Surgeons Database Research Articles

Variability in technical fee billing for cardiac CT across congenital cardiac centers.

Cardiac Computed Tomography (CCT) is increasingly used to provide 2D, 3D and 4D information in patients with congenital heart disease of all ages. Historically, negotiated rates for professional and technical fees associated with cardiac imaging were confidential, with variability in professional, technical and global charges, reimbursement and cost to patients for the same current procedural terminology (CPT) code at different institutions. Billing transparency is a key component of both the CARE act passed in 2020 and the Health Care PRICE Transparency Act 2.0 passed in 2021. Institutional technical fees and negotiated insurance rates by CPT billing code are now publicly available and can be compared between institutions. A cohort of congenital heart disease programs was identified as the top 50 programs by procedural volume (Society of Thoracic Surgeons database) and by national rankings (US News and World Report). The publicly available negotiated reimbursement rates for the technical component of billing for CPT codes used for CHD CCT (75572, 75573, and 75574) at each center was determined (trybilly.app). The cash price, average insured price and the range of negotiated insured prices for the technical component of CHD CCT were recorded. The variability of technical fee charges for programs were calculated as median, IQR and range. Technical fee correlation to RVUs was also calculated. Professional fee and global procedural fees are not available for comparison. For the 75572 code, the median charge was $1209.50, IQR (783.50, 1673.75), and range was (49,2618). For the 75573 code, the median charge was $958, IQR (718,1403), and range (60,2622). For the 75574 code the median charge was $1060, IQR (833.5,1604), and range (61,2948). There was a 53-fold difference in technical fee charges for C CT between low and high negotiated insurance prices. Charges for CCT in CHD were not correlated with US News rankings or surgical center volume. There was no correlation between RVUs and technical fees. There is significant variability in the charges for the technical component of CCT in CHD, not correlated with national ranking or surgical volume. Variability in charges for identical services across centers may have a disproportionate impact on uninsured and underinsured populations. and lead to inequity. This data may inform negotiations for reimbursement for this time-consuming skill set. The variability of technical fee associated with CT for CHD has not been previously analyzed or compared by national ranking or surgical volumes.

The Impact of Medicaid Expansion on Congenital Heart Surgery Outcomes: Data From the Society of Thoracic Surgeons Database

BACKGROUND: The Affordable Care Act expanded Medicaid eligibility and increased public insurance coverage for children across the United States. As only a subset of states adopted expansion of coverage, disparities in insurance coverage between expansion and nonexpansion states emerged. We examined the association between Medicaid expansion and cardiac surgery outcomes to understand the impact of Medicaid expansion in a medically complex pediatric population. We hypothesized that expansion of Medicaid eligibility would be associated with greater improvement in surgical outcomes. METHODS: The Society of Thoracic Surgeons Congenital Heart Surgery Database was used to evaluate perioperative outcomes for children 0 to 18 years undergoing cardiac surgery between January 2010 and December 2019. We used a difference-in-differences (DiD) design to estimate the impact of Medicaid expansion on surgical outcomes by comparing changes in outcomes between individuals in expansion states and those in nonexpansion states, both before and after the expansion. Outcomes included operative mortality, major complications and postoperative length of stay (PLOS). RESULTS: The interaction between Medicaid expansion and time period post- vs preexpansion was not significant for any of the outcome variables. The odds ratio (OR) for mortality related to the Medicaid expansion was 1.12 (confidence interval [CI], 0.95–1.32, P = .161). For major complications, the OR was 0.99 (CI, 0.90–1.09, P = .770). For PLOS, the incidence rate ratio was 1.02 (CI, 0.99–1.05, P = .141). CONCLUSIONS: There was an overall decline in congenital heart surgery mortality over time; however, states that expanded Medicaid eligibility did not experience a greater improvement in mortality relative to states that did not expand eligibility. Similarly, there was no significant difference in major complications or PLOS related to Medicaid expansion. Further studies are needed to examine long-term outcomes and the larger spectrum of accessibility to congenital cardiac care which may benefit from insurance coverage.

Comparing Patient Communication Event Demand for External Ring Fixators to Other Common Foot and Ankle Orthopaedic Procedures: A Retrospective Study

Background: Surgeons may hesitate to apply external ring fixators (ERFs) due to perceived high clinical burden. This study aims to quantify the relative demand of ERFs compared with other common foot and ankle procedures. Understanding the demand of ERFs can provide insights into postoperative experiences, potentially decreasing intimidation of their use. Methods: Patients undergoing ERF treatment, hallux valgus osteotomy (HVO), or lateral ligamentous reconstruction (LLR) were identified using current procedural terminology code search in a single surgeon database. A retrospective review at a single institution included patients undergoing one of the three surgeries between 2017 and 2023. Clinical burden was quantified using points of contact for each procedure, which included phone calls, portal messages/documented emails, in-person visits, and surgeries. Visits and surgeries were categorized as routine or unexpected. Quantified burden was then compared among the three groups. Results: One hundred ninety-four patients were included in the study (81 LLR, 64 HVO, 49 ERF), and data were collected within 6-month postoperation. ERFs had 2.27 more total clinic visits than HVO (6.91 vs. 4.64; P < 0.0001) and 2.80 more than LLR (6.91 vs. 4.11; P < 0.0001). Overall, 0.42 more unexpected clinic visits were observed for ERF than for HVO (0.94 vs. 0.52; P = 0.06) and 0.84 more than LLR (0.94 vs. 0.1; P < 0.0001). An average of 0.6 unexpected surgeries were observed for ERF, compared with 0.09 for HVO (P < 0.0001) and 0 for LLR (P < 0.0001). Conclusion: Patients with an ERF did have more frequent encounters compared with control groups. This study provides guidance about the extent of potential clinical burden of ERF. Whether this increase is clinically notable would be to the discretion of the treating surgeon.

Revisional Surgery Due to Weight Regain or Insufficient Weight Loss Following One Anastomosis Gastric Bypass.

One anastomosis gastric bypass (OAGB) is a common procedure associated with satisfactory outcomes. Revisional surgery due to weight regain or insufficient weight loss (WR/IWL) after OAGB is underreported. A retrospective analysis of a single-bariatric surgeon database was conducted. All patients undergoing revisional surgery after OAGB due to WR/IWL were included. Ten patients were included in this case series. The median time between OAGB and revisional surgery was 44.9 months. The median body mass index (BMI) was 41.6 at pre-OAGB and 38.6 at pre-revision. The median age at OAGB revision was 40 years. The median biliopancreatic limb (BPL) length at revision was 160 cm. BPL elongation was performed in three patients, conversion to Roux-en-Y gastric bypass (RYGB) with BPL elongation in three patients, RYGB without BPL elongation in three patients, and one patient underwent conversion to single anastomosis duodeno-ileal bypass with sleeve (SADI-S). Pouch resizing was performed in four patients. One patient was reoperated due to a staple line leak from pouch resizing after conversion to RYGB. At a mean postoperative follow-up of 19 months, the median BMI and total weight loss were 30 and 18%, respectively. Higher weight loss outcomes occurred with BPL elongation (average: 24.8%) and SADI-S (average: 23.4%), while conversion to RYGB, with or without elongation, showed lower weight loss outcomes (11.5% and 7.8%, respectively). WR/IWL after OAGB can be encountered during follow-up. In this case series, several options of revisions were evaluated, and BPL elongation or conversion to SADI-S correlated with better weight loss outcomes.

Baseline American Society of Anesthesiologists classification predicts worse anxiety and pain interference following Lumbar Interbody Fusion

BackgroundThe American Society of Anesthesiologists (ASA) classifications allow physicians to briefly assess a patient’s risk for general anesthesia and surgical intervention. Although simple to calculate, a patient’s ASA score may correlate with differences in outcomes following spinal operations. The purpose of this study is to establish the effect of ASA score on Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes following Lateral Lumbar Interbody Fusion (LLIF). MethodsAll patient data was collected from a single spinal surgeon database. Patients were separated into cohorts of “Lower ASA” (ASA < 3) and “Higher ASA” (ASA ≥ 3). Demographics, perioperative characteristics, preoperative Patient-Reported Outcomes (PROs), and postoperative PROs at 6 weeks and final postoperative time points were compared statistically. These included Visual Analog Scales for back and leg pain (VAS-B, VAS-L), the Oswestry Disability Index (ODI), the 9-item Patient Health Questionnaire (PHQ-9), and PROMIS measures for Physical Function (PROMIS-PF), Sleep Disturbance (PROMIS-SD), Anxiety (PROMIS-A), and Pain Interference (PROMIS-PI). PRO improvements between preoperative and postoperative time points and Minimum Clinically Important Difference (MCID) were also compared. ResultsIn total, 154 patients were included (111 and 43 in the Lower and Higher ASA cohorts, respectively). Patient age, body mass index (BMI), presence of diabetes, and Charlson Comorbidity Index (CCI) score were significantly different between the two cohorts (Table 1, p < 0.004 for all). Primary vs. non-primary surgery, number of spinal levels fused, postoperative length of stay, and rates of isthmic spondylolisthesis and foraminal stenosis also significantly differed (Table 2, p < 0.05 for all). Patients with a higher ASA score were found to have higher PROMIS-A preoperatively (Table 3, p = 0.029). These patients also had higher PROMIS-A and PROMIS-PI at final postoperative evaluation (p values of 0.007 and 0.047, respectively). Score changes over time and MCID achievement did not seem to be impacted by baseline ASA score. ConclusionsPatients with a higher preoperative ASA score were found to have worse anxiety pre-operatively and worse anxiety and pain interference at the final postoperative evaluation. Clinical improvement over time was not significantly affected by the ASA score.

Influence of Preoperative Disability on Outcomes Following Primary Surgical Treatment of Cervical Disc Herniation.

Retrospective review. To evaluate how preoperative disability influences patient-reported outcomes (PROs) following primary surgical intervention for cervical herniated disc. The effect of baseline disability has been evaluated for various spinal surgeries, but not specifically for primary cervical herniated disc. A prospectively maintained single surgeon database was retrospectively reviewed to identify patients who underwent primary cervical spine surgery for herniated nucleus pulposus. Demographics, perioperative data, and baseline/postoperative PROs were collected including Neck Disability Index (NDI), Visual Analog Scale-Arm/Neck (VAS-A/N), 12-Item Short Form Mental/Physical Component Scores (SF-12 MCS/PCS), Patient-Reported Outcome Measure Information System-Physical Function (PROMIS-PF), and 9-Item Patient-Health Questionnaire (PHQ-9). Baseline NDI <50/≥50 defined 2 cohorts. ΔPROs were determined at 6-week postoperatively/final follow-up (average 11.8±7.7 postoperative months). Overall rates of minimal clinically important difference (MCID) achievement were determined for each PRO. Perioperative characteristics/demographics/baseline PROs were compared with χ2 tests (categorical variables)/the Student t test (continuous variables). Intercohort postoperative PROs/ΔPROs/MCID attainment rates were compared with multivariate linear regression (continuous variables)/multivariate logistic regression (categorical variables) accounting for differences in insurance type. Of 190 patients, there were 69 in the NDI ≥50 group. Patients with NDI ≥50 were more likely to have workers' compensation, or Medicare/Medicaid insurance (P<0.001) and report worse baseline PROs (P≤0.001, all). After controlling for insurance type, NDI ≥50 patients continued to report worse PROs at 6 weeks/final follow-up (P≤0.037, all), except PROMIS-PF at 6 weeks postoperatively. NDI ≥50 patients reported greater NDI improvements at 6 weeks (P=0.007) and final follow-up (P<0.001). NDI ≥50 patients experienced higher overall MCID achievement rates for PHQ-9/NDI (P≤0.015, both). NDI ≥50 patients reported worse baseline mental/physical health and neck/arm pain and continued to report inferior postoperative outcomes including disability. Despite inferior absolute outcomes, NDI ≥50 patients reported greater improvements/achievement of clinically significant differences in disability through final follow-up. Further, these patients were more likely to experience clinically significant improvements in depressive burden.

Discussion to: Volume–failure to rescue relationship in acute type A aortic dissections: An analysis of The Society of Thoracic Surgeons Database

Discussion to: Volume–failure to rescue relationship in acute type A aortic dissections: An analysis of The Society of Thoracic Surgeons Database

Long-term outcomes of heparin-induced thrombocytopenia after cardiac surgery

ObjectiveHeparin-induced thrombocytopenia (HIT) after cardiac surgery may lead to greater morbidity and mortality than predicted preoperatively. The aim of this study is to assess long-term outcomes of patients surviving HIT after cardiac surgery. MethodsThis was a single-institution, retrospective study of adult patients who underwent cardiac surgery between 2011 and 2023 and developed HIT postoperatively. The institutional Society of Thoracic Surgeons database and electronic medical record were integrated with longitudinal data from phone questionnaires. HIT was defined by combined clinical (4Ts score) and serologic manifestations: a platelet decrease >50% from preoperative baseline, a high optical density positive heparin-PF4 antibody test, and a positive serotonin release assay. ResultsWe identified 88 of 11,658 patients (0.8%) with HIT after cardiac surgery. The majority were male (74%), White (73.8%), and with a mean age of 65.6 ± 11.6 years. Seventy-seven (87.5%) survived to discharge, had a 4Ts score of 5 [4-6], and 58 (75.3%) were discharged on oral anticoagulation, with only 22 (28.6%) receiving treatment for the past 3 months, for a median of 1.3 [0.8-4.5] years. Median length of stay was 24 [17-35] days and length of follow-up was 4.6 [0.3-12] years. Readmission occurred in 70.1% (n = 54) of patients, with an average of 3 [1-6] readmissions/patient. Causes of death during follow-up included cardiac (n = 7, 24.1%), infectious (n = 6, 20.7%), or neurologic events (n = 5, 17.3). Ten-year survival probability was 48% ConclusionsPatients who develop HIT after cardiac surgery have an overall poor prognosis even after hospital discharge. In addition to prolonged hospitalization, patients experience further complications leading to frequent early readmissions and elevated mortality in the long term.

Novel linkage of the Society of Thoracic Surgeons database and hospital electronic health records.

Society of Thoracic Surgeons Congenital Heart Surgery Database is the largest congenital heart surgery database worldwide but does not provide information beyond primary episode of care. Linkage to hospital electronic health records would capture complications and comorbidities along with long-term outcomes for patients with CHD surgeries. The current study explores linkage success between Society of Thoracic Surgeons Congenital Heart Surgery Database and electronic health record data in North Carolina and Georgia. The Society of Thoracic Surgeons Congenital Heart Surgery Database was linked to hospital electronic health records from four North Carolina congenital heart surgery using indirect identifiers like date of birth, sex, admission, and discharge dates, from 2008 to 2013. Indirect linkage was performed at the admissions level and compared to two other linkages using a "direct identifier," medical record number: (1) linkage between Society of Thoracic Surgeons Congenital Heart Surgery Database and electronic health records from a subset of patients from one North Carolina institution and (2) linkage between Society of Thoracic Surgeons data from two Georgia facilities and Georgia's CHD repository, which also uses direct identifiers for linkage. Indirect identifiers successfully linked 79% (3692/4685) of Society of Thoracic Surgeons Congenital Heart Surgery Database admissions across four North Carolina hospitals. Direct linkage techniques successfully matched Society of Thoracic Surgeons Congenital Heart Surgery Database to 90.2% of electronic health records from the North Carolina subsample. Linkage between Society of Thoracic Surgeons and Georgia's CHD repository was 99.5% (7,544/7,585). Linkage methodology was successfully demonstrated between surgical data and hospital-based electronic health records in North Carolina and Georgia, uniting granular procedural details with clinical, developmental, and economic data. Indirect identifiers linked most patients, consistent with similar linkages in adult populations. Future directions include applying these linkage techniques with other data sources and exploring long-term outcomes in linked populations.

Atrial Fibrillation Surgery in Australia: Are We Doing Enough?

This study aimed to examine contemporary burden and treatment trends of atrial fibrillation (AF) in patients undergoing cardiac surgery in Australia and New Zealand. This allows comparison of contemporary practice with the Society of Thoracic Surgeons guideline recommendations for the surgical treatment of AF in patients undergoing cardiac surgery. A 10-year retrospective review of the Australian & New Zealand Society of Cardiac & Thoracic Surgeons National Cardiac Surgery Database was performed, examining all adult cardiac surgery patients from 2011 to 2021. Patients were grouped by the presence or absence of AF, and simple descriptive statistical analysis was performed to assess baseline demographics and premorbid condition of the patients. The incidence of AF was analysed by type of surgery. Trends for surgical treatment of AF were then analysed using simple descriptive statistics, examining isolated left atrial appendage ligation, isolated surgical ablation, and combined ligation and ablation. In the last 10 years, the Australian & New Zealand Society of Cardiac & Thoracic Surgeons database has recorded 140,680 patients who underwent cardiac surgery. Atrial fibrillation (AF) was present in 21,077 patients (14%). Patients with AF were generally older (72.25 vs 66.65 years; p<0.001). Among patients undergoing cardiac surgery, AF was more common in female than in male patients (18% vs 13%, respectively). Patients with AF more often had a higher classification of dyspnoea according to the New York Heart Association and lower ejection fractions compared with their AF-free counterparts. The incidence of AF as a comorbid condition was more frequent in patients undergoing mitral valve surgery or combined coronary artery bypass grafting and valve surgery (aortic, mitral, or both) compared with those undergoing isolated coronary or aortic surgery. Only 11.90% (n=2,509) of patients with AF received a combined ablation and left atrial appendage ligation, and 19.54% (n=693) of those received a Cox-Maze IV ablation. The burden of concomitant AF in patients undergoing cardiac surgery in Australia is higher than previously reported (14% vs 5%-11%). Despite strong recommendation for the surgical management of AF in patients undergoing cardiac surgery and clear evidence of its benefit, both left atrial appendage ligation and surgical ablation independently or concomitantly remain heavily underutilised in this cohort.

Impact of Hospital Transfers on Cardiac Surgery Outcomes: A Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis

BackgroundTransfers for cardiac surgery are not well studied. We sought to understand the risk profile of transferred patients and determine whether transfer rates vary by cardiac surgery and whether outcomes of transferred patients vary with type of referral hospital/surgery. MethodsPatients undergoing cardiac surgery with operative risk models were identified from The Society of Thoracic Surgeons database between July 1, 2014, and December 31, 2022. Patients were stratified as no transfer, transferred from hospital with cardiac surgery, and transferred from hospital without cardiac surgery. Risk associated with transfer compared with no transfer was derived by using multivariable logistic regression for operative mortality and select perioperative outcomes. ResultsIncluded were 1,828,787 patients at 1145 hospitals, with 1,452,491 no-transfer patients (79.4%), 28,862 transfers (1.6%) from hospitals with cardiac surgery, and 347,434 transfers (19.0%) from hospitals without cardiac surgery. Most transferred patients underwent coronary artery bypass grafting (83.6%); however, transfers from hospitals with cardiac surgery were most common for mitral valve replacement (17.9%). Transferred patients had increased comorbid diseases and urgent/emergent procedures. In multivariable analysis, transfers from hospitals with/without cardiac surgery were not associated with differential risk of adverse outcomes by procedure type. Patients transferred from hospitals with cardiac surgery undergoing mitral and aortic valve replacement and coronary artery bypass grafting had significantly lower adjusted mortality risk compared with nontransferred patients, whereas composite morbidity/mortality was higher in mitral valve repair. ConclusionsPatients transferred for cardiac surgery are generally higher risk; yet, outcomes at transfer to hospitals are as expected or better. However, further research is necessary to examine patients who are transferred but do not undergo surgery.

Robotic-assisted versus video-assisted thoracoscopic surgery for thymic epithelial tumours, from the European Society of Thoracic Surgeons Database.

Minimally invasive thymectomy is an accepted approach for early-stage thymic epithelial neoplasia, reducing pain and length of stay compared with open surgery. In this study, we compare robotic and video-assisted thymectomy to assess pathological resection status, overall and disease-free survival. Data were retrieved from the European Society of Thoracic Surgeons prospectively maintained thymic database. Eighty-two international centres were invited to participate in the ESTS registry. Thirty-seven centres agreed to take part. We included all patients who had undergone complete thymectomy for malignancy through a minimally invasive approach and excluded patients in whom complete data were not available. Between October 2001 and May 2021, a total of 899 patients with thymic malignancy underwent minimal access surgical resection and were included in the study. A propensity matched analysis was conducted with interrogation of 732 patients. Median age was 55 years, and 408 (56%) patients were female. Propensity matched was performed with 1:1 matching for surgical approach (video assisted = 366, robot assisted = 366). Robot-assisted surgery conferred significantly lower odds of incomplete resection (R1; 0.203 95% CI 0.13-0.317; P < 0.001). However, there was no difference in terms of overall and disease-free survival between the 2 techniques. In this analysis, after adjusting for thymoma stage, the odds of incomplete surgical resection were higher in patients undergoing video-assisted surgery than robotic. However, there was no difference in overall or disease-free survival. With data maturation and increased follow-up, this would need repeat analysis and perhaps may provide more credence to the concept of a prospective randomized study to compare outcomes in thymic epithelial neoplasia by surgical approach with a standardized pathological work-up.

Predictors of Postoperative Morphine Milligram Equivalents in Cardiac Surgery

ObjectivesGiven both the short- and long-term deleterious effects of opioids, there has been increased focused on reducing the use of postoperative opioid analgesia. As patients undergoing cardiac surgery often require high levels opioids postoperatively, understanding risk factors for increased postoperative opioid use may be helpful for the development of patient specific opioid sparing pain regimens for this patient population. DesignThis study was a retrospective analysis of data from our electronic medical records and the Society of Thoracic Surgeon's database. SettingThis was a single-institution study at an academic medical center. ParticipantsAll patients undergoing open adult cardiac surgery were included. Exclusion criteria were patients with continuous IV narcotic drips and operative mortality. InterventionsAs this was a retrospective study, no interventions were conducted on the participants. Measurements and Main ResultsData for patient's postoperative opioid requirements was extracted from the electronic medical record. Total opioid use on postoperative days 0-3 was converted to morphine milligram equivalent (MME) via standard conversion factors. A total of 1,604 patients were included in the study. 456 patients were female, and 1,066 underwent coronary artery bypass grafting. Patients undergoing CABG had 31.0% increased use of MME (P<.001), patients with liver disease had 76.3% increased use of MME (P=.005), and patients with patient-controlled analgesia had 48.8% increased use of MME (P<.001) during postoperative days 0-3. Younger age (P<.001) and increased BMI (P<.001) were also associated with increased MME prescription. ConclusionsPatients undergoing CABG, patients with liver disease, patients with patient-controlled analgesia, in addition to younger age and increased BMI, are associated with increased narcotic use after cardiac surgery. Implementation of more aggressive perioperative multimodal opioid sparing regimens should be considered for these patient groups.

A Single-Surgeon Experience Transitioning to Total Arterial Revascularization.

Background: Coronary artery bypass grafting remains the standard of care for advanced and multifocal coronary artery disease; however, for patients that are surgical candidates, total arterial revascularization (TAR) remains underutilized due to concerns such as sternal wound infections and the learning curve. We present the results of a large cohort of mid-career surgeons transitioning to TAR, focusing on short-term outcomes and the learning curve. Methods: The surgeons transitioned to using TAR as the preferred revascularization technique in August of 2017. The Society of Thoracic Surgeons database was reviewed to identify all patients who underwent isolated non-emergent CABG performed by a single surgeon from January 2014 through January 2022. Patients were divided into two groups-those who had TAR and those who had traditional CABG using one internal mammary artery and vein grafts (IMA-SVG). Results: Eight hundred ninety-eight patients meet inclusion criteria (458 IMA-SVG and 440 TAR). The TAR group had slightly longer cardiopulmonary bypass time, cross clamp times, and operative times (all p < 0.05); however, ICU stay was shorter and 30-day readmission rate was lower for TAR compared to IMA-SVG (all p < 0.05). The TAR group also required fewer postoperative transfusions (p = 0.005). There was no difference in prolonged intubation, stroke, length of stay, mortality, or sternal wound complications between groups (all p > 0.05). The average TAR was 30 min longer; however, learning curves, stratified by number of grafts placed, showed no significant learning curve associated with TAR. Conclusions: An experienced surgeon transitioning from IMA-SVG to TAR slightly increases operative time, but decreases ICU stay, readmissions, and postoperative transfusions with no significant difference in rates of immediate post-operative complications or 30-day mortality, with a minimal learning curve.

Readmissions Among Patients With Surgically Managed Drug Use Associated-Infective Endocarditis Before and After the Implementation of an Addiction Consult Team: A Retrospective, Observational Analysis.

Patients who undergo cardiac surgery for drug use-associated infective endocarditis (DUA-IE) have high rates of readmissions for recurrent endocarditis, substance use disorder (SUD), and septicemia. Our primary objective was to assess whether exposure to an addiction consult team (ACT) was associated with reduced readmissions in this population. This single-center retrospective analysis identified patients who underwent cardiac surgery for DUA-IE between 1/2012-9/2022 using the Society for Thoracic Surgeons database, and compared the cumulative incidence of readmissions at 1, 3, 6, and 12 months among those cared for before and after the implementation of an ACT in 9/2017, accounting for competing risk of mortality and adjusted for measured confounders using inverse probability of treatment weighting. The 58 patients (35 pre-ACT and 23 post-ACT) were young (36.4 +/- 7.7 years) and predominantly White (53.4%) and male (70.7%). The post-ACT cohort had a significantly lower risk of readmission at 1 month (adjusted risk difference [RD] -23.8% [95% CI -94.4%, -8.3%], P = 0.005) and 3 months (RD -34.1% [-55.1%, -13.1%], P = 0.005), but not at 6 or 12 months. In a sensitivity analysis, the post-ACT cohort also had significantly lower risk of readmissions for SUD complications at 3 months. ACT exposure was associated with a lower risk of short-term readmission among patients with surgically managed DUA-IE, possibly due to a reduction in SUD-related complications. Additional studies are needed to replicate these findings and to identify ways to sustain the potential benefits of ACTs over the longer term.

Hematocrit and Renal Failure in Aortic Arch Surgery: A Society of Thoracic Surgeons Database Study

BackgroundThis study examined the association between cardiopulmonary bypass (CPB) hematocrit and postoperative acute renal failure (ARF) in patients undergoing aortic arch surgery with hypothermic circulatory arrest. MethodsThe Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from 2011 to 2019 for patients undergoing aortic arch surgery with hypothermic circulatory arrest. A multivariable logistic regression model estimated the adjusted odds of postoperative ARF on the basis of CPB hematocrit. Effects were stratified by preoperative kidney function and the duration of hypothermic circulatory arrest by using interaction terms. The study also investigated the association between postoperative ARF and major postoperative outcomes by using multivariable regression models. ResultsOn adjusted analysis, higher CPB hematocrit (>20%-25%, >25%-30%, >30%) was associated with lower odds of ARF as compared with lower CPB hematocrit (≤20%) (>20-25%, aOR, 0.78; 95% CI, 0.65-0.93; P = .006; >25%-30%, aOR, 0.65; 95% CI, 0.50-0.84; P = .0007; >30%, aOR, 0.45; 95% CI, 0.28-0.72; P = .0008). The predicted probability of postoperative ARF by CPB hematocrit was higher in patients with lower preoperative renal function (estimated glomerular filtration rate, <60 mL/min/1.73 m2) (interaction P = .03). The association between hematocrit and postoperative ARF was not significantly modified by hypothermic circulatory arrest time (interaction P = .74). All postoperative outcomes were significantly worse in patients with postoperative ARF (all P < .0001). ConclusionsAmong patients undergoing aortic arch surgery, a higher CPB hematocrit level is associated with reduced likelihood of postoperative ARF. Preoperative renal function, but not hypothermic circulatory arrest duration, significantly modified this association. The maintenance of higher CPB hematocrit may reduce the incidence of postoperative ARF, especially for patients with poor preoperative renal function.

The Impact of COVID-19 Infection Prior to Lung Resection on Postoperative Complications

BackgroundWe hypothesize that previous COVID-19 infection could be associated with postoperative complications (POCs) and outcomes of thoracic surgery for lung cancer. It is unknown whether the respiratory damage caused by COVID-19 infection is permanent. In addition, there is a lack of studies investigating POCs and prior COVID-19 infection in thoracic surgery. MethodsA retrospective study was performed on patients who underwent resections for lung cancer between May 2020 and July 2022. Variables relevant to the Society of Thoracic Surgeons database were collected, as well as COVID-19 status. The primary outcome was postoperative complications. ResultsA total of 361 patients underwent a resection for lung cancer. Patients with a prior COVID-19 infection (n = 21) had significantly more POCs than patients without a history of COVID-19 infection (n = 340, P < .05). Pneumothorax and infections requiring intravenous antibiotics were significantly enriched in patients with a prior COVID-19 infection. COVID-19 infection was independently associated with increased POCs at multivariable analysis (adjust odds ratio, 4.36; 95% CI, 1.48-12.8). Matched case-control analysis also reviewed similar findings, where COVID-19 infection was the only significant variable as a risk factor for POCs (P < .05). ConclusionsAfter a COVID-19 infection, patients undergoing lung cancer resections were at an increased risk of POCs. This suggests that a previous COVID-19 infection should be considered as a potential risk factor for complications after lung cancer resections.

Early Valve Surgery for Endocarditis After Acute Embolic Stroke

BackgroundPatients with active endocarditis often suffer acute stroke, with increased risk for hemorrhagic conversion at the time of valve repair or replacement. Controversy persists about timing of operative intervention. MethodsAn institutional Society of Thoracic Surgeons database of all patients with endocarditis was reviewed for patients undergoing valve surgery (2016-2024). Electronic medical records were reviewed for detailed stroke information and longitudinal follow-up. Descriptive statistics and Kaplan-Meier survival curves evaluated outcomes and survival. ResultsOperations for acute active infective endocarditis were performed in 656 patients. Preoperative stroke occurred in 98 patients (14.9%); 86 strokes (87.8%) were embolic, and 16 patients (18.6%) had microhemorrhagic and 12 (12.2%) had hemorrhagic strokes. Median time between preoperative stroke diagnosis and surgery was 5.5 days. The overall incidence of postoperative stroke was 2.1% (14 of 656), with no statistically significant difference in postoperative stroke between patients with vs without preoperative stroke (n = 4 of 98 [4.1%] vs n = 10 of 558 [1.8%]; P = .148). However, the proportion of patients with postoperative hemorrhagic strokes was higher in the preoperative stroke group (3.1% vs 0.5%, P = .016). Finally, of patients with preoperative stroke, early surgery ≤72 hours (n= 38 [38.8%]) was not associated with increased stroke (2.6% vs 5.0%, P = .564). ConclusionsThese contemporary data highlight the feasibility of an early valve surgery strategy for acute endocarditis in the setting of acute stroke, with noninferior postoperative stroke risk.

Effect of Preoperative Clopidogrel on Outcomes of Isolated Coronary Artery Bypass Graft: An STS National Database Analysis

BackgroundWe analyzed The Society of Thoracic Surgeons Database to investigate risks and optimal timing for coronary artery bypass grafting (CABG) after clopidogrel administration. MethodsPatients were categorized based on clopidogrel use within 5 days and further stratified by days from the last dose (0 to 5 days). Controls were patients who did not receive clopidogrel within 5 days of surgery. The primary outcome was operative mortality, and secondary outcomes included mediastinal reexploration for bleeding and blood product use. ResultsAmong 148,317 isolated CABG, 19,553 patients (13.2%) received clopidogrel within 5 days. Minimal differences in operative mortality (2.8% vs 2.1%, P < .001), but higher rates of mediastinal reexploration (3.5% vs 2.1%, P < .001) and blood product utilization (72.7% vs 56.8%, P < .001) were observed in the clopidogrel group. The adjusted odds ratio of operative mortality peaked on the day of clopidogrel administration but was comparable to controls thereafter. The odds of reexploration were highest on day 0, decreasing gradually to a plateau after day 3. Patients who underwent operations on day 3 after clopidogrel administration had similar odds of operative mortality and mediastinal reexploration for bleeding and shorter total and preoperative lengths of stay but higher blood product use compared with day 5. ConclusionsCABG within 5 days from clopidogrel is associated with a modest increase in operative mortality and reexploration for bleeding and a substantial increase in blood product use. Risks decreased with increasing time from discontinuation, plateauing after 3 days from clopidogrel. CABG at 3 days yields comparable outcomes as 5 days, reducing the waiting period.

Risk of Transfusion in Isolated Coronary Artery Bypass Graft: Models Developed From The Society of Thoracic Surgeons Database

BackgroundPerioperative blood transfusion is associated with adverse outcomes and higher costs after coronary artery bypass graft (CABG) surgery. We developed risk assessments for patients’ probability of perioperative transfusion and the expected transfusion volume to improve clinical management and resource use. MethodsAmong 1,266,545 consecutive (2008-2016) isolated CABG operations in The Society of Thoracic Surgeons Adult Cardiac Surgery Database, 657,821 (51.9%) received perioperative transfusions of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate, and/or platelets. We developed “full” models to predict perioperative transfusion of any blood product, and of RBC, FFP, or platelets. Using least absolute shrinkage and selection operator model selection, we built a rapid risk score based on 5 variables (age, body surface area, sex, preoperative hematocrit, and use of intra-aortic balloon pump). ResultsC statistics for the full model were 0.785, 0.815, 0.707, and 0.699 for any blood product, RBC, FFP, and platelets, respectively. C statistics for rapid risk assessments were 0.752, 0.785, 0.670, and 0.661 for any blood product, RBC, FFP, and platelets, respectively. The observed vs expected risk plots showed strong calibration for full models and risk assessment tools; absolute differences between observed and expected risks of transfusion were <10.8% in each percentile of expected risk. Risk assessment–predicted probabilities of transfusion were strongly and nonlinearly associated (P < .0001) with total units transfused. ConclusionsThese robust and well-calibrated risk assessment tools for perioperative transfusion in CABG can inform surgeons regarding patients’ risks and the number of RBC, FFP, and platelets units they can expect to need. This can aid in optimizing outcomes and increasing efficient use of blood products.