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Infective endocarditis affects patients of all socioeconomic status. We hypothesized that the Distressed Communities Index (DCI), a comprehensive assessment of socioeconomic status, would be associated with risk-adjusted mortality for patients with endocarditis. All patients with endocarditis (2001-2017) in a regional Society of Thoracic Surgeons database were analyzed. DCI scores range from 0 (no socioeconomic distress) to 100 (severe distress) and account for unemployment, poverty rate, median income, housing vacancies, education level, and business growth by zip code. The most distressed patients (top quartile, DCI > 75) were compared to all other patients. Hierarchical logistic regression modeled the association between DCI and mortality. A total of 2,075 patients were included (median age 55 years, 65.2% urgent/emergent cases, 42.7% self-pay). Major morbidity was 32.8% and operative mortality was 9.5%. Tricuspid/pulmonic valve endocarditis was present in 12.5% of cases, with significantly worse mean DCI compared to patients with left-sided endocarditis (median 55.3, IQR 20.3-77.6 vs 46.8, IQR 17.3-74.2, P = 0.016). High socioeconomic distress (DCI > 75) was associated with higher rates of major morbidity, operative mortality, increased length of stay, and higher total cost. After risk-adjustment, DCI was independently predictive of higher operative mortality for patients with endocarditis (OR 1.24 per DCI quartile increase, 95% CI 1.06-1.45, P < 0.001). Increasing DCI, an indicator of poor socioeconomic status, independently predicts increased risk-adjusted mortality and resource utilization for patients with endocarditis. Accounting for socioeconomic status allows for more accurate risk prediction and resource allocation for patients with endocarditis. [Display omitted] [ABSTRACT FROM AUTHOR]

Our understanding of the impact of a center's case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR. Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year. A total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly greater center-level major complication rates but lower mortality and FTR rates (all P values <.01). Observed-to-expected FTR was significantly associated with case volume (P =.040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P =.001). Increasing center case volume is significantly associated with improved FTR rates. Assessment of low-volume centers' FTR performance represents an opportunity for quality improvement. [Display omitted] [ABSTRACT FROM AUTHOR]

Limited multi-institutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raised concern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort. Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis. Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P =.383) or major morbidity (7.9% open vs 7.2% MICS CABG, P =.795). However, open CABG patients received more blood products (22.2% vs 12.2%, P =.013), and had longer intensive care unit (45 vs 30 hours, P =.049) as well as hospital lengths of stay (7 vs 6 days, P =.005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P <.001) compared with MICS CABG. Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost. [ABSTRACT FROM AUTHOR]

• To recognize one of the major mechanical complications of late presenting acute myocardial infarction in the COVID-19 era. • To understand the role of mechanical circulatory support in acute myocardial infarction complicated by ventricular septal rupture • To outline the decision making process in the management of ventricular septal rupture with consequent cardiogenic shock. • To highlight the importance of a multidisciplinary cardiogenic shock team. The COVID 19 pandemic resulted in a total reduction in the number of hospitalizations for acute coronary syndromes. A consequence of the delay in coronary revascularization has been the resurgence of structural complications of myocardial infarctions. Ventricular septal rupture (VSR) complicating late presenting acute myocardial infarction (AMI) is associated with high mortality despite advances in both surgical repair and perioperative management. Current data suggests a declining mortality with delay in VSR repair; however, these patients may develop cardiogenic shock while waiting for surgery. Available options are limited for patients with VSR who develop right ventricular failure and cardiogenic shock. The survival rate is very low in patients with cardiogenic shock undergoing surgical or percutaneous VSR repair. In this study we present two late presenting ST elevation MI patients who were complicated by rapidly declining hemodynamics and impending organ failure. Both patients were bridged with venoarterial extracorporeal membrane oxygenation (ECMO) to cardiac transplant. [ABSTRACT FROM AUTHOR]

Concomitant surgical ablation for atrial fibrillation (AF) at the time of mitral valve surgery is a Society of Thoracic Surgeons Class IA recommendation with evidence from randomized trial data. We hypothesized that concomitant AF ablation rates have increased over time with implementation of this evidence-based practice. All patients (N = 7261) undergoing mitral valve operations (2011-2018) were queried from a regional Society of Thoracic Surgeons database. Patients with preoperative AF were stratified by concomitant AF ablation. Trends in concomitant ablation were evaluated over time as well as by center and surgeon mitral surgical volume. The associations between patient and center factors on implementation of concomitant ablation were assessed with multivariate regression. A total of 1675 patients with preoperative AF underwent isolated mitral valve operations, with 1044 (64.6%) undergoing concomitant ablation. The utilization of concomitant ablation decreased over the study period (-2.82%/year), and was strongly associated with surgeon mitral valve volume (high 78.2% vs medium 62.5% vs low 59.0%; P <.001). Multivariate regression demonstrated age and comorbidities were strong predictors, but high volume mitral surgeons (odds ratio [OR], 2.2; P <.001) were twice as likely to perform concomitant AF ablation. Finally, patients with preoperative AF undergoing ablation were significantly less likely to be in AF at discharge (10.1% vs 53.8%; P <.001). Despite increasing evidence and societal recommendations, we demonstrate a persistent underutilization of concomitant AF ablation during isolated mitral surgery across a large number of low-volume and high-volume centers. These data suggest significant variability and may represent an opportunity for improvement. [ABSTRACT FROM AUTHOR]

The prevalence of non–vitamin K oral anticoagulant use after cardiac surgery is unknown, particularly in patients with bioprosthetic valves. We sought to define the contemporary use and short-term safety of non–vitamin K oral anticoagulants after cardiac surgery. All patients undergoing bioprosthetic aortic valve replacement, bioprosthetic mitral valve replacement, or isolated coronary artery bypass grafting (2011-2018) were evaluated from a multicenter, regional Society of Thoracic Surgeons database. Patients were stratified by anticoagulant type (non–vitamin K oral anticoagulant vs vitamin K antagonist) and era (early [2011-2014] vs contemporary [2015-2018]). Of 34,188 patients, 18% (6063) were discharged on anticoagulation, of whom 23% were prescribed non–vitamin K oral anticoagulants. Among those receiving anticoagulation, non–vitamin K oral anticoagulant use has significantly increased from 10.3% to 35.4% in contemporary practice (P <.01). This trend was observed for each operation type (coronary artery bypass grafting 0.86%/year, bioprosthetic aortic valve replacement: 2.15%/year, bioprosthetic mitral valve replacement: 2.72%/year, all P <.01). In patients with postoperative atrial fibrillation receiving anticoagulation, non–vitamin K oral anticoagulant use has increased from 6.3% to 35.4% and 12.3% to 40.3% after bioprosthetic valve replacement and isolated coronary artery bypass grafting, respectively (both P <.01). In patients receiving anticoagulation at discharge, adjusted 30-day mortality (odds ratio, 1.94; P =.12) and reoperation (odds ratio, 0.79; P =.34) rates were not associated with anticoagulant choice, whereas non–vitamin K oral anticoagulant use was associated with an adjusted 0.9-day decrease (P <.01) in postoperative length of stay. Non–vitamin K oral anticoagulant use after cardiac surgery has dramatically increased since 2011. This trend is consistent regardless of indication for anticoagulation including bioprosthetic valves. Short-term outcomes support their safety in the cardiac surgery setting with shorter postoperative hospital stays. Long-term studies on the efficacy of non–vitamin K oral anticoagulants after cardiac surgery are still necessary. The study population included more than 34,000 patients in the VCSQI. Over time, the use of NOACs has increased significantly for all included subgroups. Risk-adjusted outcomes after cardiac surgery are similar to patients being prescribed VKAs with an associated reduction in length of stay. [ABSTRACT FROM AUTHOR]

Continuation of dual antiplatelet therapy (DAPT) after coronary artery bypass grafting (CABG) after acute myocardial infarction is recommended by current guidelines. We sought to evaluate guideline adherence over time and factors associated with postoperative DAPT within a regional consortium. Isolated CABG patients from 2011 to 2017 who had a myocardial infarction within 21 days prior to surgery were included. Patients were stratified by DAPT prescription at discharge and by time period, early (2011-2014) vs late (2015-2017). Hierarchical regressions were then performed to evaluate factors influencing DAPT use after CABG. A total of 7314 patients were included with an overall rate of DAPT utilization of 31.2% that increased from 29.6% in the early to 33.4% in the late era (P <.01). There was considerable variability in hospital rates of DAPT (range 9.5%-92.1%) and hospital level changes over time (26% increased, 11% decreased, and 63% remained stable). After adjustment for clinical factors, era was not associated with DAPT use but treating hospital remained significantly associated with DAPT use. Other clinical factors associated with increased DAPT utilization included off-pump surgery (odds ratio [OR] 4.48, P <.01) and prior percutaneous coronary intervention (OR 2.02, P <.01), and atrial fibrillation (OR 0.39, P <.01) was associated with decreased utilization. Dual antiplatelet use has increased between 2011 and 2017, driven primarily by evolving patient demographics. Significant hospital-level variability drives inconsistency in DAPT utilization. Efforts to promote DAPT use for patients treated with CABG after myocardial infarction in concordance with current guidelines should be targeted at the hospital level. [ABSTRACT FROM AUTHOR]

Readmissions cost an estimated $41 billion in the United States each year. To address this, a single institution recently developed a new risk model predictive of 30-day readmission after adult cardiac surgery. The purpose of this study is to validate and refine this new readmission risk model using a statewide database. A total of 19,964 patients were analyzed using a statewide Society of Thoracic Surgeons database (2014-2017). The aforementioned multivariate model was replicated (model 1): race, hospital length of stay, chronic lung disease, operation type, and renal failure. Model 2 also included discharge location. Thirty-day readmission risk scores and low-risk (0%-10%), moderate-risk (10%-13%), and high-risk (≥13%) categories were calculated. The overall 30-day readmission rate was 11.1% with both models 1 and 2 predicting readmission (odds ratio, 1.09; 95% confidence interval, 1.08-1.11 vs odds ratio, 1.10; 95% confidence interval, 1.08-1.11). Statistically significant differences were observed across all risk categories in discharge location and total cost. For models 1 and 2, 86% of low-risk patients were discharged to home vs 66.9% and 42.9% of patients in high-risk groups, respectively (P <.001). The largest increases were observed with a hospice discharge location for both model 1 (from $37,930 to $89,285) and model 2 (from $37,930 to $89,230). Both risk models significantly predicted 30-day readmission in our multiinstitutional dataset, confirming the score is valid and a generalizable quality improvement tool. The addition of discharge location and total cost adds valuable information of the ongoing efforts to identify patients at high risk for readmission. [ABSTRACT FROM AUTHOR]

With a rising emphasis on public reporting, we hypothesized that select hospitals are becoming increasingly risk-averse by avoiding high-risk operations. Further, we evaluated the association between risk-averse practices, outcomes, and publicly reported quality measures. Clinical data from 78,417 patients undergoing cardiac surgery (2002-2016) from a regional consortium was paired with publicly available reimbursement and quality data. High-risk surgery was defined as predicted risk of mortality ≥5%. Hospital risk aversion was defined as a significant decrease in both high-risk volume and proportion, with cases stratified by hospital risk aversion status for univariate analysis. The rate of high-risk cases decreased from 17.9% in 2002 to 12.6% in 2016. Significant risk aversion was seen in 39% of hospitals, which had a 59% decrease in high-risk volume vs a 16% decrease at non-risk-averse hospitals. In the last 5 years, declining high-risk cases at risk-averse hospitals were driven by fewer cases from transfers (19.2% vs 28.1%, P <.001) and the emergency department (17.6% vs 19.2%, P =.001). Only non-risk-averse hospitals had mortality rates lower than expected (risk-averse: 0.97 [95% confidence interval, 0.91-1.03], P =.30; non-risk-averse: 0.88 [95% confidence interval, 0.83-0.94], P =.001). There were no differences by risk aversion status in reported ratings or financial incentives (all P >.05). Over 60% of hospitals continue to operate on high-risk patients, with concentration of care driven by transfer patterns. These non-risk-averse hospitals are high-performing with better-than-expected outcomes, particularly in high-risk cases. Transparency and objectivity in reporting are essential to ensure continued access for these high-risk patients. [ABSTRACT FROM AUTHOR]

Transfer from hospital to hospital for cardiac surgery represents a large portion of some clinical practices. Previous literature in other surgical fields has shown worse outcomes for transferred patients. We hypothesized that transferred patients would be higher risk and demonstrate worse outcomes than those admitted through the emergency department. All patients undergoing cardiac operations with a Society of Thoracic Surgeons Predicted Risk of Mortality were evaluated from a multicenter, statewide Society of Thoracic Surgeons database. Only patients requiring admission before surgery were included. Patients were stratified by admission through the emergency department or in transfer. Transfers were further stratified by the cardiothoracic surgery capabilities at the referring center. A total of 13,094 patients met the inclusion criteria of admission before surgery. This included 7582 (57.9%) transfers, of which 502 (6.6%) were referred from cardiac centers. Compared with emergency department admissions, transfers had increased hospital costs despite lower operative risk (Predicted Risk of Mortality 1.5% vs 1.6%, P <.01) and equivalent postoperative morbidity (15.6% vs 15.3% P =.63). In risk-adjusted analysis, transfer status was not independently associated with worse outcomes. Patients transferred from centers that perform cardiac surgery are higher risk than general transfers (Predicted Risk of Mortality 2.5% vs 1.5, P <.01), but specialized care results in excellent risk-adjusted outcomes (observed/expected: mortality 0.81; morbidity or mortality 0.90). Transfer patients have similar rates of postoperative complications but increased resource use compared with patients admitted through the emergency department. Patients transferred from centers that perform cardiac surgery represent a particularly high-risk subgroup. The study populations, surgical outcomes, resource use, and trends in nonelective admissions are shown. Although there is no significant risk-adjusted impact of transfers on clinical outcomes, transferred patients incur increased risk-adjusted hospital costs than patients admitted through the ED. Among transferred patients, there is a higher-risk cohort, existing in large part because of referral bias, which includes patients transferred from one CTS center to another. [ABSTRACT FROM AUTHOR]

Frailty measurement in cardiac surgery is poorly studied. The study purposes were to identify a simple but accurate frailty tool by comparing the simplified frailty index, Study of Osteoporotic Fractures (SOF), to a more complex frailty index, the Cardiovascular Health Study (CHS), and outcomes of frail patients to nonfrail patients. Patients aged 65 years or older admitted for elective coronary artery bypass grafting (CABG), valvular surgery (valve), or a combination of CABG/valve were recruited and administered the SOF and CHS indexes. Surgical outcomes were defined by The Society of Thoracic Surgeons. A hand-held dynamometer assessed grip strength. Health-related quality of life was assessed by the 12-Item Short Form Health Survey. Patients (n = 167) were primarily male (75%), white (88%), and CABG (23%), valve (50%), or CABG/valve (25%). Frailty agreement between the CHS (frail, n = 47) and SOF (frail, n = 15) was poor (κ = 0.185). SOF frail patients had poorer health, were men (67% vs 61%), had a decreased ejection fraction (0.467 vs 0.537), an increased Society of Thoracic Surgeons Risk (5.0 vs 3.5), and increased European System for Cardiac Operative Risk Evaluation score (8.2 vs 5.2). All SOF frail patients reported lack of energy vs 8.7% CHS frail patients, and 80% vs 23.9% reported an unintentional weight loss of 5% or more. SOF frail patients were significantly more likely to experience prolonged ventilation (20% vs 6.5%), pneumonia (20% vs 6.5%), prolonged intensive care unit hours (158.6 vs 85.01), and readmission within 30 days (20% vs 8.7%). All frail patients reported a significantly lower physical health-related quality of life. The SOF tool better identified patients considered "frail." Frail patients had more adverse outcomes and poorer health-related quality of life. [ABSTRACT FROM AUTHOR]

The effects of socioeconomic factors other than insurance status and race on outcomes after cardiac operations are not well understood. We hypothesized that the Distressed Communities Index (DCI), a comprehensive socioeconomic ranking by zip code, would predict operative mortality after coronary artery bypass grafting (CABG). All patients who underwent isolated CABG (2010 to 2017) in the Virginia Cardiac Services Quality Initiative database were analyzed. The DCI accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies, with scores ranging from 0 (no distress) to 100 (severe distress). Patients were stratified by DCI quartiles (I: 0 to 24.9, II: 25 to 49.9, III: 50 to 74.9, IV: 75 to 100) and compared. Hierarchical linear regression modeled the association between the DCI and mortality. A total of 19,756 CABG patients were analyzed, with mean predicted risk of mortality of 2.0% ± 3.5%. Higher DCI scores were associated with increasing predicted risk of mortality. Overall operative mortality was 2.1% (n = 424) and increased with increasing DCI quartile (I: 1.6% [n = 95], II: 2.1% [n = 77], III: 2.4% [n = 114], IV: 2.6% [n = 138]; p = 0.0009). The observed-to-expected ratio for mortality increased as level of socioeconomic distress increased. After risk adjustment for The Society of Thoracic Surgeons predicted risk of mortality, year of surgical procedure, and hospital, the DCI remained predictive of operative mortality after CABG (odds ratio, 1.14 for each 25-point increase in DCI; 95% confidence interval 1.04 to 1.26; p = 0.007). The DCI independently predicts risk-adjusted operative mortality after CABG. Socioeconomic status, although not part of traditional risk calculators, should be considered when building risk models, evaluating resource utilization, and comparing hospitals. [ABSTRACT FROM AUTHOR]

Although liver disease increases surgical risk, it is not considered in The Society for Thoracic Surgeons (STS) risk calculator. This study assessed the impact of Model for End-Stage Liver Disease (MELD) on outcomes after cardiac surgical procedures and the additional predictive value of MELD in the STS risk model. Deidentified records of 21,272 patients were extracted from a regional STS database. Inclusion criteria were any cardiac operation with a risk score available (2011–2016). Exclusion criteria included missing MELD (n = 2,895) or preoperative anticoagulation (n = 144). Patients were stratified into three categories, MELD < 9 (low), MELD 9 to 15 (moderate), and MELD > 15 (high). Univariate and multivariate logistic regression assessed risk-adjusted associations between MELD and operative outcomes. Increasing MELD scores were associated with greater comorbid disease, mitral operation, prior cardiac operation, and higher STS-predicted risk of mortality (1.1%, 2.3%, and 6.0% by MELD category; p < 0.0001). The operative mortality rate increased with increasing MELD score (1.6%, 3.9%, and 8.4%; p < 0.0001). By logistic regression MELD score was an independent predictor of operative mortality (odds ratio, 1.03 per MELD score point; p < 0.0001) as were the components total bilirubin (odds ratio, 1.22 per mg/dL; p = 0.002) and international normalized ratio (odds ratio, 1.40 per unit; p < 0.0001). Finally, MELD score was independently associated with STS major morbidity and the component complications renal failure and stroke. Increasing MELD score, international normalized ratio, and bilirubin all independently increase risk of operative mortality. Because high rates of missing data currently limit utilization of MELD, efforts to simplify and improve data collection would help improve future risk models. [ABSTRACT FROM AUTHOR]

Background A statewide database identified prolonged ventilation (PV) and acute renal failure (RF) as the biggest cost drivers after isolated coronary artery bypass grafting. Reducing these complications through regional collaboration should improve outcomes and lower health care costs. Methods A total of 27,978 patients who underwent isolated coronary artery bypass grafting were divided into pre- and post-quality improvement initiative groups (early era: 2008 to 2011, n = 15,176; later era: 2012 to 2015, n = 12,802). Focused learning sessions on PV and postoperative RF were undertaken in the earlier era. Incidence of death, PV, and RF in the two groups was analyzed using one-way analysis of variance and Fisher exact tests. Results The Society of Thoracic Surgeons (STS) predicted risk of mortality and predicted risk of mortality/morbidity were significantly higher in the later era ( p < 0.01), as were STS predicted PV (10.1% vs 11.3%) and RF (3.4% vs 3.8%). Despite these increased risks, STS observed-to-expected ratios for mortality and mortality/morbidity fell. Observed rates for PV (10.5% vs 8.8%, p < 0.01) and RF (3.6% vs 2.3%, p < 0.01) were associated with STS observed-to-expected ratios of PV (1.04 vs 0.78) and RF (1.03 vs 0.60). Adjusting for case volume in the two eras, 271 cases of PV and 170 of RF were avoided, with estimated cost savings of $10,212,637 and $8,519,630, respectively. Conclusions A regional collaboration using a statewide STS and an all-payor database with focused quality improvement is a powerful tool for change. Despite rising risks for mortality and morbidity, outcomes for PV and RF improved and produced significant cost savings. Applying these efforts nationally can enormously affect patient care and health care costs. [ABSTRACT FROM AUTHOR]

Background Although tricuspid valve operations remain associated with high mortality (approximately 8% to 10%), no robust prediction models exist to support clinical decision making. We developed a preoperative clinical risk model with an easily calculable clinical risk score (CRS) to predict mortality and major morbidity after isolated tricuspid valve surgery. Methods The Society of Thoracic Surgeons database records were evaluated for 2,050 isolated TV repair and replacement operations for any etiology performed at 50 hospitals (2002 to 2014) in a number of states. Parsimonious preoperative risk prediction models were developed using multiple-level mixed effects regression to estimate mortality and composite major morbidity risk. Model results were utilized to establish a novel CRS for patients undergoing tricuspid valve operations. Models were evaluated for discrimination and calibration. Results Operative mortality and composite major morbidity rates were 9% and 42%, respectively. Final regression models performed well (both p < 0.001; areas under the receiver-operating characteristics curve 0.74 and 0.76) and included preoperative factors: age, sex, stroke, hemodialysis, ejection fraction, lung disease, New York Heart Association class, reoperation, and urgent or emergency status (all p < 0.05). A simple CRS from 0 to 10+ was highly associated ( p < 0.001) with incremental increases in predicted mortality and major morbidity. Predicted mortality risk ranged from 2% to 34% across CRS categories, and predicted major morbidity risk ranged from 13% to 71%. Conclusions Mortality and major morbidity after isolated tricuspid valve surgery can be predicted using preoperative patient data from The Society of Thoracic Surgeons National Adult Cardiac Database. A simple clinical risk score predicts mortality and major morbidity after isolated tricuspid valve surgery. This score may facilitate perioperative counseling and identification of suitable patients for tricuspid valve surgery. [ABSTRACT FROM AUTHOR]

In the late 1990s, several federal government health policy decisions threatened the viability of thoracic surgery as a specialty. To respond to such decisions, active participation in political processes was given extremely high priority by the Executive Committee of The Society of Thoracic Surgeons (STS). Creation of the STS Political Action Committee (STS-PAC) in 1997 was a part of the platform of participation. The purpose of the STS-PAC is to enhance the Society’s voice and stature in health care policymaking. Although the STS-PAC receives voluntary contributions from STS members, on average, only 10% of STS members contribute to the STS-PAC. For the 2015–2016 election cycle, there were 542 contributors to the STS-PAC totaling $273,000. An annual contribution of $100 from every STS member would put the STS-PAC into the top 10 for medical PACs (whereas currently it is ranked 22nd of 28 in the group of physician and dental association PACs). Despite the relatively small dollar amount the STS-PAC directs, its strategic disbursement of these dollars has yielded impressive results. For example, the STS-PAC was able to use its influence to effectively stop the Centers for Medicare and Medicaid Services from implementing a potentially calamitous rule that would effectively end traditional global surgical payments. Other advocacy successes include providing guidance to the Centers for Medicare and Medicaid Services in developing the national coverage determination for transcatheter aortic valve replacement and structuring its complex reimbursement schedule, and ensuring that a provision was included in the bill that would give the STS National Database access to claims data. The STS-PAC is a principal component of the STS’ advocacy armamentarium. Despite the many successes of the STS-PAC, with even modest contributions by more STS members, the STS-PAC could become a leading medical PAC, and would give the STS an even stronger presence and voice in Washington, DC. Clearly, contributing to the STS-PAC provides STS members the opportunity to have a voice and an impact on health policy and the care of their patients. [ABSTRACT FROM AUTHOR]

Background Thirty-one states approved Medicaid expansion after implementation of the Affordable Care Act. The objective of this study was to evaluate the effect of Medicaid expansion on cardiac surgery volume and outcomes comparing one state that expanded to one that did not. Methods Data from the Virginia (nonexpansion state) Cardiac Services Quality Initiative and the Michigan (expanded Medicaid, April 2014) Society of Thoracic and Cardiovascular Surgeons Quality Collaborative were analyzed to identify uninsured and Medicaid patients undergoing coronary bypass graft or valve operations, or both. Demographics, operative details, predicted risk scores, and morbidity and mortality rates, stratified by state and compared across era (preexpansion: 18 months before vs postexpansion: 18 months after), were analyzed. Results In Virginia, there were no differences in volume between eras, whereas in Michigan, there was a significant increase in Medicaid volume (54.4% [558 of 1,026] vs 84.1% [954 of 1,135], p < 0.001) and a corresponding decrease in uninsured volume. In Virginia Medicaid patients, there were no differences in predicted risk of morbidity or mortality or postoperative major morbidities. In Michigan Medicaid patients, a significant decrease in predicted risk of morbidity or mortality (11.9% [8.1% to 20.0%] vs 11.1% [7.7% to 17.9%], p = 0.02) and morbidities (18.3% [102 of 558] vs 13.2% [126 of 954], p = 0.008) was identified. Postexpansion was associated with a decreased risk-adjusted rate of major morbidity (odds ratio, 0.69; 95% confidence interval, 0.51 to 0.91; p = 0.01) in Michigan Medicaid patients. Conclusions Medicaid expansion was associated with fewer uninsured cardiac surgery patients and improved predicted risk scores and morbidity rates. In addition to improving health care financing, Medicaid expansion may positively affect patient care and outcomes. [ABSTRACT FROM AUTHOR]

Background Two large, randomized trials are underway evaluating transcatheter aortic valve replacement (AVR) against conventional surgical AVR. We analyzed contemporary, real-world outcomes of surgical AVR in low-risk patients to provide a practical benchmark of outcomes and cost for evaluating current and future transapical AVR technology. Methods From 2010 to 2015, 2,505 isolated AVR operations were performed for severe aortic stenosis at 18 statewide cardiac institutions. Of these, 2,138 patients had a Society of Thoracic Surgeons predicted risk of mortality of less than 4%, and 1,119 met other clinical and hemodynamic criteria as outlined in the PARTNER 3 (The Placement of Transcatheter Aortic Valves) protocol. Patients with endocarditis, end-stage renal disease, ejection fraction of less than 0.45, bicuspid valves, and previous valve replacements were excluded. Outcomes of interest included operative death and postoperative adverse events. Results The median Society of Thoracic Surgeons predicted risk of mortality for the study-eligible patients was 1.44%, with a median age of 72 years (interquartile range [IQR], 65 to 78 years). Operative mortality was 1.3%, permanent stroke was 1.3%, and pacemaker requirement was 4.2%. The most common adverse events were transfusion of 2 or more units of red blood cells (18%) and atrial fibrillation (28%). The median length of stay was 6 days (IQR, 5 to 8 days). Median total hospital cost was $37,999 (IQR, $30,671 to $46,138). Examination of complications by age younger than 65 vs 65 or older demonstrated a significantly lower need for transfusion (11.2%, p < 0.001) and incidence of atrial fibrillation (17.1%, p < 0.001) but no difference in operative mortality (2.2% vs 0.9%, p = 0.1), major morbidity (10.4% vs 12.6%, p = 0.3), or total hospital costs. Conclusions Low-risk patients undergoing surgical AVR in the current era have excellent results. The most common complications were atrial fibrillation and bleeding. These real-world results should provide additional context for upcoming transcatheter clinical trial data. [ABSTRACT FROM AUTHOR]

Background The surgical management of acute type A aortic dissection is evolving, and many aortic centers of excellence are reporting superior outcomes. We hypothesize that similar trends exist in a multiinstitutional regional consortium. Methods Records for 884 consecutive patients who underwent aortic operations (2003 to 2015) for acute type A aortic dissection were extracted from a regional The Society of Thoracic Surgeons database. Patients were stratified into three equal operative eras. Differences in outcomes and risk factors for morbidity and mortality were determined. Results Surgical procedures for type A aortic dissection are increasing in extent and complexity. Aortic root repair was performed in 16% of early era cases compared with 67% currently ( p < 0.0001). Similarly, aortic arch repair increased from 27% to 37% cases ( p < 0.0001). Cerebral perfusion is currently used in 85% of circulatory arrest cases, most frequently antegrade (57%). Total circulatory arrest times increased (29 minutes vs 31 minutes vs 36 minutes; p = 0.005), but times without cerebral perfusion were stable (12 minutes vs 6 minutes; p = 0.68). Although the operative mortality rate remained stable at 18.9% during the 3 operative eras, there were significant decreases in pneumonia and reoperations ( p < 0.05). Predictors of operative mortality and major morbidity are age (odds ratio [OR], 1.04; p < 0.0001), previous stroke (OR, 2.09; p = 0.03), and elevated creatinine (OR, 1.31; p = 0.01). Importantly, the extent of aortic operation did not increase risk for morbidity or mortality. Conclusions Operative morbidity and mortality remain significant for type A aortic dissection, but lower than historical outcomes. The extent of aortic surgery has increased, resulting in adaptive cerebral protection changes in contemporary “real-world” practice. [ABSTRACT FROM AUTHOR]

Background Transcatheter aortic valve replacement (TAVR) represents a disruptive technology that is rapidly expanding in use. We evaluated the effect on surgical aortic valve replacement (SAVR) patient selection, outcomes, volume, and cost. Methods A total of 11,565 patients who underwent SAVR, with or without coronary artery bypass grafting (2002 to 2015), were evaluated from the Virginia Cardiac Services Quality Initiative database. Patients were stratified by surgical era: pre-TAVR era (2002 to 2008, n = 5,113), early-TAVR era (2009 to 2011, n = 2,709), and commercial-TAVR era (2012 to 2015, n = 3,743). Patient characteristics, outcomes, and resource utilization were analyzed by univariate analyses. Results Throughout the study period, statewide SAVR volumes increased with median volumes of pre-TAVR: 722 cases/year, early-TAVR: 892 cases/year, and commercial-TAVR: 940 cases/year ( p = 0.005). Implementation of TAVR was associated with declining Society of Thoracic Surgeons predicted risk of mortality among SAVR patients (3.7%, 2.6%, and 2.4%; p < 0.0001), despite increasing rates of comorbid disease. The mortality rate was lowest in the current commercial-TAVR era (3.9%, 4.3%, and 3.2%; p = 0.05), and major morbidity decreased throughout the time period (21.2%, 20.5%, and 15.2%; p < 0.0001). The lowest observed-to-expected ratios for both occurred in the commercial-TAVR era (0.9 and 0.9, respectively). Resource utilization increased generally, including total cost increases from $42,835 to $51,923 to $54,710 ( p < 0.0001). Conclusions At present, SAVR volumes have not been affected by the introduction of TAVR. The outcomes for SAVR continue to improve, potentially due to availability of transcatheter options for high-risk patients. Despite rising costs for SAVR, open approaches still provide a significant cost advantage over TAVR. [ABSTRACT FROM AUTHOR]

Background The risk of patient–prosthesis mismatch drives most surgeons to select the largest bioprosthesis possible during aortic valve replacement, but interactions between the native aortic annulus and valve prosthesis remain poorly defined. We examined the hemodynamic and functional consequences of oversizing contemporary bioprostheses in an in vitro model. Methods Three sizes each (21, 23, and 25 mm) of 5 aortic bioprostheses (Magna, Edwards Lifesciences, Irvine, CA; Trifecta and Epic, St. Jude, St. Paul, MN; and Mosaic and Hancock II, Medtronic, Minneapolis, MN) were tested on a mock annulus in a pulsatile aortic simulator. After the annulus was sized to match each valve, the annulus was decreased by 3 mm and then by 6 mm to simulate oversizing. We measured the effective orifice area and the mean pressure gradient. Changes in prosthetic leaflet behavior and geometric orifice area were assessed with slow-motion video. Statistical analysis used mixed-effects models for repeated-measures data, allowing comparison within and between groups. Results For each valve model and size, oversizing resulted in decreased effective orifice areas and geometric orifice areas and increased pressure gradients. This was more pronounced with smaller valve sizes and higher flow rates but varied between valve types. Slow-motion imaging revealed this change in geometric orifice area was a result of an inward shift of the valve leaflet hinge point. Conclusions Bioprosthetic oversizing impairs hemodynamic performance of aortic valve bioprostheses. The magnitude of this effect varies by valve model and size. Clinically, these data suggest that during aortic valve replacement, placing a valve whose internal orifice closely matches the aortic annulus will provide the optimal hemodynamic performance. [ABSTRACT FROM AUTHOR]

Background Minimally invasive mitral valve surgery (mini-MVR) has grown in popularity. Although single centers have reported excellent outcomes, data on real-world outcomes and costs of mini-MVR are limited. Moreover, mini-MVR has been criticized as adding additional cost without clear benefit. We hypothesized that mini-MVR provides superior outcomes with incremental increased costs in a multi-institutional cohort. Methods Records for patients undergoing mitral valve surgical procedures with or without atrial ablation from 2011 to 2014 were extracted from a multi-institutional, regional Society of Thoracic Surgeons database and stratified according to right chest approach/minimally invasive or conventional sternotomy. Patients undergoing coronary artery bypass grafting or other concomitant procedures were excluded. Patients undergoing isolated mitral surgical procedure were propensity matched according to factors, including age, comorbidities, and preoperative laboratory values; clinical outcomes and cost differences were assessed by approach. Results A total of 1,304 patients underwent mitral operations, including 425 (32.6%) by minimally invasive approach. In the propensity-matched analysis (n = 355 per group), patients undergoing mini-MVR had similar rates of mortality, stroke, and other complications compared with conventional MVR. Meanwhile, patients with mini-MVR experienced shorter intensive care unit and hospital lengths of stay and fewer transfusions. Importantly, total hospital costs were no different between the two matched groups. Conclusions Compared with conventional sternotomy, mini-MVR in the “real world” demonstrated no differences in rates of major morbidity, but it was associated with shorter length of stay and fewer transfusions. Contrary to our hypothesis, mini-MVR can be performed with similar total hospital costs as conventional sternotomy. In summary, minimally invasive mitral surgical procedure in select patients can provide superior outcomes without increased cost. [ABSTRACT FROM AUTHOR]

We assessed the effect of a transcatheter aortic valve replacement (TAVR) program and Heart Team concept on our approach to severe isolated symptomatic aortic stenosis (AS) with regard to surgical practice, patient selection, perioperative outcomes, 1-year survival, and AVR volume. TAVR program began in August 2011. Patients having isolated surgical AVR between January 2008 and August 2011, when the program began (n = 282, 42 months), were compared with those after the program began until February 2015 (n = 344, surgical AVR and n = 126, TAVR, 42 months). Isolated surgical AVR accounted for 21% of all valve procedures (isolated and concomitant) before and after the TAVR program. However, the volume of all isolated AVR (surgical and transcatheter) increased to 27% of all valve procedures (isolated and concomitant) after the TAVR program implementation. Mean Society Of Thoracic Surgeons (STS)-predicted mortality risk was similar among patients who had surgical AVR pre-TAVR and post-TAVR implementation (2.3% vs 2.1%, P = 0.227), but addition of patients who had TAVR (STS risk = 7.1%) increased STS-predicted risk for all isolated AVR (surgical and transcatheter) procedures (2.3% vs 3.4%, P < 0.001). A similar trend was found for age, including a slight decrease in octogenarians for surgical AVR post-TAVR (18% vs 13%, P = 0.084). Operative mortality for isolated surgical AVR was similar in pre-TAVR and post-TAVR (2.1% vs 1.8%, P = 0.798), as were observed/expected (O/E) ratios (0.91 vs 0.82). For all isolated AVR, O/E ratio was 0.91 pre-TAVR and 0.82 post-TAVR (n = 470), including O/E = 0.79 for patients who had TAVR. No changes were found in proportion of isolated surgical AVR cases or patient risk and outcomes after introduction of TAVR program and Heart Team. However, volume of patients with severe AS treated increased significantly post-TAVR. Our results reflect growing awareness of TAVR availability and accompanying increases in patients referred to our Heart Team for AS treatment. [ABSTRACT FROM AUTHOR]

Background Renal failure remains a major source of morbidity after cardiac surgery. Whereas the relationship between poor renal function and worse cardiac surgical outcomes is well established, the ability to predict the impact of preoperative renal insufficiency on hospital costs and health care resource utilization remains unknown. Methods Patient records from a statewide The Society for Thoracic Surgeons (STS) database linked with estimated cost data were evaluated for isolated coronary artery bypass graft (CABG) operations (2000 to 2012). Patients with documented preoperative renal failure/dialysis were excluded. Preoperative renal function was determined using calculated creatinine clearance (CrCl). Multivariable regression analyses utilizing restricted cubic splines evaluated the continuous relationship between CrCl and risk-adjusted outcomes. Results A total of 46,577 isolated CABG operations were evaluated with a median STS predicted risk of mortality score of 1.2% (interquartile range, 0.7% to 2.4%), including 9% off-pump CABG. Median CrCl was 85 mL/min (range, 2 to 120 mL/min), and median total cost was $25,011. After adjustment for preoperative risk factors, worsening CrCl (declining renal function) was highly associated with greater total costs of hospitalization (coefficient = −122, p < 0.001) and postoperative length of stay (coefficient = −0.03, p < 0.001). Furthermore, predicted total costs were incrementally increased by 10%, 20%, and 30% with worsening of CrCl from 80 mL/min to 60, 40, and 20 mL/min. As expected, decreasing CrCl was also associated with an increased risk-adjusted likelihood for hemodialysis and mortality (both p < 0.001). Conclusions Preoperative renal function is highly associated with the cost of CABG. Assessment of renal function may be used to preoperatively predict cost and resource utilization. Optimizing renal function preoperatively has the potential to improve patient quality and costs by approximately 6% ($1,250) for every 10 mL/min improvement in creatinine clearance. [ABSTRACT FROM AUTHOR]

Background The Placement of Aortic Transcatheter Valve (PARTNER) trial suggested an economic advantage for transcatheter aortic valve replacement (TAVR) for high-risk patients. The purpose of this study was to evaluate the cost effectiveness of TAVR in the “real world” by comparing TAVR with surgical aortic valve replacement (SAVR) in intermediate-risk and high-risk patients. Methods A multiinstitutional database of The Society of Thoracic Surgeons (STS) (2011 to 2013) linked with estimated cost data was evaluated for isolated TAVR and SAVR operations (n = 5,578). TAVR-treated patients (n = 340) were 1:1 propensity matched with SAVR-treated patients (n = 340). Patients undergoing SAVR were further stratified into intermediate-risk (SAVR-IR: predicted risk of mortality [PROM] 4% to 8%) and high-risk (SAVR-HR: PROM >8%) cohorts. Results Median STS PROM for TAVR was 6.32% compared with 6.30% for SAVR (SAVR-IR 4.6% and SAVR-HR 12.4%). A transfemoral TAVR approach was most common (61%). Mortality was higher for TAVR (10%) compared with SAVR (6%, p < 0.047), whereas the SAVR group accrued higher major morbidity (27% vs 14%, p < 0.001) and longer postoperative hospital duration (7 days vs 6 days, p < 0.001). Importantly, TAVR incurred twice the median total costs compared with SAVR ($69,921 vs $33,598, p < 0.001). The increased cost of TAVR was largely driven by the cost of the valve (all p < 0.001). Intermediate-risk patients undergoing SAVR demonstrated the most exaggerated cost savings versus TAVR. Conclusions TAVR was associated with greater total costs and mortality compared with SAVR in intermediate-risk and high-risk patients while conferring lower major morbidity and improved resource use. Increased cost of TAVR appears largely related to the cost of the valve. Until the price of TAVR valves decreases, these data suggest that TAVR may not provide the most cost-effective strategy, particularly for intermediate-risk patients. [ABSTRACT FROM AUTHOR]

Background Recent financial challenges highlight the importance of accurate prediction of length of hospital stay (LOS). We assessed reliability of The Society of Thoracic Surgeons (STS) risk prediction for extended and shorter LOS and examined whether modifiable clinical variables are associated with LOS in first-time cardiac surgery patients. Methods Isolated aortic valve, mitral valve, and coronary artery bypass graft surgery patients since 2008 were included (n = 3,472). Multivariate regression was used to evaluate nonmodifiable and potentially modifiable (preoperative hematocrit, hemoglobin A 1c , body mass index, current smoker, major perioperative morbidity, and blood product transfusion) predictors of LOS in days. Results Mean age was 63.9 ± 11.2 years, 76% were males, and mean STS mortality risk was 1.9% ± 3.2%. Median (interquartile range) LOS was 4 (3 to 6) days. Predicted STS risk was 6.2% ± 7.1% for extended LOS (>14 days) and 48.3% ± 20.2% for short LOS (<6 days). Extended LOS was observed in 5.2% of patients (observed versus expected, 0.84; p = 0.019). Observed short LOS was better than predicted (67.8%; observed versus expected, 1.40; p < 0.001). Inclusion of modifiable variables in the LOS prediction model was significant ( p < 0.001). Significant modifiable predictors were lower hematocrit, higher hemoglobin A 1c , major morbidity, and transfusion. Longer predicted LOS from the model correlated with longer actual LOS ( r s = 0.63; p < 0.001). Applying the prediction equation from the model to a hypothetical average patient, predicted LOS was 4.6 days. Conclusions The STS risk model was reliably predictive of short and extended LOS but did not allow prediction of exact LOS in days. Accounting for potentially modifiable clinical variables, such as low hematocrit and blood transfusion, especially in elective patients, should lead to shorter LOS, higher satisfaction, and reduced financial burden. [ABSTRACT FROM AUTHOR]

Objective Blood transfusion in cardiac surgery patients is associated with increased morbidity and cost. The decision to transfuse patients after surgery varies but is often based on low hemoglobin (Hgb) levels, regardless of symptom status. This study examined whether asymptomatic patients discharged with lower Hgb levels had increased risk for perioperative complications and 1-year mortality. Methods Between 2008 and mid-2014, a total of 1107 valve-only procedures were performed. Patients discharged alive with complete data (N = 1044) were divided into 2 groups with discharge Hgb levels of ≤8 g/dL (n = 153) or >8 g/dL (n = 891). Propensity score matching was conducted between Hgb groups, resulting in 152 patient pairs. Results In multivariate analyses, discharge Hgb level did not predict 30-day mortality (odds ratio [OR] = 1.01, P = .991), 1-year survival (hazard ratio [HR] = 0.87, P = .34), or readmission <30 days (OR = 0.92, P = .31). Furthermore, after propensity score matching, no differences were found between groups with Hgb levels ≤8 versus >8 g/dL in 30-day mortality (0% vs 0.7%, P > .99) or readmissions (14% vs 16%, P = .52). Cumulative 1-year survival was similar between matched groups with discharge Hgb level of ≤8 versus >8 g/dL (89.3% vs 91.4%, P = .67). Matched groups with Hgb level ≤8 versus >8 g/dL had similar physical (28% vs 18% increase; P = .27) and mental (7% vs 6% increase; P = .94) health-related quality of life (HRQL) improvements at 6 months. Conclusions Asymptomatic patients discharged with lower Hgb levels did not manifest inferior outcomes, including perioperative morbidity/mortality, readmission <30 days, HRQL, and 1-year survival. The practice of blood transfusion to correct lower Hgb levels in asymptomatic patients should be eliminated, as it may be associated with increased morbidity without apparent clinical benefits after valve surgery. [ABSTRACT FROM AUTHOR]

The United States Congress recently passed the bill titled H.R.2: the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) to repeal the Sustainable Growth Rate (SGR). The SGR, part of the Balanced Budget Act of 1997, was passed to attempt to control the rate of growth for Medicare spending for physician services. As a result, all physicians were annually subject to the aggregate cuts in compensation depending on rate of economic growth in the country, requiring Congress to pass legislation each year to defer the scheduled pay cuts. Will MACRA, however, truly be a reprieve to providers from the threat of annual cuts in reimbursement of between 21% and 30%, or will it result in a Pyrrhic victory for both providers and patients after the financial impact of the repeal has been realized and the quality of health care delivery and true access to care for our seniors have been evaluated? This article from The Society of Thoracic Surgeons Workforce on Health Policy, Advocacy, and Reform attempts to summarize MACRA and considers its impact on the specialty of cardiothoracic surgery. [ABSTRACT FROM AUTHOR]

Background Postoperative stroke remains one of the most devastating complications after cardiac surgery. Variations in stroke rates and ability to rescue from mortality after stroke between surgical centers are not understood. This study evaluated patient risk and institutional factors associated with likelihood of postoperative stroke as well as hospital variation in risk-adjusted stroke and rates of failure to rescue (FTR) after stroke after cardiac surgery. Methods Patient records from The Society of Thoracic Surgeons’ multiinstitutional certified database for cardiac operations (2001 to 2011) were analyzed. The relative contribution of patient- and hospital-related factors to the likelihood of postoperative stroke was assessed by univariate and multivariate analyses. Variations in risk-adjusted stroke and rates of FTR after stroke were compared, and impact of stroke on hospital resource utilization and costs were evaluated. Results A total of 57,387 patients was included. Postoperative stroke rate was 1.5%, with significant variation across hospitals (range, 0.8% to 2%, p < 0.001). Stroke patients (versus no stroke patients) presented with more comorbid disease and higher risk profiles (The Society of Thoracic Surgeons predicted risk of mortality, 3% versus 1%, p < 0.001). Mortality was expectedly higher after stroke compared with no stroke (18% versus 2%, p < 0.001). Postoperative stroke was associated with nearly double the total cost of hospitalization. After risk adjustment, individual hospitals demonstrated a strong association with likelihood for stroke ( p < 0.001). Furthermore, high-performing hospitals with low stroke rates performed fewer aortic valve operations, more coronary artery bypass graft operations, and accrued longer intensive care unit lengths of stay. Significant hospital variations were observed for risk-adjusted stroke and rates of FTR after stroke (both p < 0.001). Conclusions Institutional variation, more so than individual patient risk factors, is highly associated with postoperative stroke and FTR rates after stroke after cardiac surgery. Postoperative stroke remains significantly associated with mortality and morbidity. Institutional practice patterns may confer a disproportionate influence on postoperative stroke independent of case mix. Understanding differences between high and low performing centers is essential to improving outcomes, costs, and hospital quality. [ABSTRACT FROM AUTHOR]

Background Bilateral internal mammary arterial (BIMA) grafts have repeatedly demonstrated superior outcomes compared with single IMA (SIMA) after coronary artery bypass grafting (CABG). Despite known survival benefits with BIMA use, perceived perioperative challenges often preclude BIMA use. We hypothesized that the use of BIMA remains underutilized, even in low-risk patients. Methods A total of 43,823 primary, isolated CABG patients in a regional Society of Thoracic Surgeons Database were evaluated. Patients were stratified by BIMA versus SIMA use. Surgical candidates considered “low risk” for BIMA use included the following: age less than 70 years; no or mild chronic lung disease; body mass index less than 30; and absence of diabetes. The BIMA patients (n = 1,333) were 1:1 propensity matched to SIMA patients (n = 1,333) and outcomes were compared. Results Overall, BIMA use was 3%; 24% (n = 10,327) of patients met “low-risk” criteria for BIMA use. Among “low-risk” patients, BIMA utilization was 6%. Propensity-matched comparisons revealed similar preoperative risk profiles between BIMA and SIMA patients (Predicted Risk of Mortality [PROM] 1.1% vs 1.1%, p > 0.05). The BIMA use was associated with longer cross-clamp time (71 vs 62 minutes, p < 0.05). Importantly, BIMA use was not associated with increased postoperative mortality, morbidity, or hospital length of stay (all p > 0.05). However, hospital readmission within 30 days was 41% greater for BIMA patients compared with SIMA patients ( p = 0.01). Conclusions Bilateral IMA graft use appears to remain underutilized in the modern surgical era, even in low surgical risk patients. The BIMA use does not appear to increase the risk of postoperative morbidity, although requires longer operative times and a higher risk for readmission. Efforts to more clearly understand surgeon motivators for the use of BIMA grafting are needed. [ABSTRACT FROM AUTHOR]

Background Several single-center studies have reported excellent outcomes with minimally invasive aortic valve replacement (mini-AVR). Although criticized as requiring more operative time and complexity, mini-AVR is increasingly performed. We compared contemporary outcomes and cost of mini-AVR versus conventional AVR in a multi-institutional regional cohort. We hypothesized that mini-AVR provides equivalent outcomes to conventional AVR without increased cost. Methods Patient records for primary isolated AVR (2011-2013) were extracted from a regional, multi-institutional Society of Thoracic Surgeons database and stratified by conventional versus mini-AVR, performed by either partial sternotomy or right thoracotomy. To compare similar patients, a 1:1 propensity-matched cohort was performed after adjusting for surgeon; operative year; and Society of Thoracic Surgeons risk score, including age and risk factors (n = 289 in each group). Differences in outcomes and cost were analyzed. Results A total of 1341 patients underwent primary isolated AVR, of which 442 (33%) underwent mini-AVR at 17 hospitals. Mortality, stroke, renal failure, and other major complications were equivalent between groups. Mini-AVR was associated with decreased ventilator time (5 vs 6 hours; P = .04) and decreased blood product transfusion (25% vs 32%; P = .04). A greater percentage of mini-AVR patients were discharged within 4 days of the operation (15.2% vs 4.8%; P < .001). Consequently, total hospital costs were lower in the mini-AVR group ($36,348 vs $38,239; P = .02). Conclusions Mortality and morbidity outcomes of mini-AVR are equivalent to conventional AVR. Mini-AVR is associated with decreased ventilator time, blood product use, early discharge, and reduced total hospital cost. In contemporary clinical practice, mini-AVR is safe and cost-effective. [ABSTRACT FROM AUTHOR]

Objective: Pay-for-performance measures, part of the Affordable Care Act, aim to reduce health care costs by linking value with Medicare payments, but until now the concept of value has not been applied to specific procedures. We sought to define value in coronary artery bypass grafting (CABG) and provide a framework to identify high-value centers. Methods: In a multiinstitutional statewide database, clinical patient-level data from 42,839 patients undergoing CABG were matched with cost data. Hierarchical models adjusting for relevant preoperative patient characteristics and comorbidities were used to estimate center-specific risk-adjusted costs and risk-adjusted postoperative length of stay. Variation in value across centers was assessed by the correlation between risk-adjusted measures of quality (mortality, morbidity/mortality) and resource use (costs and length of stay). Results: There were no significant correlations between risk-adjusted costs and risk-adjusted mortality (r = 0.20, P = .45) or morbidity/mortality (r = 0.15, P = .57) across centers. Risk-adjusted costs and length of stay were not significantly associated (r = 0.23, P = .37) because of cost accounting differences across centers. This may explain the lack of correlation between risk-adjusted quality and risk-adjusted cost measures. When risk-adjusted length of stay and morbidity/mortality were used for the framework, there was a strong positive correlation (r = 0.67, P = .003), indicating that higher risk-adjusted quality is associated with shorter risk-adjusted length of stay. Conclusions: Risk-adjusted length of stay and risk-adjusted combined morbidity/mortality are important outcome measures for assessing value in cardiac surgery. The proposed framework can be used to define value in CABG and identify high-value centers, thereby providing information for quality improvement and pay-for-performance initiatives. [ABSTRACT FROM AUTHOR]

Objectives: Cardiothoracic surgical leadership recently challenged the surgical community to achieve an operative mortality rate of 1.0% for the performance of isolated coronary artery bypass grafting (CABG). The possibility of achieving this goal remains unknown due to the increasing number of high-risk patients being referred for CABG. The purpose of our study was to identify a patient population in which this operative mortality goal is achievable relative to the estimated operative risk. Methods: Patient records from a multi-institution (17 centers) Society of Thoracic Surgeons (STS) database for primary, isolated CABG operations (2001-2012) were analyzed. Multiple logistic regression modeling with spline functions for calculated STS predicted risk of mortality (PROM) was used to rigorously assess the relationship between estimated patient risk and operative mortality, adjusted for operative year and surgeon volume. Results: A total of 34,416 patients (average patient age, 63.9 ± 10.7 years; 27% [n = 9190] women) incurred an operative mortality rate of 1.87%. Median STS predicted risk of mortality was 1.06% (interquartile range, 0.60%-2.13%) and median surgeon CABG volume was 544 (interquartile range, 303-930) operations over the study period. After risk adjustment for the confounding influence of surgeon volume and operative year, the association between STS PROM and operative mortality was highly significant (P < .0001). More importantly, the adjusted spline function revealed that an STS PROM threshold value of 1.27% correlated with a 1.0% probability of death, accounting for 57.3% (n = 19,720) of the total study population. Further, the STS PROM demonstrated a limited predictive capacity for operative mortality for STS PROM > 25% as observed to expected mortality began to diverge. Conclusions: Achieving the goal of 1.0% operative mortality for primary, isolated CABG is feasible in appropriately selected patients in the modern surgical era. However, this goal may be achieved in only 60% of CABG patients without other improvements in processes of care. Calculated STS PROM can be used to strongly identify patients with estimated mortality risk <1.27% to achieve this goal, but it appears limited in its predictive capacity for those patients with estimated risk >25.0%. These data provide a foundation for further study to determine if 1.0% mortality for CABG is achievable nationwide. [ABSTRACT FROM AUTHOR]

Background The MitraClip REALISM (Abbott Vascular, Menlo Park, CA) trial included several inclusion criteria to identify patients at high risk for conventional mitral valve (MV) surgery. This study evaluated contemporary surgical outcomes for high-risk surgical patients who met these defined criteria to serve as a benchmark to evaluate appropriateness in treatment allocation between surgical and percutaneous MV repair. Methods A statewide Society for Thoracic Surgeons (STS) database was queried for patients undergoing isolated mitral valve surgery over a 12-year study period from 17 different hospitals. Patients were stratified into high-risk (HR) versus non-high-risk (non-HR) cohorts based upon clinical criteria similar to those utilized in the REALISM trial. Mixed effects multivariable regression modeling was used to evaluate study endpoints including mortality, morbidity, and resource utilization. Results Of 2,440 isolated mitral operations, 29% (n = 698) were HR per REALISM criteria. Median STS Predicted Risk of Mortality (PROM) for HR patients was 6.6% compared with 1.6% for non-HR patients ( p < 0.001). The HR patients more commonly underwent MV replacement as well as urgent (30% vs 19%, p < 0.001) operations. High-risk patients incurred higher morbidity and mortality (7% vs 1.6%) with longer intensive care unit (48 vs 41 hours) and hospital stays (7 vs 6 days, all p < 0.001). Among REALISM criteria, STS PROM 12% or greater and high-risk STS criteria were the only criteria associated with mortality. Conclusions Select REALISM criteria, including reoperation with patent grafts and functional MR with ejection fraction less than 0.40, may not identify patients truly at high risk of death with surgery. In addition to conventional STS criteria, risk assessment by surgeons is essential to direct appropriate treatment allocation for high-risk mitral disease. [ABSTRACT FROM AUTHOR]

Objectives Mitral valve (MV) repair rates have lagged despite reported superior outcomes in patients with mitral regurgitation. The purpose of the present study was to evaluate the relationship between procedure volume and the propensity for MV repair in a multi-institution, regional patient cohort. Methods Society of Thoracic Surgeons-certified patient records of those undergoing MV repair or MV replacement (MVR) for moderate or severe mitral regurgitation were evaluated from 17 different centers (2001-2011). The relationship between the annual hospital and surgeon volume and the propensity for MV repair over MVR was analyzed using multivariable, mortality risk-adjusted models with restricted cubic splines. Results A total of 4194 patients were evaluated (MV repair, 2516; MVR, 1662). The median annual mitral procedure volume was 54 operations for hospitals and 13 operations for surgeons. The overall MV repair rate was 60%, with significant variations among hospitals (range, 35%-70%) and surgeons (range, 0%-90%). The MVR patients presented with higher Society of Thoracic Surgeons Predicted Risk of Mortality scores (6% vs 2%, P < .001). After adjustment for Predicted Risk of Mortality score, both annual hospital (P = .04) and surgeon (P < .0001) procedure volume were associated with the probability of MV repair. The likelihood for MV repair correlated with an operative volume of ≥20 procedures annually. Among surgeons and hospitals performing ≥20 mitral operations annually, MV repair rates were greater (73% vs 26% and 62% vs 37%, respectively, P < .001 for both). Conclusions Significant variation in the performance of MV repair over MVR for mitral regurgitation persists in the modern surgical era. Average annual surgeon volume was more significantly associated with MV repair rate than institutional volume, with an increased likelihood for performance of MV repair among surgeons performing >20 procedures annually. In the upcoming era of percutaneous MV repair, surgeon volume and expertise as a gatekeeper should dictate access to this technology and the decisions for the best approach to MV repair. [ABSTRACT FROM AUTHOR]

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

Background Among all postoperative complications, cardiac arrest after cardiac surgical operations has the greatest association with mortality. However, hospital variation in the ability to rescue after cardiac arrest is unknown. The purpose of this study was to characterize the impact of cardiac arrest on mortality and determine the relative impact of patient, operative, and hospital factors on failure to rescue (FTR) rates and surgical mortality after cardiac arrest. Methods A total of 79,582 patients underwent operations at 17 different hospitals (2001 through 2011), including 5.2% (n = 4,138) with postoperative cardiac arrest. Failure to rescue was defined as mortality after cardiac arrest. Patient risk, operative features, and outcomes were compared among hospitals. Results Overall FTR rate was 60% with significant variation among hospitals (range, 50% to 83%; p < 0.001). Failure-to-rescue patients were slightly older, presented with increased preoperative risk, and underwent more emergent operations (all p < 0.05). After risk adjustment, the variable "individual hospital" demonstrated the strongest association with likelihood for FTR (likelihood ratio = 39.1; p < 0.001). Overall risk-adjusted mortality, cardiac arrest, and FTR rates varied across hospitals and did not correlate. High-performing hospitals with lowest FTR rates accrued longer postoperative and intensive care unit stays after the index operation (2 to 3 days; p < 0.001). Conclusions Significant hospital variation exists in cardiac surgical mortality and FTR rates after cardiac arrest. Institutional factors appear to confer the strongest influence on the likelihood for mortality after cardiac arrest compared with patient and operative factors. Identifying best practice patterns at the highest performing centers may serve to improve surgical outcomes after cardiac arrest and improve patient quality. [ABSTRACT FROM AUTHOR]

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

Background: The financial burden of postoperative morbidity after cardiac operations remains ill defined. This study evaluated the costs associated with the performance of coronary artery bypass grafting (CABG) with and without aortic valve replacement (AVR) and determined the incremental costs associated with major postoperative complications. Methods: A total of 65,534 regional patients undergoing CABG (n = 55,167) ± AVR (n = 10,367) were evaluated from 2001 to 2011. Patient-related, hospital-related, and procedure-related cost data were analyzed by use of Medicare-based cost reports. Hierarchical multivariable regression modeling was used to estimate risk-adjusted incremental cost differences in postoperative complications. Results: The mean age was 64 years, and women accounted for 31% of patients. CABG + AVR patients had higher rates of overall complication (40% vs 35%, p < 0.001) and operative mortality (5% vs 3%, p < 0.001) than did CABG patients. CABG + AVR patients also accrued increased median postoperative lengths of stay (7 vs 5 days, p < 0.001) and total costs ($26,527 vs $24,475, p < 0.001). After mortality risk adjustment, significant positive relationships existed between total costs and major postoperative complications. Interestingly, the highest incremental costs among CABG patients included newly instituted hemodialysis ($71,833), deep sternal wound infection ($56,003), and pneumonia ($50,025). Among CABG + AVR patients, these complications along with perioperative myocardial infarction ($68,917) dominated costs. Conclusions: Postoperative complications after CABG ± AVR are associated with significantly increased incremental costs. The most costly complications include newly instituted hemodialysis, infectious complications, and perioperative myocardial infarction. Identification of the most common and the most costly complications provides opportunities to target improvement in patient quality and the delivery of cost-effective care. [Copyright &y& Elsevier]

Background: The introduction of transcatheter aortic valve replacement (TAVR) led to more rigorous evaluation of surgical aortic valve replacement (SAVR) as a benchmark for TAVR. However, limited real-life cost data of SAVR are available. Therefore, the purpose of our study was to assess actual costs and resource utilization of SAVR in patients at different operating risk. Methods: Study data were drawn from a multi-institutional statewide database comprised of all cardiac surgical procedures in the Commonwealth of Virginia. The study included 2,530 elective, primary, isolated SAVRs performed from 2003 to 2012. Clinical data were matched with universal billing data. Patients were stratified into low-, intermediate- and high-risk categories according to the Society of Thoracic Surgeons- Predicted Risk of Mortality (STS-PROM) score: 0% to 4%, 4% to 8% , and greater than 8%, respectively. Clinical outcomes, resource use, and costs were compared between categories. Results: With increasing risk, there were higher rates of postoperative mortality (low 1.2% versus intermediate 2.7% versus high 6.2%, p < 0.001) and renal failure (2.7% vs 7.2% vs 10.6%; p < 0.001). The proportion of patients with any postoperative complication was higher with increasing risk (34% vs 48% vs 53%; p < 0.001). Length-of-stay increased from 6.8 days in the low-risk category to 10.2 and 11.3 days in the intermediate- and high-risk category, respectively (p < 0.001). There was an increase in mean total costs from the low- (n = 2,002) to intermediate- (n = 415) to high-risk (n = 113) category ($35,021 ± $22,642 vs $46,101 ± $42,460 vs $51,145 ± $31,655; p < 0.001). Conclusions: Higher STS-PROM was significantly associated with higher postoperative mortality, complications, length-of-stay, and costs. The SAVR cost data provide a basis for the analysis of TAVR cost-effectiveness and its impact on payment systems. [Copyright &y& Elsevier]

Background: Efforts to reduce blood product use have the potential to avoid transfusion-related complications and reduce health care costs. The purpose of this investigation was to determine whether a multi-institutional effort to reduce blood product use affects postoperative events after cardiac surgical operations and to determine the influence of perioperative transfusion on risk-adjusted outcomes. Methods: A total of 14,259 patients (2006-2010) undergoing nonemergency, primary, isolated coronary artery bypass grafting operations at 17 different statewide cardiac centers were stratified according to transfusion guideline era: pre-guideline (n = 7059, age = 63.7 ± 10.6 years) versus post-guideline (n = 7200, age = 63.7 ± 10.5 years). Primary outcomes of interest were observed differences in postoperative events and mortality risk-adjusted associations as estimated by multiple regression analysis. Results: Overall intraoperative (24% vs 18%, P < .001) and postoperative (39% vs 33%, P < .001) blood product transfusion were significantly reduced in the post-guideline era. Patients in the post-guideline era demonstrated reduced morbidity with decreased pneumonia (P = .01), prolonged ventilation (P = .05), renal failure (P = .03), new-onset hemodialysis (P = .004), and composite incidence of major complications (P = .001). Operative mortality (1.0% vs 1.8%, P < .001) and postoperative ventilation time (22 vs 26 hours, P < .001) were similarly reduced in the post-guideline era. Of note, after mortality risk adjustment, operations performed in the post-guideline era were associated with a 47% reduction in the odds of death (adjusted odds ratio, 0.57; P < .001), whereas the risk of major complications and mortality were significantly increased after intraoperative (adjusted odds ratio, 1.86 and 1.25; both P < .001) and postoperative (adjusted odds ratio, 4.61 and 4.50, both P < .001) transfusion. Intraoperative and postoperative transfusions were associated with increased adjusted incremental total hospitalization costs ($4408 and $10,479, respectively). Conclusions: Implementation of a blood use initiative significantly improves postoperative morbidity, mortality, and resource utilization. Limiting intraoperative and postoperative blood product transfusion decreases adverse postoperative events and reduces health care costs. Blood conservation efforts are bolstered by collaboration and guideline development. [Copyright &y& Elsevier]

Background: Although studies have demonstrated clinical advantages in high-volume (HV) centers performing esophageal and pancreatic resections, thoracic aortic aneurysm repair has not been studied in the same fashion. We sought to determine if HV centers have better outcomes after thoracic aortic aneurysm surgery relative to lower-volume (LV) centers. Study Design: Retrospective review of prospectively collected data pooled from the 17 institutions participating in the Virginia Cardiac Surgery Quality Initiative (VCSQI) database was performed during a 3-year period. LV centers were those that performed <40 operations during the study period, and HV centers were those that performed >80 operations. Preoperative risk factors and outcomes were compared between the 2 groups. Multivariate analysis was performed to evaluate the impact of center volume on mortality. Only elective operations were studied. Results: HV centers performed 515 operations during the study period compared with 216 operations from LV centers. Perioperative mortality was significantly lower in HV centers (3.7%, n = 19) versus LV centers (8.3%, n = 18) (p = 0.02). Incidence of renal failure (HV: 4.5%; LV: 8.3%; p = 0.05) and prolonged ventilator course (HV: 16.7%; LV: 25.5%; p = 0.01) were also lower in the HV centers relative to LV centers. HV centers had higher stroke rates compared with LV centers (HV: 4.8%, LV: 1.4%; p < 0.01). Total hospital cost was $42,736 in HV centers and $51,296 in LV centers (p = 0.04). On regression analysis, LV centers were significantly associated with increased complications and mortality (all p < 0.05). Conclusions: Although LV centers had lower stroke rates, HV centers had overall better outcomes, lower mortality rates, and considerably lower cost compared with LV centers. [Copyright &y& Elsevier]