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In a recent trial, tricuspid annuloplasty (TA) during mitral valve surgery (MVS) for degenerative mitral regurgitation and moderate or less tricuspid regurgitation (TR) reduced the composite rate of death, reoperation for TR, or TR progression at 2 years. However, this benefit was counterbalanced by an increase in implantation of permanent pacemakers (PPMs). In this study, we analyzed the timing, indications, and risk factors for these implantations. We randomized 401 patients (MVS alone = 203; MVS + TA = 198). Potential risk factors for PPMs were assessed using multivariable time-to-event models with death and PPM implantation for heart failure indications as competing risks. A PPM was implanted in 36 patients (9.6; 95% CI, 6.8-13.0) within 2 years of randomization, with 30/187 (16.0%) in the MVS + TA and 6/188 (3.2%) in the MVS groups (rate ratio, 5.08; 95% CI, 2.16-11.94; P <.001). Most (29/36; 80.6%) implantations occurred within 30 days postoperatively. Independent risk factors for PPM implantation within 2 years were TA (hazard ratio [HR], 5.94; 95% CI, 2.27-15.53; P <.001), increasing age (5 years, HR, 1.23; 95% CI, 1.01-1.52; P =.04), and left ventricular ejection fraction (LVEF; HR, 0.96; 95% CI, 0.92-0.99; P =.02). In the subset of TA recipients (n = 197), age (5 years, HR, 1.05; 95% CI, 1.00-1.10; P =.04) and LVEF (HR, 0.95; 95% CI, 0.91-0.99; P =.01) were associated with PPM within 2 years. Concomitant TA, age, and baseline LVEF were risk factors for PPM implantation in patients who underwent MVS for degenerative mitral regurgitation. Although TA was effective in preventing progression of TR, innovation is needed to identify ways to decrease PPM implantation rates. [Display omitted] [ABSTRACT FROM AUTHOR]

There are conflicting reports in the literature comparing outcomes after open Ravitch and minimally invasive Nuss procedures for pectus excavatum repair, and there is relatively little data available comparing the outcomes of these procedures performed by thoracic surgeons. The 2010 to 2018 Society of Thoracic Surgeons General Thoracic Surgery Database was queried for patients age 12 or greater undergoing open or minimally invasive repair of pectus excavatum. Patients were stratified by operative approach. Multivariable logistic regression was performed with a composite outcome of 30-day complications. A total of 1,767 patients met inclusion criteria, including 1,017 and 750 patients who underwent minimally invasive pectus repair and open repair, respectively. Open repair patients were more likely to be American Society of Anesthesiologists (ASA) class III or greater (24% vs 14%; P <.001), have a history of prior cardiothoracic surgery (26% vs 14%; P <.001), and require longer operations (median 268 vs 185 minutes; P <.001). Open repair patients were more likely to require greater than 6 days of hospitalization (18% vs 7%; P <.001), undergo transfusion (7% vs 2%; P <.001), and be readmitted (8% vs 5%; P =.004). After adjustment, open repair was not associated with an increased risk of a composite of postoperative complications (odds ratio 0.99, 95% confidence interval 0.67–1.46). This finding persisted after propensity score matching (odds ratio 1.11, 95% confidence interval 0.74–1.67). Pectus excavatum repair procedure type was not associated with the risk of postoperative complications after adjustment. Further investigation is necessary to determine the impact of pectus excavatum repair type on recurrence and patient reported outcomes, including satisfaction, quality of life, and pain control. [ABSTRACT FROM AUTHOR]

This study describes the impact of organism and valve type on surgically managed infective endocarditis (IE) from The Society of Thoracic Surgeons (STS) database. We developed a risk model for surgically managed endocarditis that includes the microbiological organism. The STS database was queried for adult patients with surgically managed endocarditis from July 1, 2011, to June 30, 2016. Outcomes were compared based on (1) causative microbiological organism, (2) valve type (native vs prosthetic), and (3) endocarditis on the right (tricuspid) vs left (mitral, aortic) sides. Univariate and risk adjusted models were developed with odds ratios for mortality for each organism type referenced against Streptococcus. The study population included 21,388 operations (93%) for left-sided IE and 1698 (7%) for right-sided IE. Streptococcus (28%) and Staphylococcus (27%) were the most common infecting organisms, followed by Enterococcus (11%). After multivariate adjustment, microbiological organism type was significantly associated with operative mortality for patients with left-sided endocarditis, with an adjusted odds ratio of 2.9 for fungal, 1.4 for Staphylococcus , and 1.3 for culture-negative vs Streptococcus. For right-sided endocarditis, there were no differences in outcomes by organism type. Left-sided prosthetic valve endocarditis had a higher operative mortality than left-sided native valve endocarditis (12% vs 8%, P <.001). In contrast, surgery for right-sided endocarditis carried lower operative mortality, with no mortality difference between prosthetic valve endocarditis and native valve endocarditis (5% vs 4%, P =.6). Organism type influences the operative mortality for left-sided endocarditis. Surgery for left-sided and prosthetic valve endocarditis is associated with higher operative mortality. Risk adjustment for operative outcomes in endocarditis may need to account for microbiological organism type. [ABSTRACT FROM AUTHOR]

Objective: To investigate trends in long-term graft and patient outcomes following liver transplantation using grafts from donors ≥60 years old. Summary Background Data: The scarcity of donor livers has led to increased utilization of organs from donors ≥60 years old. However, few studies have examined how long-term transplant outcomes from older donors have evolved over time. Methods: The OPTN/UNOS database was queried for all first-time isolated adult liver transplants. We identified 14,796 adult liver transplant using donors ≧60-year-old suitable for analysis from 1990 to 2014. Cohorts were then developed based on 5-year intervals of transplant date. Kaplan–Meier analysis was used to compare graft and patient survival for recipients from older donor across each 5-year era. Results: Utilization of donor grafts ≥60 years old increased steadily for the first 15 years of the study, but has leveled off over the last 10 years. Comparison of the earliest and latest eras in the study was notable for an increase in median recipient age (51 vs. 59, P < 0.001) and reduction in median cold ischemic time (10 vs. 6 h, P = 0.001). Unadjusted 5-year graft and patient survival has improved significantly over time (P < 0.0001). More importantly, the discrepancy in survival between older and younger grafts has narrowed substantially over time (P < 0.0001). Conclusions: This study demonstrates significant improvement in transplant outcomes with donor grafts ≥60-years old and supports increased but judicious use of extended criteria donors liver grafts. Improved patient selection and reduction in cold ischemia time appear to be contributing factors. [ABSTRACT FROM AUTHOR]

Background Unlike coronary artery bypass and aortic and mitral valve procedures, there is no predictive risk model for aortic root replacement procedures. As a first step toward development of a risk model, this study analyzed The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database to determine factors predictive of mortality and morbidity in patients undergoing elective aortic root replacement (ARR). Methods The STS database was queried (from July 2011 to June 2016) for elective ARR with the following exclusion criteria: urgent or salvage cases, endocarditis, redo cardiac surgery, circulatory arrest, and aortic arch surgery. Adjusted multivariate logistic regression models for outcomes of mortality and composite STS morbidity were performed using covariates of the STS aortic valve risk set (expressed as odds ratios [ORs]). Results Of 24,244 patients undergoing ARR, 8,807 (77.6% male) met inclusion criteria in 808 centers; 33.7% (n = 2,965) had a bicuspid aortic valve, and 3.7% (n = 327) had Marfan syndrome. The median age was 58.0 years (interquartile range, 49 to 67 years). Median intensive care unit and hospital stays were 46 hours and 6 days, respectively. Significant predictors for mortality included: atrial fibrillation (OR, 2.06), body surface area (OR, 0.14), chronic obstructive pulmonary disease (OR, 1.2), New York Heart Association class IV (OR, 2.53), diabetes (OR, 2.48), coronary artery bypass grafting (OR, 2.77), mitral valve surgery (OR, ≥2.18), and Bentall operation (OR, 2.08). Regression analysis for risk factors for STS morbidity yielded 14 significant factors. A glomerular filtration rate increase of 20 units was predictive of improved mortality (OR, 0.85) and morbidity (OR, 0.91). Conclusions Elective ARR is performed with excellent postoperative outcomes. Analysis of the STS database reveals several significant risk factors that are independently associated with increased mortality and morbidity. The investigators anticipate that future studies inclusive of the nonelective ARR cases in the database will facilitate development of a risk model for root replacement procedures. [ABSTRACT FROM AUTHOR]

Abstract Background Subclavian artery revascularization is frequently performed in the setting of thoracic endovascular aortic repair (TEVAR). However, there is little information on the short- and long-term outcomes of patients undergoing carotid to subclavian artery bypass in this clinical setting. As such, this study sought to define the early and late outcomes associated with this procedure. Methods Patients undergoing carotid-subclavian bypass in conjunction with TEVAR between June 2005 and September 2016 were retrospectively identified from a prospectively maintained, single-center aortic surgery database. The 30-day outcomes specific to the carotid-subclavian bypass procedure were analyzed, including cervical plexus nerve injury, bleeding complications, and local vascular complications. All preoperative and postoperative chest radiographs were carefully analyzed to assess for hemidiaphragm elevation indicative of phrenic nerve palsy. Long-term outcomes included primary graft patency and anastomotic complications. Results Of 579 consecutive patients undergoing TEVAR during this time interval, 112 patients (19%) underwent concomitant carotid-subclavian bypass. The cohort was 38% female (n = 43), with a mean age of 65 ± 14 years. The majority of conduits were 8-mm polytetrafluoroethylene grafts (n = 107 [95.5%]), with a minority being reversed saphenous vein (n = 4 [3.6%]) or Dacron (n = 1 [0.9%]) grafts. The bypass procedure was done concurrently at the time of TEVAR in 91% (n = 102) of cases. The short-term complication rate attributed specifically to the carotid-subclavian bypass was 29% (n = 33). These complications included phrenic nerve palsy in 25% (n = 27), recurrent laryngeal nerve palsy in 5% (n = 6), axillary nerve palsy in 2% (n = 2), and neck hematoma requiring re-exploration in 1% (n = 1) of patients. The 30-day in-hospital all-cause mortality rate was 5% (n = 6), and the rate of permanent paraparesis or paraplegia was 0.9% (n = 1). Of the operative survivors (n = 106), follow-up imaging of the bypass graft was available in 87% (n = 92) of patients. Actuarial primary graft patency was 97% at 5 years. There were three patients (3%) with bypass graft occlusions, two of which were clinically silent and detected on follow-up imaging. The third was detected because of symptoms of subclavian steal and required repeated revascularization. Two patients (2%) developed a late anastomotic pseudoaneurysm requiring either endovascular (n = 1) or surgical (n = 1) intervention. Conclusions Carotid-subclavian bypass for revascularization of the subclavian artery performed in the setting of TEVAR is durable, although the true complication rate is likely higher than is generally reported in the literature because of a not insignificant rate of phrenic nerve palsy. These data should serve well as "gold standard" comparison data for emerging branch graft devices. [ABSTRACT FROM AUTHOR]

Background The primary surgical therapy for hypertrophic cardiomyopathy with obstruction is septal myectomy (SM). The current outcomes of SM with and without concomitant mitral operations in the United States was examined using The Society of Thoracic Surgeons database. Methods From July 2014 through June 2017, 4,274 SM operations were performed. Emergent status, endocarditis, aortic stenosis, and planned aortic valve operations were excluded. In the final cohort of 2,382 patients, 1,581 (66.4%) received SM alone (group 1), and 801 (33.6%) had SM with mitral valve repair or replacement (group 2). Group 2 was subdivided into mitral valve repair (MVr [n = 500]) and mitral valve replacement (MVR [n = 301]). Baseline characteristics were compared and risk-adjusted operative mortality and major morbidity were evaluated between treatment groups. Results Baseline comorbidity was lower in group 1 versus group 2 and for MVr versus MVR. Operative mortality and major morbidity was lower for group 1 versus 2 (1.6% versus 2.8%, p = 0.046, and 10.9% versus 20.0%, p < 0.001, respectively). For patients with severe 3-4+ mitral regurgitation, SM alone was effective in reducing mitral regurgitation in 85.5% (355 of 415), and SM with MVr was effective in 88.0% (176 of 200; p = 0.4061). After risk adjustment, odds ratio for composite of mortality and major morbidity for group 2 versus group 1 was 1.8 (95% confidence interval: 1.4 to 2.4, p < 0.0001). Conclusions Septal myectomy for hypertrophic cardiomyopathy is safe. Septal myectomy alone may have risk-adjusted outcome advantages over SM with mitral valve repair or replacement. Septal myectomy and SM with MVr provide similar reduction in mitral regurgitation. Further longitudinal analyses are required to define technical efficacy and outcomes in selected pathoanatomic groups. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text Objective: To determine whether surgery with adjuvant chemotherapy offers a survival advantage over concurrent chemoradiation for patients with cT1-2N0M0 small cell lung cancer (SCLC). Background: Although surgery with adjuvant chemotherapy is the recommended treatment for patients with cT1-2N0M0 SCLC per international guidelines, there have been no prospective or retrospective studies evaluating the impact of surgery versus optimal medical management for cT1-2N0M0 SCLC. Methods: Outcomes of patients with cT1-2N0M0 SCLC who underwent surgery with adjuvant chemotherapy or concurrent chemoradiation in the National Cancer Data Base (2003–2011) were evaluated using Cox proportional hazards analyses and propensity-score-matched analyses. Results: During the study period, 681 (30%) patients underwent surgery with adjuvant chemotherapy and 1620 (70%) underwent concurrent chemoradiation. After propensity-score matching, all 14 covariates were well balanced between the surgery (n = 501) and concurrent chemoradiation (n = 501) groups. Surgery was associated with a higher overall survival (OS) than concurrent chemoradiation (5-year OS 47.6% vs 29.8%, P < 0.01). To minimize selection bias due to comorbidities, we limited the propensity-matched analysis to 492 patients with no comorbidities; surgery remained associated with a higher OS than concurrent chemoradiation (5-year OS 49.2% vs 32.5%, P < 0.01). Conclusions: In a national analysis, surgery with adjuvant chemotherapy was used in the minority of patients for early stage SCLC. Surgery with adjuvant chemotherapy for node-negative SCLC was associated with improved long-term survival when compared to concurrent chemoradiation. These results suggest a significant underuse of surgery among patients with early stage SCLC and support an increased role of surgery in multimodality therapy for cT1-2N0M0 SCLC. [ABSTRACT FROM AUTHOR]

Background National outcomes of robotic mitral valve repair (rMVr) compared with sternotomy (sMVr) in older patients are currently unknown. Methods From 2011 to 2014, all patients aged 65 years and older undergoing MVr in The Society of Thoracic Surgeons Adult Cardiac Surgery Database linked to Medicare claims data were identified. Patients who underwent rMVr were propensity matched to patients who underwent sMVr. Standard differences and falsification outcome of baseline characteristics were tested to ensure a balanced match. Cox models were used to calculate 3-year mortality, heart failure readmission, and mitral valve reintervention, adjusting for competing risks where appropriate. Results After matching, 503 rMVr patients from 65 centers and 503 sMVr from 251 centers were included. There were no significant differences in comorbidities or falsification outcome. Cardiopulmonary bypass and cross-clamp times were longer with rMVr versus sMVr at 125 versus 102 minutes (p < 0.0001) and 85 versus 75 minutes (p < 0.0001), respectively. The rMVr patients had shorter intensive care unit (27 vs 47 hours, p < 0.0001) and hospital stay (5 vs 6 days, p < 0.0001), less frequent transfusion (21% vs 35%, p < 0.0001), and less atrial fibrillation (28% vs 40%, p < 0.0001). Three-year mortality (hazard ratio, 1.21; 95% confidence interval, 0.68 to 2.16; p = 0.52), heart failure readmission (hazard ratio, 1.42; 95% confidence interval, 0.80 to 2.52, p = 0.10), and mitral valve reintervention (hazard ratio, 0.42; 95% confidence interval, 0.15 to 1.18; p = 0.22) did not differ between the groups. Conclusions The rMVr procedure was associated with less atrial fibrillation, less frequent transfusion requirement, and shorter intensive care unit and hospital stay, without a significant difference in 3-year mortality, heart failure readmission, or mitral valve reintervention. In older patients, rMVr confers short-term advantages without a detriment to midterm outcomes. [ABSTRACT FROM AUTHOR]

Background Lobar resection is the gold standard therapy for medically fit patients with stage I non-small cell lung cancer (NSCLC). However, considerable variability exists in the use of surgical therapy. This study tested the hypothesis that center-based variation in the use of surgical therapy affects survival in NSCLC. Methods We queried the National Cancer Database for patients with stage I NSCLC. Mixed-effects multivariable models were developed to establish the per-center adjusted rate of surgical therapy. Patients were stratified into quartiles based on the treating center's adjusted rate of surgical therapy. Survival was estimated and then tested by using Kaplan-Meier and the log-rank test. Multivariable Cox proportional hazard models were developed to estimate the effect of rate of surgical therapy on overall survival. Results A total of 139,802 patients met the criteria. There was wide variation in the per-center rate of surgical resection in the highest (80.8%) versus lowest (41.4%, p < 0.001) quartile. Across cohorts, patients were similar in age (mean 68.8 years in the highest quartile versus 69.7 in the lowest quartile) and Charlson-Deyo Score of 2 or greater (15.1% in the highest quartile versus 14.4% in the lowest quartile). Five-year survival was higher for patients treated at high-use centers (52.7% versus 36.7%, p < 0.001). After adjustment, an adjusted rate of surgical therapy in the lowest 25th percentile was associated with lower survival (adjusted hazard ratio 1.40, 95% confidence interval: 1.37 to 1.40, p < 0.001). Conclusions Treatment at a center with a higher rate of surgical therapy confers a considerable survival advantage, even after adjustment for hospital volume, surgical approach, and other confounders. Targeted efforts to improve adherence to guidelines about provision of surgical therapy in early-stage NSCLC may represent a meaningful opportunity to improve outcomes. [ABSTRACT FROM AUTHOR]

Background Results of hybrid arch repair (HAR) using the native zone 0 proximal landing zone (PLZ) have been unsatisfactory in many series, especially in the setting of ascending aortic dilation (>4.0 cm). This study reports early and late outcomes of planned two-stage HAR with open first-stage proximal aortic replacement, followed by second-stage thoracic endovascular aortic repair (TEVAR) with PLZ within the Dacron-replaced zone 0. Methods Between January 2006 and August 2017, 34 patients underwent planned two-stage HAR. The first-stage proximal aortic replacement included ascending aorta (with or without valve, with or without root) and total arch replacement, which was performed with creation of an elephant trunk in 22 patients (65%) and without an elephant trunk in 12 (35%). Primary outcomes included 30-day/in-hospital results and Kaplan-Meier estimates of overall/aorta-specific survival and freedom from reintervention. Results Mean age was 59 ± 12 years. Both stages of repair were completed in a single hospitalization in 53% of patients, including operations done since January 2012. The 30-day/in-hospital rates of mortality, stroke, permanent paraparesis/plegia, and new dialysis were 6%, 3%, 0%, and 0%, respectively. Kaplan-Meier overall and aorta-specific survivals at 5 years were 63% and 94%, respectively, with 5-year freedom from reintervention of 78%. Conclusions Planned two-stage HAR with open first-stage proximal aortic replacement, followed by second-stage TEVAR with Dacron-replaced PLZ yields excellent short-term and long-term results, including low rates of reintervention likely due to the long-segment PLZ within the Dacron-replaced aorta. The technique should be considered in patients with even mild (>4.0 cm) ascending aortic dilation in whom HAR is otherwise the preferred treatment option. [ABSTRACT FROM AUTHOR]

Background Existing research demonstrates superior short-term outcomes (length of stay, 1-year survival) after lung transplantation in patients with preoperative functional independence. The aim of this study was to determine whether advantages remain significant in the long-term. Methods The United Network for Organ Sharing database was queried for adult, first-time, isolated lung transplantation records from January 2005 to December 2015. Stratification was performed based on Karnofsky Performance Status Score (3 groups) and on employment at the time of transplantation (2 groups). Kaplan-Meier and Cox analyses were performed to determine the association between these factors and survival in the long-term. Results Of 16,497 patients meeting criteria, 1,581 (9.6%) were almost completely independent at the time of transplant vs 5,662 (34.3%) who were disabled (completely reliant on others for activities of daily living). Cox models adjusting for recipient, donor, and transplant factors demonstrated a statistically significant association between disability at the time of transplant and long-term death (hazard ratio, 1.26; 95% confidence interval, 1.14 to 1.40; p < 0.001). There were 15,931 patients with available data on paid employment at the time of transplantation. Multivariable analysis demonstrated a statistically significant association between employment at the time of transplantation and death (hazard ratio, 0.86; 95% confidence interval, 0.75 to 0.91; p < 0.001). Conclusions Preoperative functional independence and maintenance of employment are associated with superior long-term outcomes in lung recipients. The results highlight potential benefits of pretransplant functional rehabilitation for patients on the waiting list for lungs. [ABSTRACT FROM AUTHOR]

Background After pediatric heart operations, we sought to determine the incidence of unplanned cardiac reinterventions during the same hospitalization, assess risk factors for these reinterventions, and explore associations between reinterventions and outcomes. We hypothesized that younger patients undergoing more complex operations would be at greater risk for unplanned cardiac reinterventions and that operative mortality and postoperative length of stay (PLOS) would be greater in patients who undergo reintervention than in those who do not. Methods Patients aged 18 years or younger in The Society of Thoracic Surgeons Congenital Heart Surgery Database (January 2010 to June 2015) were included. We used multivariable regression to evaluate risk factors for unplanned cardiac reintervention (operation or therapeutic catheterization) and associations of reintervention with operative mortality and PLOS. Results Of 84,404 patients (117 centers), 21% were neonates and 36% infants. An unplanned cardiac reintervention was performed in 5.4% of patients, including 11.8% of neonates, 5.2% of infants, and 2.8% of children. Independent risk factors for unplanned reintervention included presence of noncardiac anomalies/genetic syndromes, nonwhite race, younger age, lower weight among neonates and infants, prior cardiothoracic operations, preoperative mechanical ventilation, other Society of Thoracic Surgeons preoperative risk factors, and higher Society of Thoracic Surgeons–European Association for Cardiothoracic Surgery Mortality Category (adjusted p < 0.001 for all). Unplanned reintervention was a risk factor for operative mortality (adjusted odds ratio, 5.3; 95% confidence interval, 4.8 to 5.8; p < 0.001) and longer PLOS (adjusted relative risk, 2.3; 95% confidence interval, 2.2 to 2.4; p < 0.001). Conclusions Unplanned cardiac reinterventions are not rare, particularly in neonates, and are independently associated with operative mortality and increased PLOS. Patients at greater risk may be identified preoperatively, presenting opportunities for quality improvement. [ABSTRACT FROM AUTHOR]

Objective Since thoracic endovascular aortic repair (TEVAR) received U.S. Food and Drug Administration approval for the treatment of descending thoracic aneurysms in March 2005, excellent 30-day and midterm outcomes have been described. However, data on long-term outcomes are lacking with Medicare data suggesting that TEVAR has worse late survival compared with open descending repair. As such, the purpose of this study was to examine the long-term outcomes for on-label use of TEVAR for repair of descending thoracic aneurysms. Methods Of 579 patients undergoing TEVAR between March 2005 and April 2016 at a single referral center for aortic surgery, 192 (33.2%) were performed for a descending thoracic aneurysm indication in accordance with the device instructions for use, including 106 fusiform (55.2%), 80 saccular (41.7%), and 6 with both saccular and fusiform (3.1%) aneurysms. All aneurysms were located distal to the left subclavian artery and proximal to the celiac axis, and hybrid procedures including arch or visceral debranching were excluded with the exception of left carotid-subclavian artery bypass. Aortic dissection and intramural hematoma as indications for TEVAR were also excluded. Primary 30-day and in-hospital outcomes included mortality, stroke, need for new permanent dialysis, and permanent paraparesis or paraplegia. Primary long-term outcomes included survival and rate of reintervention secondary to endoleak. The Kaplan-Meier method was used to estimate long-term overall and aorta-specific survivals. Results The mean age was 71.1 ± 10.4 years. All aneurysms in this series were degenerative in nature and no patients with a connective tissue disorder were included. The mean aortic diameter was 5.9 ± 1.5 cm at time of intervention. Rates of 30-day and in-hospital mortality, stroke, permanent dialysis, and permanent paraparesis and paraplegia were 4.7%, 2.1%, 0.5%, and 0.5%, respectively. At a mean follow-up of 69 ± 44 months (range, 3-141 months), there were 68 late deaths (35.4%), two of which were due to aortic rupture. Overall and aorta-specific survivals at 141 months (11.8 years) were 45.7% and 96.2%, respectively. Endovascular reintervention was required in 14 patients (7.3%) owing to type I (n = 10), type II (n = 2), and type III (n = 2) endoleak, all of which subsequently resolved. No patient required open reintervention for any cause. Conclusions Long-term (12-year) aorta-specific survival after on-label endovascular repair of degenerative descending thoracic aneurysms in nonsyndromic patients is excellent (96%) with sustained protection from rupture, and a low rate of reintervention owing to endoleak (7%). Endovascular repair should be considered the treatment of choice for this pathology. [ABSTRACT FROM AUTHOR]

Background The number of adults referred to high-volume centers for extracorporeal membrane oxygenation (ECMO) is increasing. Outcomes of patients requiring transport are not well characterized, and referral guidelines are lacking. This study describes the experience and outcomes of a single high-volume center. Methods A retrospective study was performed that included adults undergoing ECMO between June 2009 and December 2015. Patient characteristics and outcomes were acquired from the medical record. Logistic regression was used to identify predictors of survival to hospital discharge. The Kaplan-Meier method was used to depict rates of survival. Results Of 133 patients, 77 (57.9%) underwent venoarterial (VA) ECMO and 56 (42.1%) underwent venovenous (VV) ECMO. Median transport distance was 88.8 miles (range 0.2–1,434 miles). Median duration of support was 6 days (range, 1–32.5 days). Age older than 60 years, pulmonary hypertension, and body mass index (BMI) greater than 30 were associated with worse survival to discharge for VA ECMO; a history of hypertension and presence of left ventricular (LV) vent were associated with better survival. Age older than 60 years and diabetes were associated with worse survival to hospital discharge for VV ECMO. Survival to decannulation was 66.2% and 76.8%, and to hospital discharge it was 48.1% and 69.6% for VA and VV ECMO, respectively. Of hospital survivors, Kaplan-Meier estimates of 1-year survival were 82.4% and 95.5% for VA and VV, respectively. Conclusions Outcomes are favorable after transport to high-volume ECMO centers. Guidelines and infrastructure for short- and long-distance ECMO transport is imperative for the efficient and successful management of these patients. [ABSTRACT FROM AUTHOR]

Background Lung cancer ranks as the top cancer killer in the United States. Using The Society of Thoracic Surgeons General Thoracic Surgery Database (GTSD), the geographic variability of lung cancer lobectomy for operative mortality and major morbidity were examined. Methods From January 2009 to June 2015, the GTSD lung cancer lobectomy records (excluding robotic procedures) were assigned to a US Census region using hospital location. Surgeons performing fewer than seven lung cancer lobectomies per year were categorized as “low volume.” The American College of Surgeons Oncology Group criteria were used to classify patients as “high risk.” Applying the published GTSD risk algorithms, regional unadjusted and adjusted odds ratios were computed using univariable and multivariable generalized estimating equation logistic regression. Across geographic regions, patient risk factors and outcomes were compared using Kruskal-Wallis and χ 2 tests. Results From 2009 to 2015, there were 39,078 lung cancer lobectomies that met study inclusion criteria (31.5% Northeast, 23.5% Midwest, 31.1% South, and 14.0% West). Fewer high-risk cases were seen in the West region (18.9% Northeast, 19.6% Midwest, 19.9% South, and 15.9% West; p < 0.001). Across geographic regions, there was no statistically significant difference in the proportion of low-volume surgeons (39.8% Northeast, 44.8% Midwest, 45.8% South, and 56.3% West; p = 0.0512). Adjusted odds ratios for operative mortality and major perioperative morbidity did not show statistically significant differences across regions ( p = 0.761 and p = 0.600, respectively). Conclusions Despite geographic variations in the proportion of high-risk lobectomies, the risk-adjusted mortality and morbidity outcomes did not vary by region. [ABSTRACT FROM AUTHOR]

Background Although the use of adjuvant chemotherapy in patients with pathologically node-positive (pN+) atypical carcinoid tumor of the lung is an accepted practice, controversy exists about its use in pathologically node-negative (pN0) patients. Our aim was to determine whether a survival advantage exists in patients receiving chemotherapy postoperatively for pN0 or pN+ atypical carcinoid tumors of the lung. Methods Adult patients treated with lobectomy or pneumonectomy for pulmonary atypical carcinoid tumor were identified using the National Cancer Data Base, 2006 to 2011. Propensity scoring (4:1 nearest neighbor algorithm) and survival analysis were used to examine the association between adjuvant chemotherapy and pN+ versus pN0 atypical carcinoid tumors. Results Of the total 581 patients identified with a diagnosis of atypical carcinoid of the lung, 363 (62.5%) were found to be node negative at the time of operation and 218 (37.5%) had node-positive disease. Adjuvant chemotherapy was used in 15 patients (4.1%) with pN0 disease and 89 patients (40.8%) with pN+ disease. Unadjusted survival, at 12 and 60 months, was similar between pN+ patients who were treated with adjuvant chemotherapy versus patients who received operation alone (adjuvant chemotherapy: 98.9% at 12 months and 47.9% at 60 months versus operation alone: 98.4% and 12 months and 67.1% at 60 months, p = 0.46) and for propensity-matched pN0 (adjuvant chemotherapy: 86.7% at 12 months and 73.3% at 60 months versus operation alone: 87.9% at 12 months and 72.3% at 60 months, p = 0.54). Conclusions In a national-level analysis, the use of adjuvant chemotherapy postoperatively in patients with pN+ and pN0 disease conferred no survival advantage; further study is needed to determine proper chemotherapy use for these patients. [ABSTRACT FROM AUTHOR]

Objective: To determine the impact of race and insurance on use of minimally invasive (MIS) compared with open techniques for rectal cancer in the United States. Background: Race and socioeconomic status have been implicated in disparities of rectal cancer treatment. Methods: Adults undergoing MIS (laparoscopic or robotic) or open rectal resections for stage I to III rectal adenocarcinoma were included from the National Cancer Database (2010–2012). Multivariate analyses were employed to examine the adjusted association of race and insurance with use of MIS versus open surgery. Results: Among 23,274 patients, 39% underwent MIS and 61% open surgery. Overall, 86% were white, 8% black, and 3% Asian. Factors associated with use of open versus MIS were black race, Medicare/Medicaid insurance, and lack of insurance. However, after adjustment for patient demographic, clinical, and treatment characteristics, black race was not associated with use of MIS versus open surgery [odds ratio [OR] 0.90, P = 0.07). Compared with privately insured patients, uninsured patients (OR 0.52, P < 0.01) and those with Medicare/Medicaid (OR 0.79, P < 0.01) were less likely to receive minimally invasive resections. Lack of insurance was significantly associated with less use of MIS in black (OR 0.59, P = 0.02) or white patients (OR 0.51, P < 0.01). However, among uninsured patients, black race was not associated with lower use of MIS (OR 0.96, P = 0.59). Conclusions: Insurance status, not race, is associated with utilization of minimally invasive techniques for oncologic rectal resections. Due to the short-term benefits and cost-effectiveness of minimally invasive techniques, hospitals may need to improve access to these techniques, especially for uninsured patients. [ABSTRACT FROM AUTHOR]

Background The long-term survival benefit of lobectomy over sublobar resection for early-stage non-small cell lung cancer must be weighed against a potentially increased risk of perioperative mortality. The objective of the current study was to create a risk score to identify patients with favorable short-term outcomes following lobectomy. Methods The 2005–2012 American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing a lobectomy or sublobar resection (either segmentectomy or wedge resection) for lung cancer. A multivariable logistic regression model was utilized to determine factors associated with 30-day mortality among the lobectomy group and to develop an associated risk score to predict perioperative mortality. Results Of the 5,749 patients who met study criteria, 4,424 (77%) underwent lobectomy, 1,098 (19%) underwent wedge resection, and 227 (4%) underwent segmentectomy. Age, chronic obstructive pulmonary disease, previous cerebrovascular event, functional status, recent smoking status, and surgical approach (minimally invasive versus open) were utilized to develop the risk score. Patients with a risk score of 5 or lower had no significant difference in perioperative mortality by surgical procedure. Patients with a risk score greater than 5 had significantly higher perioperative mortality after lobectomy (4.9%) as compared to segmentectomy (3.6%) or wedge resection (0.8%, p < 0.01). Conclusions In this study, we have developed a risk model that predicts relative operative mortality from a sublobar resection as compared to a lobectomy. Among patients with a risk score of 5 or less, lobectomy confers no additional perioperative risk over sublobar resection. [ABSTRACT FROM AUTHOR]

The best method of aortic root repair in older patients remains unknown given a lack of comparative effectiveness of long-term outcomes data. The objective of this study was to compare long-term outcomes of different surgical approaches for aortic root repair in Medicare patients using The Society of Thoracic Surgeons Adult Cardiac Surgery Database-Centers for Medicare & Medicaid Services–linked data. A retrospective cohort study was performed by querying the Society of Thoracic Surgeons Adult Cardiac Surgery Database for patients aged 65 years or more who underwent elective aortic root repair with or without aortic valve replacement. Primary long-term end points were mortality, any stroke, and aortic valve reintervention. Short-term outcomes and long-term survival were compared among each root repair strategy. Additional risk factors for mortality after aortic root repair were assessed with a multivariable Cox proportional hazards model. A total of 4173 patients aged 65 years or more underwent elective aortic root repair. Patients were stratified by operative strategy: mechanical Bentall, stented bioprosthetic Bentall, stentless bioprosthetic Bentall, or valve-sparing root replacement. Mean follow-up was 5.0 (±4.6) years. Relative to mechanical Bentall, stented bioprosthetic Bentall (adjusted hazard ratio, 0.80; confidence interval, 0.66-0.97) and stentless bioprosthetic Bentall (adjusted hazard ratio, 0.70; confidence interval, 0.59-0.84) were associated with better long-term survival. In addition, stentless bioprosthetic Bentall (adjusted hazard ratio, 0.64; confidence interval, 0.47-0.80) and valve-sparing root replacement (adjusted hazard ratio, 0.51; confidence interval, 0.29-0.90) were associated with lower long-term risk of stroke. Aortic valve reintervention risk was 2-fold higher after valve-sparing root replacement compared with other operative strategies. In the Medicare population, there was poorer late survival and greater late stroke risk for patients undergoing mechanical Bentall and a higher rate of reintervention for valve-sparing root replacement. Bioprosthetic Bentall may be the procedure of choice in older patients undergoing aortic root repair, particularly in the era of transcatheter aortic valve replacement. [Display omitted] [ABSTRACT FROM AUTHOR]

Background The objective of this study was to evaluate outcomes of minimally invasive approaches to esophagectomy using population-level data. Methods Multivariable regression modeling was used to determine predictors associated with the use of minimally invasive approaches for patients in the National Cancer Data Base who underwent resection of middle and distal clinical T13N03M0 esophageal cancers from 2010 to 2012. Perioperative outcomes and 3-year survival were compared between propensity-matched groups of patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE) or open esophagectomy (OE). A subgroup analysis was performed to evaluate the impact of using robotic-assisted operations as part of the minimally invasive approach. Results Among 4,266 patients included, 1,308 (30.6%) underwent MIE. It was more likely to be used in patients treated at academic (adjusted odds ratio [OR], 10.1; 95% confidence interval [CI], 4.2–33.1) or comprehensive cancer facilities (adjusted OR, 6.4; 95% CI, 2.6–21.1). Compared with propensity-matched patients who underwent OE, patients who underwent MIE had significantly more lymph nodes examined (15 versus 13; p = 0.016) and shorter hospital lengths of stay (10 days versus 11 days; p = 0.046) but similar resection margin positivity, readmission, and 30-day mortality (all p > 0.05). Survival was similar between the matched groups at 3 years for both adenocarcinoma and squamous cell carcinoma ( p > 0.05). Compared with MIE without robotic assistance, use of a robotic approach was not associated with any significant differences in perioperative outcomes ( p > 0.05). Conclusions The use of minimally invasive techniques to perform esophagectomy for esophageal cancer is associated with modestly improved perioperative outcomes without compromising survival. [ABSTRACT FROM AUTHOR]

To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR). Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed. NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P =.006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P <.001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P =.002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P =.03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P =.01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P <.001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P =.03), respectively. QOL did not differ significantly between groups. NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery. [Display omitted] [ABSTRACT FROM AUTHOR]

The 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. All 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. After 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. Whereas 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. [ABSTRACT FROM AUTHOR]

Objective Lobectomy is considered optimal therapy for early-stage non–small cell lung cancer, but sublobar wedge resection and stereotactic body radiation therapy are alternative treatments. This study compared outcomes between wedge resection and stereotactic body radiotherapy. Methods Overall survival of patients with cT1N0 and tumors ≤2 cm who underwent stereotactic body radiotherapy or wedge resection in the National Cancer Data Base from 2008 to 2011 was assessed via a Kaplan-Meier and propensity score–matched analysis. A center-level sensitivity analysis that used observed/expected mortality ratios was conducted to identify an association between center use of stereotactic body radiotherapy and mortality. Results Of the 6295 patients included, 1778 (28.2%) underwent stereotactic body radiotherapy, and 4517 (71.8%) underwent wedge resection. Stereotactic body radiotherapy was associated with significantly reduced 5-year survival compared with wedge resection in both unmatched analysis (30.9% vs 55.2%, P < .001) and after adjustment for covariates (31.0% vs 49.9%, P < .001). Stereotactic body radiotherapy also was associated with worse overall survival than wedge resection after 2 subgroup analyses of propensity-matched patients ( P < .05 for both). Centers that used stereotactic body radiotherapy more often as opposed to surgery for patients with cT1N0 patients with tumors <2 cm were more likely to have an observed/expected mortality ratio > 1 for 3-year mortality ( P = .034). Conclusions In this national analysis, wedge resection was associated with better survival for stage IA non–small cell lung cancer than stereotactic body radiotherapy. [ABSTRACT FROM AUTHOR]