, SUD-IE was associated with increased frequency of midterm mortality (53% vs 31%, P= .003). Our data reflect high rates of postvalve surgery morbidity and mortality in people with SUD-IE at a tertiary care center. The midterm postoperative period is a vulnerable period for people with SUD-IE worthy of further investigation.

Impact of Cerebral Perfusion on Outcomes of Aortic Surgery: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

Limited data inform cerebral protection during circulatory arrest. This study was designed to identify optimal approaches from a national clinical registry. A total of 7830 adults (mean age, 63.1 years, SD 13.1 years) who underwent hemiarch (n= 6891; 88.0%) or total arch (n= 939; 12.0%) replacement with hypothermic circulatory arrest between 2014 and 2016 were identified from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (version 2.81). Aortic dissections were excluded from the analysis. Multivariable logistic regression was used to adjust for 29 baseline and operative variables, including demographics, comorbidity, surgery, and nadir temperature, comparing outcomes according to protection strategy. The primary end point was a composite of 30-day and in-hospital mortality or major permanent neurologic complications. The rate of death or permanent neurologic complication was 10.9% (n= 850). Antegrade cerebral perfusion was most commonly used (n= 3369; 43%; median nadir temperature 23°C; median arrest time 30 minutes) compared with retrograde cerebral perfusion (n= 1898; 24%; 20°C; 24 minutes) and no cerebral perfusion (n= 2563; 33%; 20°C, 22 minutes). In multivariable analysis, deep hypothermia with antegrade (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.52 to 0.81) or retrograde (OR, 0.57; 95% CI, 0.45 to 0.71) perfusion and moderate hypothermia with antegrade perfusion (OR, 0.61; 95% CI, 0.46 to 0.79) were associated with significant reductions in death and stroke compared with deep hypothermia without cerebral perfusion. Risk reduction was greatest in circulatory arrest lasting longer than 30 minutes. For patients without aortic dissection and who require more than 30 minutes of circulatory arrest, optimal cerebral protection strategies are deep hypothermia with either antegrade or retrograde cerebral perfusion and moderate hypothermia with antegrade cerebral perfusion.

Aortic Valve Replacement in Bioprosthetic Failure: Insights From The Society of Thoracic Surgeons National Database

This study was conducted to determine the current nationwide trends and outcomes of reoperative surgical aortic valve replacement (SAVR) performed for a degenerated bioprosthesis. Data from The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database were used. All patients who underwent isolated reoperative SAVR for a degenerated aortic bioprosthesis between January 2012 and December 2016 were included. Patients who had other concomitant cardiac surgery procedures or active endocarditis were excluded. Changes during this period were tracked with trend analyses. The number of patients undergoing SAVR for bioprosthetic failure increased substantially between 2012 and 2014 (782 in 2012 to 844 in 2013 and to 900 in 2014; relative change,+7.25%); this trend reversed significantly between 2015 and 2016 (decreased to 873 in 2015 and to 840 in 2016; relative change,-3.4%; P= .005). Patients were older in 2012-2014 (65.80 ± 13.52 years) compared with 2015-2016 (64.45 ± 12.91 years; P= .001). Mean STS-predicted mortality risk score decreased from 4.55% in 2012-2014 to 4.25% in 2015-2016 (P= .001). There was no difference in postoperative stroke (1.80% vs 1.80%, P= .87), renal failure requiring dialysis (2.7% vs 2.8%, P= .69), or operative mortality (3.5% vs 4.0%, P= .36) after reoperative SAVR in 2012-2014 and 2015-2016, respectively. The number of patients undergoing SAVR for a degenerated bioprosthesis is decreasing in the United States, particularly among older and high-risk patients. These trends may reflect the adoption of valve-in-valve transcatheter aortic valve replacement for a degenerated bioprosthesis after its United States Food and Drug Administration approval in2015.

Distressed communities are associated with worse outcomes after coronary artery bypass surgery

ObjectivesAlthough low socioeconomic status has been associated with increased risk of complications after cardiac surgery, analyses have typically focused on insurance status, race, or median income. We sought to determine if the Distressed Communities Index, a composite socioeconomic metric, could predict operative mortality after coronary artery bypass grafting. MethodsAll patients who underwent isolated coronary artery bypass grafting (2011-2018) in the National Society of Thoracic Surgeons adult cardiac surgery database were analyzed. Clinical data were paired with the Distressed Communities Index, which accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies by ZIP code. Developed by the Economic Innovation Group, Distressed Communities Index scores range from 0 (no distress) to 100 (severe distress). A distressed community was defined as one having a Distressed Communities Index of 75 or greater for univariate analyses. ResultsOf the 575,900 patients undergoing coronary artery bypass grafting with a Distressed Communities Index score, the median age was 65 years. The operative mortality rate was 2.0%, and the composite morbidity or mortality rate was 11.5%. Distressed communities were associated with increased Society of Thoracic Surgeons predicted risk of mortality (1.97% vs 1.85%, P < .0001) and risk of composite morbidity or mortality (12.8% vs 11.7%, P < .0001). After adjusting for Society of Thoracic Surgeons risk model, the Distressed Communities Index remained significantly associated with mortality (odds ratio, 1.12; P < .0001) and composite morbidity and mortality (odds ratio, 1.03; P = .002). ConclusionsPatients from distressed communities are at increased risk for adverse events and death after coronary artery bypass grafting. The Distressed Communities Index is a useful, holistic measure of socioeconomic status that may help identify high-risk patients for quality improvement and should be considered when building risk models or comparing hospitals.

Parasternal Pectoral Block for Right Anterior Minimally Invasive Thoracotomy in Cardiac Surgery

MINIMALLY invasive cardiac surgery (MICS) is being increasingly performed. 1 Gammie J.S. Zhao Y. Peterson E.D. et al. Less-invasive mitral valve operations: Trends and outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2010; 90 (1401-10.e1) Abstract Full Text Full Text PDF Scopus (270) Google Scholar Several approaches are listed under the term MICS, such as ministernotomy for aortic valve replacement, left minithoracotomy for minimally invasive direct coronary artery bypass, and right anterior minimally invasive thoracotomy (RMIT) principally for mitral or aortic valve surgery. Minimally invasive thoracotomy is associated with intense and prolonged postsurgical pain, which can be equal to that occurring after conventional sternotomy. Pain after RMIT is caused by rib retraction, pectoralis and intercostal muscle dissection, and intercostal nerve lesions. Moreover, this pain is exacerbated by breathing movements, coughing, respiratory physiotherapy, and chest tubes. 2 Furrer M. Rechsteiner R. Eigenmann V. et al. Thoracotomy and thoracoscopy: Postoperative pulmonary function, pain and chest wall complaints. Eur J Cardiothorac Surg. 1997; 12: 82-87 Crossref PubMed Scopus (150) Google Scholar

Factors associated with acute stroke after type A aortic dissection repair: An analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database

ObjectivesData from the Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to examine the incidence and factors associated with acute stroke following type A repair. MethodsAcute type A aortic dissection repairs performed from 2014 to 2017 were identified from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The effect of cannulation strategy (eg, axillary, femoral, direct, or innominate), lowest temperature, cerebral protection techniques (antegrade cerebral profusion, retrograde cerebral perfusion, both, or none), repair technique, and institutional volume on postoperative stroke was investigated. ResultsAcute type A repair was performed on 8937 patients at 772 centers, of which 7353 met inclusion criteria. Operative mortality was 17% and incidence of postoperative stroke was 13%. Axillary cannulation was associated with lower risk of stroke versus femoral (odds ratio, 0.60; P < .001). Retrograde cerebral perfusion was associated with reduced risk for stroke compared with no cerebral perfusion (odds ratio, 0.75; P = .008) or antegrade cerebral perfusion (odds ratio, 0.75; P = .007). Total arch replacement was associated with greater risk for stroke versus hemiarch technique (odds ratio, 1.30; P = .013). Longer circulatory arrest time, cerebral perfusion time, and cardiopulmonary bypass time were all related to higher risk of postoperative stroke. ConclusionsStroke is a common complication after type A repair. Axillary cannulation was associated with lower incidence of stroke, whereas femoral cannulation significantly increased the risk of stroke regardless of the cerebral perfusion strategy or the degree of hypothermia. Retrograde cerebral profusion was found to have reduced risk for postoperative stroke. Degree of hypothermia and center volume were not related to stroke incidence.

Surgical valve selection in the era of transcatheter aortic valve replacement in the Society of Thoracic Surgeons Database

ObjectivesTime trends in surgical valve selection have not been explored in detail in the era of transcatheter aortic valve replacement (TAVR) in nationally representative data. Herein, we explore valve selection trends in the TAVR era using the Society of Thoracic Surgeons Adult Cardiac Surgery Database. MethodsIsolated first-time biological or mechanical aortic valve replacements (AVR) from 2004 to 2016 in the Society of Thoracic Surgeons Adult Cardiac Surgery Database were included. Patient characteristics were examined in the pre-TAVR era (2004-2007) and the post-TAVR era (2008-2016) using the year 2007 as the cut-point. Using a piece-wise regression analysis to model the relationship between time and type of valve used, a change-point analysis was performed to empirically determine the time of change in practice, both overall and in age-specific subgroups (≤60 years and >60 years). ResultsIn total, 214,390 patients underwent isolated primary mechanical or biological AVR from 2004 to 2016. The patients' mean age increased slightly between the 2 eras (67.1 vs 68.6 years, P < .001), whereas the proportion of mechanical AVRs decreased (24.8% vs 12.2%, P < .001). Piece-wise regression demonstrated that the proportion of mechanical valves decreased over time. An empirically estimated slope change-point was found after the first quarter 2010; from 2004 to 2009, the overall proportion of mechanical valves was decreasing quickly (−2.81%/year, 95% confidence interval [95% CI], −3.03% to −2.60%), compared with 2010 to 2016. The early decline was steeper for younger patients (−4.21%/year, 95% CI, −4.74 to −3.69) compared with older patients (−1.44%/year, 95% CI −1.64 to −1.23). ConclusionsUse of mechanical AVR declined significantly from 2004 to 2016 and was decreasing before the introduction or the approval of TAVR in the United States.

Characterizing Risks Associated With Mitral Annular Calcification in Mitral Valve Replacement

Mitral annular calcification (MAC) increases technical complexity for surgeons during mitral valve (MV) procedures. This study assesses the risks conferred by the presence of MAC in patients undergoing MV replacement (MVR) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database. A total of 52,816 MVR procedures were performed between 2011 and June 2017. Individuals with concomitant tricuspid procedures were included, but those from institutions that reported < 1 MAC case/y were excluded. Operative mortality and in-hospital complications in MAC patients were compared with controls from the same institution. The contribution of hospital MV procedure volume (stratified by mean procedures per year during) to adjusted operative mortality was also assessed. Overall, 9551 MVR cases were classified as MAC (18.1%). Observed operative mortality was 5.8% for MAC and 4.4% for non-MAC patients (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.19-1.38). Although postoperative stroke and reoperation rates were similar, MAC was associated with increased risk of acute kidney injury (relative risk, 1.15) and reintubation (relative risk, 1.26) (all P < .001). After risk adjustment, MAC remained a risk factor for operative mortality (OR, 1.24; 95% CI, 1.08-1.42). Centers with less than 50 MV procedures/y were also associated with increased operative mortality (OR, 1.21; 95% CI, 1.08-1.37; observed-to-expected mortality among MAC patients 1.09 vs 0.82 in centers with ≥ 50 MV procedures; P= .001) CONCLUSIONS: The presence of MAC alone, regardless of severity, was independently associated with increased operative mortality and adverse postoperative outcomes. Even after adjusting for attendant cardiovascular and metabolic comorbidities, centers with low MV case volumes were found to have worse outcomes after MVR.

SS24. Short-Term Outcomes of Open Thoracoabdominal Aortic Aneurysm Repairs: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database

SS24. Short-Term Outcomes of Open Thoracoabdominal Aortic Aneurysm Repairs: Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2019 Update on Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2019 Update on Research