Search

Background Glycated albumin (GA) is a short-term measure of glycemic control. Several studies have demonstrated an inverse association between body mass index (BMI) and GA, which may affect its performance as a biomarker of hyperglycemia. We investigated cross-sectional associations between GA and multiple measures of adiposity, and compared its performance as a glycemic biomarker by obesity status, in a nationally representative sample of US adults. Methods We measured GA in adults from the 1999–2004 National Health and Nutrition Examination Survey. Separately in adults with and without diabetes, we assessed associations of GA with adiposity measures (BMI, waist circumference, trunk fat, total body fat, and fat mass index) in sex-stratified multivariable regression models. We compared sensitivity and specificity of GA to identify elevated hemoglobin A1c (HbA1c), by obesity status. Results In covariate-adjusted regression models, all adiposity measures were inversely associated with GA in adults without diabetes (β=−0.48 to −0.22%-point GA per 1 SD adiposity measure; n = 9750) and with diabetes (β=−1.73 to −0.92%-point GA per SD). Comparing adults with vs without obesity, GA exhibited lower sensitivity (43% vs 54%) with equivalent specificity (99%) to detect undiagnosed diabetes (HbA1c ≥ 6.5%). Among adults with diagnosed diabetes (n = 1085), GA performed well to identify above-target glycemia (HbA1c ≥ 7.0%), with high specificity (>80%) overall but lower sensitivity in those with vs without obesity (81% vs 93%). Conclusions Inverse associations between GA and adiposity were present in people with and without diabetes. GA is highly specific but may not be sufficiently sensitive for diabetes screening in adults with obesity.

Background: Adipokines mediate many metabolic effects of adipose tissue. While regional body composition is associated with metabolic risk, it is unclear if metabolic risk associations differ for adipokine expression in visceral and subcutaneous tissue and adipokine concentrations in the circulation. Methods: We obtained visceral and subcutaneous fat samples, and pre-surgical serum samples from Geisinger Obesity Registry patients undergoing bariatric surgery. We used real-time PCR to quantify mRNA expression of adipokines (adiponectin, leptin, leptin/adiponectin ratio) in fat samples, and targeted assays (ELISA) to measure serum adipokines. Using multivariable linear regression, we evaluated the individual and combined associations of visceral, subcutaneous and serum adipokines (per-1-SD and tertiles) with a metabolic syndrome (MetS) severity Z-score. Results: 181 participants (mean age 45 years, mean BMI 47 kg/m 2 , 85% female) with available fat and serum samples were included. Visceral, subcutaneous and serum adipokines were all weakly correlated (all ρ Conclusion: Visceral, but not subcutaneous, adipokine expression provides complementary information to serum adipokines on metabolic risk. This indicates significant differences in the physiologic impact of regional adipose tissue and highlights adipokines as a potential target for modifying cardiometabolic risk.

Introduction: N-terminal pro-brain-type natriuretic peptide (NT-proBNP) is widely used as a diagnostic biomarker for heart failure. Higher diet quality is associated with lower risk of cardiovascular disease. However, the association between diet and subclinical cardiovascular disease, as assessed by biomarker concentrations, is less well-studied. Hypothesis: We hypothesized that higher diet quality, assessed by the Healthy Eating Index-2015 (HEI-2015), would be associated with lower serum levels of NT-proBNP. Methods: We included 9,782 adults from the National Health and Nutrition Examination Survey (NHANES), 1999-2004. The HEI-2015 ranges from 0 to 100, with higher scores indicating better diet quality, and was categorized into sex-specific quintiles. Weighted multivariable linear regression models were used to estimate associations between the overall HEI-2015 score as well as its 13 components and log-transformed NT-proBNP. Results: Among 9,782 participants, mean age was 45 years, 48% were men, and 72% were non-Hispanic White adults. After adjusting for sociodemographic characteristics, lifestyle factors, and medical history, persons in the highest HEI-2015 quintile had a 10.0% lower NT-proBNP level compared to those in the lowest HEI-2015 quintile (95% CI: -17.7% to -2.6%). There was a dose-response relationship between HEI-2015 and NT-proBNP ( Figure ). For each 1-unit higher sodium and added sugars score, NT-proBNP was lower by 7.7% and 6.8% respectively (95% CI: -13.8 % to -2.2%, and 95% CI: -13.1% to -0.9% respectively). Conclusion: Higher diet quality, especially lower intakes of sodium and added sugars, was associated with lower serum levels of NT-proBNP.

Background: Physical activity (PA) patterns over time influence diabetes risk through incompletely understood mechanisms. Adipokines secreted by adipose tissue have myriad endocrine effects and are affected by PA. It is unknown the extent to which adipokines mediate the association between changes in PA and diabetes. Methods: We conducted a cross-sectional study of 10,908 ARIC participants (mean age 54; 55% female; 21% Black adults) who attended Visits 1 (V1; 1987-1989) and 3 (V3; 1993-1995) of the ARIC Study. We used mediation analyses to determine the extent to which the association of changes in PA from V1 to V3 and diabetes status at V3 was explained by adipokines. Analyses were stratified by obesity status. PA was defined using American Heart Association guidelines as inactive, intermediate, and recommended (150 minutes of moderate-vigorous activity/week); the intermediate group was further divided into low and moderate (below or above the median activity level). Participants were categorized by PA at V1 and V3 - (1) stable low: inactive or low at both visits; (2) increasing: higher category at V3 than V1; (3) decreasing: lower category at V3 than V1; and (4) stable high: moderate or high at both visits. Results: Increasing PA was associated with higher adiponectin and lower leptin at V3 compared to stable low PA, while decreasing PA was associated with lower adiponectin and higher leptin compared to stable high PA (p Conclusions: The associations between changes in PA and diabetes may be mediated in part by adipokines.

Objective Obesity is a global public health challenge and strongly associated with type 2 diabetes (T2D), but its burden and effects are not well understood in people with type 1 diabetes (T1D). Particularly, the link between obesity and chronic kidney disease (CKD) in T1D is poorly characterized. Research Design and Methods We included all T1D and, for comparison, T2D in the Geisinger Health System from 2004 to 2018. We evaluated trends in obesity (body mass index ≥ 30 kg/m2), low estimated glomerular filtration rate (eGFR) (≤60 mL/min/1.73m2), and albuminuria (urine albumin-to-creatinine ratio ≥ 30 mg/g). We used multivariable logistic regression to evaluate the independent association of obesity with CKD in 2018. Results People with T1D were younger than T2D (median age 39 vs 62 years). Obesity increased in T1D over time (32.6% in 2004 to 36.8% in 2018), while obesity in T2D was stable at ~60%. The crude prevalence of low eGFR was higher in T2D than in T1D in all years (eg, 30.6% vs 16.1% in 2018), but after adjusting for age differences, prevalence was higher in T1D than T2D in all years (eg, 16.2% vs 9.3% in 2018). Obesity was associated with increased odds of low eGFR in T1D [adjusted odds ratio (AOR) = 1.52, 95% CI 1.12-2.08] and T2D (AOR = 1.29, 95% CI 1.23-1.35). Conclusions Obesity is increasing in people with T1D and is associated with increased risk of CKD. After accounting for age, the burden of CKD in T1D exceeded the burden in T2D, suggesting the need for increased vigilance and assessment of kidney-protective medications in T1D.

Diabetes and prediabetes are growing concerns among US youth. Fasting glucose (FG) and HbA1c are standard diabetes screening tests, but HbA1c may be unreliable in some settings and fasting is burdensome in children. Glycated albumin (GA) is a non-fasting test that was recently cleared for clinical use in the US, but studies in youth without diabetes are limited. We conducted a cross-sectional analysis in 6826 youth without diabetes aged 8-19 years in the 1999-2004 National Health and Nutrition Examination Survey (NHANES). We evaluated the associations of GA with HbA1c, FG, and cardiometabolic risk factors. Glycated albumin was poorly correlated with HbA1c (ρ = 0.074) and FG (ρ = -0.047) and was negatively associated with BMI and cardiometabolic risk factors. Compared to youth in the highest tertile of GA (≥13.5%), those in the lowest GA tertile (

We sought to evaluate the performance of glycated albumin (GA) as a measure of hyperglycemia in pregnant women.We used data from 555 pregnant women aged 20-40 years who participated in NHANES 1999-2004 and did not report a pre-pregnancy diagnosis of diabetes. We used Pearson's correlations and evaluated the area under the curve (AUC) for GA to detect elevated concentrations of random glucose, HbA1c, or fasting glucose (subset). We compared results to 1607 nonpregnant women aged 20-40 without diabetes.In pregnant women, 1.9 % had HbA1c ≥ 39 mmol/mol (≥5.7 %), 9.1 % had random glucose ≥ 5.3 mmol/L (≥95 mg/dL), and 10.7 % had fasting glucose ≥ 5.3 mmol/L. In pregnancy, GA was poorly correlated with HbA1c (r = 0.08) and random glucose (r = 0.17). BMI was positively associated with HbA1c (r = 0.33) and random glucose (r = 0.25) but was inversely associated with GA (r = -0.27). GA had poor discrimination for detecting hyperglycemia in pregnant women, defined as HbA1c ≥ 39 mmol/mol (AUC = 0.634) or random glucose ≥ 5.3 mmol/L (AUC = 0.628). Similar patterns were observed among nonpregnant women.GA is not a sensitive test to screen for hyperglycemia in pregnancy. GA was inversely associated with adiposity in pregnant women without diabetes. Pregnancy-related weight gain may complicate interpretation of repeated GA measurements.

Objective Hybrid arch procedures (arch vessel debranching with thoracic endovascular aneurysm repair [TEVAR] coverage of arch pathology) have been presented as an alternative to total arch replacement (TAR). But multicenter-based analyses of these two procedures are needed to benchmark the field and establish areas of improvement. Methods The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from July 2014 to December 2015 was queried for elective TAR and hybrid arch procedures. Demographics and operative characteristics were compared and stepwise variable selection was used to create a risk-set used for adjustment of all multivariable models. Results A total of 1,011 patients met inclusion criteria, 884 underwent TAR, and 127 had hybrid arch procedures. TAR patients were younger (mean age: 62.7 ± 13.3 vs. 66.7 ± 11.9 years; p = 0.001) and had less peripheral vascular disease (34.0 vs. 49.6%; p Conclusion TAR remains the gold standard for elective aortic arch pathologies. Despite risk adjustment, hybrid arch procedures were associated with increased risk of mortality and stroke, advocating for careful adoption of these strategies.

Increasing diverse engagement in the Society for Epidemiologic Research (SER) will positively impact the field of epidemiology. As the largest and longest-running epidemiologic society in North America, SER has long been a pioneer in promoting diversity and inclusion. A recent survey of SER members, however, showed there is still room for improving diversity, inclusion, representation, and participation in the Society. In this commentary, as members of both the SER and the Johns Hopkins Bloomberg School of Public Health Department of Epidemiology’s Inclusion, Diversity, Equity, Anti-Racism, and Science (Epi IDEAS) Working Group, we recommend 4 goals for the SER Annual Meeting and beyond: 1) convene epidemiologic researchers with diverse backgrounds and ideas; 2) promote an inclusive environment at the SER Annual Meeting; 3) develop, compile, and disseminate best practices to honor diversity in epidemiologic research; and 4) increase prioritization of health disparities research and methods. We also suggest strategies for achieving these goals so that SER can better include, support, and elevate members from historically disadvantaged groups. While our recommendations are tailored specifically to SER, the greater epidemiologic and academic communities could benefit from adopting these goals and strategies within their professional societies and conferences.

Background: Prediabetes identifies people at high risk for diabetes and future cardiometabolic disease. It is unclear if remission of prediabetes is associated with better outcomes. Methods: We conducted a prospective cohort study of 7506 participants without diabetes who attended visit 2 (V2, 1990-1992) and visit 4 (V4, 1996-1998) of the Atherosclerosis Risk in Communities (ARIC) Study. We used Cox models to compare risk of mortality, incident diabetes, and cardiovascular and kidney disease over median 21.2 years of follow-up. Participants were classified by glycemia at V2 and V4 - stable normoglycemia: fasting glucose (FG) Results: There were 4064 (54%) participants (mean age: 56 years; 65% female; 12% black) with stable normoglycemia, 1149 (15%) participants (mean age: 57 years; 52% female; 18% black) with remission of prediabetes at V4, and 1511 (20%) participants (mean age: 57 years; 43% female; 20% black) with persistent prediabetes. As compared to participants with stable normoglycemia, participants with remission of prediabetes had higher risk of incident diabetes (HR 95%CI 1.71, 1.49-1.98), but no other outcomes. Participants with persistent prediabetes had increased risk of all outcomes, including mortality (HR 95%CI 1.13, 1.03-1.24), and incident diabetes (HR 95% CI 3.24, 2.88-3.65) ( Table ). Conclusions: Persistent prediabetes over 6 years in middle age was associated with increased risk of mortality and cardiometabolic disease as compared to stable normoglycemia. People with remission of prediabetes had increased risk of diabetes, but no increased risk of long-term clinical outcomes. Repeat measures of glycemia in middle age could improve risk-stratification for future cardiometabolic disease.

BACKGROUND: The optimal approach to screening and diagnosis of prediabetes and diabetes in youth is uncertain. METHODS: We conducted a cross-sectional analysis of 14 119 youth aged 10 to 19 years in the 1999–2016 NHANES. First, we examined the performance of American Diabetes Association risk-based screening criteria. Second, we evaluated the performance of current clinical definitions of prediabetes and diabetes based on hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), either HbA1c or FPG, or both HbA1c and FPG (confirmatory definition) to identify youth at high cardiometabolic risk. RESULTS: Overall, 25.5% of US youth (10.6 million in 2016) were eligible for screening. Sensitivity and specificity of the screening criteria for detecting any hyperglycemia were low for both HbA1c ≥5.7% (sensitivity = 55.5%, specificity = 76.3%) and FPG ≥100 mg/dL (sensitivity = 35.8%, specificity = 77.1%). Confirmed undiagnosed diabetes (HbA1c ≥6.5% and FPG ≥126 mg/dL) was rare, 85%) cases of diabetes were diagnosed. Associations with cardiometabolic risk were consistently stronger and more specific for HbA1c-defined hyperglycemia (specificity = 98.6%; sensitivity = 4.0%) than FPG-defined hyperglycemia (specificity = 90.1%; sensitivity = 19.4%). CONCLUSIONS: One-quarter of US youth are eligible for screening for diabetes and prediabetes; however, few will test positive, especially for diabetes. Most cases of diabetes in US youth are diagnosed. Regardless of screening eligibility, we found that HbA1c is a specific and useful nonfasting test to identify high-risk youth who could benefit from lifestyle interventions to prevent diabetes and cardiovascular risk in adulthood.

Background Hospital readmission after pediatric cardiac surgery is incompletely understood. This study analyzed data from The Society of Thoracic Surgeons Congenital Heart Surgery Database to determine prevalence, to describe patient characteristics, and to evaluate risk factors for readmission. Methods Readmission was defined by the "readmission within 30 days after discharge" field. Routine variables were summarized. Regression analysis was used to identify factors associated with readmission. Results The study cohort included 56,429 patient records from 100 centers. Overall, 6,208 (11%) patients were readmitted. The most common reasons for readmission were respiratory or airway complications (14.2%), septic or infectious complications (11.4%), and reasons not related to the preceding surgical procedure (20.2%). Primary reason for readmission varied across benchmark operation groups. In multivariable analysis, factors associated with increased odds of readmission included the presence of noncardiac abnormalities (odds ratio [OR], 1.24), chromosomal abnormalities or genetic syndromes (OR, 1.24), preoperative mechanical circulatory support (OR, 1.36), other preoperative factors (OR, 1.21), prior cardiac surgery (OR, 1.31), Hispanic ethnicity (OR, 1.13), higher STAT procedural complexity (Society of Thoracic Surgeons/European Association for Cardio-Thoracic Surgery) (STAT level 3 vs 1, OR, 1.22; STAT 4 vs 1, OR, 1.48; STAT 5 vs 1, OR, 2.62), prolonged postoperative length of stay (OR, 1.07 per day from 0 to 14 days; OR, 1.01 per week >14 days), any major complication (OR, 1.27), any other postoperative complications (OR, 2.00), and discharge on a weekday (OR, 1.07). Conclusions Readmission is common after congenital heart surgery, mostly for noncardiovascular reasons. Process improvement initiatives targeted at high-risk patients could minimize its impact.

Background: Few studies have examined the natural history of prediabetes, specifically, regression to normoglycemia as well as progression to clinical diabetes. Furthermore, there are several definitions of prediabetes in current use. Methods: We conducted a prospective cohort analysis of 8214 participants without diabetes who attended visit 2 (1990-1992) and visit 4 (1996-1998) of the Atherosclerosis Risk in Communities (ARIC) Study. We used multinomial logistic regression to compare cumulative incidence of diabetes and regression to normoglycemia among persons meeting different definitions of prediabetes (American Diabetes Association criteria): fasting glucose (FG) 100-125 mg/dL; A1C 5.7-6.4%; or elevations in both tests (single-sample confirmatory). Incident diabetes was defined as a self-reported diagnosis, medication use, or both FG ≥ 126 mg/dL and A1C ≥ 6.5%; normoglycemia was defined as both FG < 100mg/dL and A1C < 5.7% and no diabetes diagnosis or medication use. Analyses were adjusted for age, sex, and race-center. Results: The prevalence of prediabetes at visit 2 (age range, 46-69; 57% female; 17% black) was 37.6% (n=3089) based on FG criteria, 17.4% (n=1427) based on A1C criteria, and 10.6% (N=867) by both FG and A1C criteria. The 6-year cumulative incidence of diabetes was 7.2% in participants with FG-defined prediabetes, 17.1% in participants with A1C-defined prediabetes, and 22.4% in participants meeting both criteria. Among participants with prediabetes by FG criteria, regression to normoglycemia was 1.9 times as likely as progression to diabetes (14.0% vs. 7.2%). However, when prediabetes was defined by A1C and by confirmatory criteria, progression to diabetes was 1.5 times and 3.5 times more likely than regression to normoglycemia, respectively. Conclusions: Risks of progression to diabetes and regression to normoglycemia differed by prediabetes definition. Prediabetes identified by A1C criteria and single-sample confirmatory criteria identified people at highest risk for diabetes.

Introduction: Trends in the prevalence of chronic kidney disease (CKD) and obesity in adults with type 1 diabetes have not been rigorously characterized. We hypothesized that, like the type 2 diabetes population, there have been increases in the prevalence of eGFR 30 kg/m2 (obesity) in the population with type 1 diabetes. Methods: We conducted a retrospective analysis of 4215 patients in the Geisinger Health System (central Pennsylvania) with type 1 diabetes, defined using the validated Klompas algorithm. We constructed period prevalent cohorts within each calendar year from 2004 to 2018 and estimated the prevalence of CKD and obesity using average values within each calendar year. Results: The 2004 cohort contained 530 people with type 1 diabetes; the 2018 cohort contained 1485 people. Percent female was 54.0% in 2004 and 50.4% in 2018; average age was 43.9 (SD, 16.1) and 48.1 (SD, 15.9), respectively. The prevalence of CKD was 14.7% in 2004 and 17.4% in 2018 (p-trend = 0.80) (Figure). The prevalence of obesity was 30.0% in 2004 and 38.9% in 2018 (p-trend =0.006). The average BMI was 27.6 (6.0) in 2004 and 29.1 (6.6) in 2018 (p-trend = 0.002). In associations adjusted for demographics, trends were similar. Conclusions: The prevalence of obesity increased, but there was no change in the prevalence of CKD over the last 15 years among people with type 1 diabetes in a rural health care system. Disclosure A. Wallace: None. A.R. Chang: None. M. Grams: Other Relationship; Self; DCI. E. Selvin: None. Funding National Heart, Lung, and Blood Institute (T32HL007024)

Introduction: Natriuretic peptides are regulators of the cardiovascular system that are also related to adiposity and insulin resistance. NT-proBNP levels are inversely associated with adiposity and increase with weight loss, which may have hemodynamic implications in obesity. However, it is unclear if the changes in NT-proBNP with weight loss are independent of changes in insulin resistance and related metabolic risk factors. Hypothesis: NT-proBNP increases with surgical weight loss are partially independent of changes in other metabolic risk factors. Methods: We investigated 71 patients from the BARI-Heart Study, a prospective cohort with anthropometrics, metabolic risk factors and biomarkers before and after bariatric surgery. We compared data between pre- and post-surgical visits (1-2 weeks and 6 months, respectively) using t-tests, and performed regression analysis examining the association of changes adiposity measures with NT-proBNP before and after adjusting for metabolic risk factors. Results: After bariatric surgery, major reductions in weight, body-mass index (BMI) and body fat percentage (BFP) (mean change) were observed (Table 1), whereas NT-proBNP levels increased (mean change +61 pg/mL, SD 104). There were significant reductions post-surgery in HOMA-IR (from 9.9 to 2.6; p r -0.27; p=0.03). In regression analysis, the inverse association remained statistically significant after adjustment for changes in the other metabolic risk factors (Table 2). Conclusions: Reductions in adiposity are linked to increases in NT-proBNP independent of changes in metabolic risk factors. The mechanisms and cardiovascular implications of this direct link between weight loss and NT-proBNP deserve further investigation.

Background: The N-Terminal of pro-B-type natriuretic peptide (NT-proBNP) is a potent biomarker for heart failure (HF), reflecting left ventricular dilation and stress. The association among obesity, HF, and NT-proBNP is complex, with paradoxically lower levels of NT-proBNP in obese individuals, despite their elevated HF risk. Furthermore, a few studies have reported decreased HF risk, but also increases in NT-proBNP, after weight loss via bariatric surgery. However, studies have not simultaneously evaluated changes in NT-proBNP and cardiac function after bariatric surgery. Hypothesis: There will be discordance between improvements in cardiac filling pressures (as reflected by E/e’) and increases in NT-proBNP with weight loss following bariatric surgery. Methods: We conducted a single-center analysis of participants in the BARI-Heart Study who underwent bariatric surgery and attended study visits 3-6 months and 2 weeks before surgery, and 6 and 12 months after surgery. We examined pre- and post-surgery changes in NT-proBNP and in echocardiographic measures of cardiac function. We also assessed the correlation between NT-pro-BNP and E/e’, at 2 weeks pre- and 6 months post-surgery. Results: Among 71 BARI-Heart participants (mean age 45 years, 74% female, 87% white, mean BMI 47.0 kg/m 2 ), there were no significant pre-surgery changes in BMI, NT-proBNP, or E/e’. By 6-12 months, there were marked reductions in BMI and significant increases in NT-proBNP, but decreases in E/e’ ( Figure ). Changes from surgery to the 6 month visit in NT-proBNP and E/e’ were associated (r=0.295; p=0.02). There was a tendency towards stronger correlations between NT-proBNP and E/e’ post- (r= 0.436; p Conclusions: Weight loss is associated with increases in NT-proBNP despite reduced LV filling pressures, suggesting a non-cardiac etiology underlying increases in NT-proBNP after weight loss. The interpretation of NT-proBNP for cardiac dysfunction may change with decreasing adiposity.

The early postnatal course for a newborn with critical congenital heart disease (CHD) can be negatively impacted if diagnosis is delayed. Despite this, there continues to be inconsistent evidence regarding potential benefits associated with prenatal diagnosis (PND) in neonates who undergo cardiac surgery. The objective of this study was to better define the impact of a PND on pre-operative morbidity by utilizing a large clinical database. Neonates (

More than 90% of coronary artery bypass grafting (CABG) is performed with a single-arterial bypass graft (SABG), based on the left internal thoracic artery (ITA) with supplemental vein grafts. This practice, often justified by safety concerns with multiple-arterial grafting (MABG), defies evidence of improved late survival achieved with bilateral ITA (BITA-MABG) or left ITA plus radial artery (RA-MABG). We hypothesized that MABG and SABG are equally safe.We analyzed The Society of Thoracic Surgeons National Database (2004 to 2015) to assess the operative safety of BITA-MABG (n = 73,054) and RA-MABG (n = 97,623) vs SABG (n = 1,334,511). Primary end points were operative (30-day or same hospitalization) mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were derived from by logistic regression with sensitivity analyses in multiple subcohorts including MABG use rate.SABG (73.8% men; median age, 66 years), BITA-MABG (85.1% men; median age, 59 years), and RA-MABG (82.5% men; median age, 61 years) showed distinctly different patient characteristics. Compared with SABG (1.91% OM; 0.73% DSWI), observed OM was lower for BITA-MABG (1.19%, p0.001) and RA-MABG (1.19%, p0.001). DSWI was higher among BITA-MABG (1.08%, p0.001) and similar for RA-MABG (0.71%, p = 0.55). BITA-MABG showed marginally increased, likely not clinically significant, OM (AOR, 1.14; 95% CI, 1.00 to 1.30; p = 0.05) and doubled DSWI (AOR, 2.09; 95% CI, 1.80 to 2.43; p0.001). RA-MABG had similar OM (AOR, 1.01; 95% CI, 0.89 to 1.15; p = 0.85) and DSWI (AOR, 0.97; 95% CI, 0.83 to 1.13; p = 0.70). Results were consistent across multiple subcohorts. A U-shaped OM vs BITA use relation was documented, with worse OM at hospitals with low (5%: AOR, 1.38; 95% CI, 1.18 to 1.61; p0.001) and high (≥40%: AOR, 1.31; 95% CI, 1.00 to 1.70; p = 0.049) BITA use.MABG in the United States is associated with OM comparable to SABG and increased DSWI risk with BITA-MABG. Our findings highlight the importance of surgeon and institutional experience and careful patient selection for BITA-MABG. Our short-term results should not in any way dissuade the use of MABG, given its well-established long-term survival advantage.

Systemic-to-pulmonary shunt failure is a potentially catastrophic complication. We analyzed a large multicenter clinical registry to describe the prevalence and evaluate risk factors.Infants (aged ≤365 days) undergoing shunt operations (systemic artery-to-pulmonary artery or systemic ventricle-to-pulmonary artery) in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) from 2010 to 2015 were included. Multivariable logistic regression was used to evaluate risk factors for in-hospital shunt failure. Model covariates included patient characteristics, preoperative factors, procedural factors including shunt type, and center effects. Centers with more than 15% missing data for key covariates were excluded.Shunt operations were performed in 9,172 infants (118 centers). In-hospital shunt failure occurred in 674 (7.3%). In multivariable analysis, risk factors for in-hospital shunt failure included lower weight at operation (odds ratio [OR], 1.35; p = 0.001), preoperative hypercoagulable state (OR, 2.47; p = 0.031), and the presence of any other STS-CHSD preoperative risk factors (OR, 1.24; p = 0.038). Shunt failure was less likely with a systemic ventricle-to-pulmonary artery shunt than a systemic artery-to-pulmonary artery shunt (OR, 0.65; p = 0.020). Neither cardiopulmonary bypass nor single-ventricle diagnosis was a risk factor for shunt failure. Patients with in-hospital shunt failure had significantly higher rates of operative mortality (31.9% vs 11.1%, p 0.001) and major morbidity (84.4% vs 29.4%, p0.001), and longer median postoperative length of stay among survivors (45 vs 22 days, p0.001).In-hospital shunt failure is common, and associated mortality risk is high. These data highlight at-risk patients and procedural cohorts that warrant expectant surveillance and may benefit from enhanced antithrombotic prophylaxis or other management strategies to reduce shunt failure. These findings may inform planning of future clinical trials.

Background Congenital heart disease is common in patients with Trisomy 13 (T13) and Trisomy 18 (T18), but offering cardiac surgery to these patients has been controversial. We describe the landscape of surgical management across the United States, perioperative risk factors, and surgical outcomes in patients with T13 and T18. Methods and Results Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database with T13 and T18 who underwent cardiac surgery (2010–2017) were included. There were 343 operations (T13: n=73 and T18: n=270) performed on 304 patients. Among 125 hospitals, 87 (70%) performed at least 1 operation and 26 centers (30%) performed ≥5 T13/T18 operations. Operations spanned the full spectrum of complexity with 29% (98/343) being in the highest categories of estimated risk. The operative mortality rate was 15%, with a 56% complication rate. Preoperative mechanical ventilation was associated with an odds ratio of mortality >8 for both patients with T13 and T18 (both P P =0.03) or prior cardiac surgery (odds ratio, 0.2; P =0.02) was associated with better survival in patients with T18 but not patients with T13. Conclusions Data from this nationally representative sample indicate that most centers offer surgical intervention for both patients with T13 and T18, even in highly complex patients. However, the overall mortality rate was high in this select patient cohort. The association of preoperative mechanical ventilation with mortality suggests that this subset of patients with T13 and T18 should perhaps not be considered surgical candidates. This information is valuable to clinicians and families for counseling and deciding what interventions to offer.

Background: Postoperative transcatheter interventions (TCIs) are performed after congenital heart surgery to treat residual or recurrent anatomic lesions. We used the Society of Thoracic Surgeons Congenital Heart Surgery Database to evaluate rates of postoperative TCIs, center variability, and to determine whether center approaches to postoperative TCI might be associated with outcomes. Methods and Results: Patients R 2 =0.23; P =0.02) but did not have higher post-TCI mortality ( P =0.10). There was no correlation between center TCI rates and failure-to-rescue ( P =0.19). Conclusions: Patients undergoing postoperative TCI represent a high-risk cohort. Wide center variability suggests the potential for improving outcomes, but further study is necessary to better understand optimal approaches.

OBJECTIVE: Although minimally invasive techniques have led to shorter hospitalizations, discharge on postoperative day 1 is still uncommon. We hypothesized that day 1 discharge could be performed safely and that there might be significant variation in day 1 discharge rates between hospitals. METHODS: We identified patients with lung cancer who underwent lobectomy and segmentectomy in the Society of Thoracic Surgeons Database from 2012 to 2017. The 10% longest hospital stay outliers were excluded. A multivariable regression model was created to assess for factors associated with day 1 discharge and readmission. RESULTS: A total of 46,325 patients were examined, and 1821 patients (3.9%) were discharged on day 1. This rate increased from 3.4% to 5.3% over the course of the study (P < .0001). In multivariable analysis, factors associated with day 1 discharge included age, Zubrod score, body mass index greater than 25, forced expiration value at 1 second, middle or upper lobectomy, minimally invasive technique, and procedure time. Outpatient 30-day mortality was similar (0.3% vs 0.4%, P = .472). Patients discharged on day 1 were not at increased risk of readmission. Readmission after day 1 discharge was associated with male sex, coronary artery disease, chronic obstructive pulmonary disease, and longer procedure time. There was substantial variation in day 1 discharge rate between institutions, with 11 centers (4.0%) discharging more than 20% of their patients on day 1, whereas 102 centers (36.7%) had no day 1 discharges. CONCLUSIONS: Day 1 discharge after anatomic lung resection is uncommon but is becoming more common. Carefully selected patients may be discharged on day 1 without an increased risk of readmission or death.

Turner syndrome (TS) is a genetic syndrome characterized by monosomy X (45,XO) in phenotypic females and is commonly associated with congenital heart disease. We sought to describe the distribution, mortality, and morbidity of congenital heart surgery in TS and compare outcomes to individuals without genetic syndromes.The Society of Thoracic Surgeons Congenital Heart Surgery Database was used to evaluate index cardiovascular operations performed from 2000 to 2017 in pediatric patients (aged 0-18 years) with and without TS. Analyses were stratified by the most common operations, including coarctation repair, aortic arch repair, partial anomalous pulmonary venous return repair, Norwood, superior cavopulmonary anastomosis (Glenn), and Fontan.Included were 780 operations in TS and 62,659 operations in controls. The most common TS operations were coarctation repair in 274 (35%), aortic arch repair in 116 (15%), and Norwood in 59 (8%). Compared with controls, TS patients had lower weight-for-age Z-scores across all operations (P.01 for all); however, operative mortality rates did not differ significantly. The chylothorax rate was higher in TS after coarctation repair (8.8% vs 2.8%, P.001) and Norwood (22% vs 8.1%, P .001). The median (interquartile range) postoperative length of stay was longer in TS for coarctation repair (6.5 [5.0-15.5] days vs 5.0 [4.0-9.0] days, P.001), aortic arch repair (15.0 [8.0-27.5] days vs 11.0 [7.0-21.0] days, P = .004), and Glenn (9.0 [6.0-16.0] days vs 6.0 [5.0-11.0] days, P = .013).Turner syndrome patients most commonly underwent operations for left-sided obstructive lesions. Despite increased morbidity for select operations, TS was not associated with increased operative mortality.

Recent evidence shows that multi-arterial coronary artery bypass grafting (MABG) based on bilateral internal thoracic (BITA) or left internal thoracic (LITA) and radial artery (RA) improves long-term outcomes compared with single arterial coronary artery bypass grafting (SABG) (LITA + saphenous vein graft). How this evidence affected the worldwide use of MABG, if at all, is not well defined. Accordingly, we report 10-year temporal trends of MABG utilization from 2 continents. A study population of 1,683,434 non-emergent, primary, isolated LITA-based coronary artery bypass grafting (CABG) (≥2 grafts) patients was derived from the Society of Thoracic Surgeons (STS) (1,307,528 (79.5%) of 1,644,388 isolated CABG; total 1179 centers) and the Australia New Zealand Cardiothoracic (ANZ) Databases (34,213 (87%) of 39,046 isolated CABG; 24 centers) between 2004 and 2014. Patients were excluded based on the following: (1) no LITA, (2) if arterial grafts were other than RA or ITA, or (3) if grafting data were missing. The 3 MABG groups were LITA + RA, BITA, and BITA + RA, each with or without supplemental vein grafts. Grafting trends and their associated patient demographics were analyzed. SABG (89.3% STS, 51.4% ANZ) was the most common grafting strategy. MABG was most frequently accomplished by LITA + RA: (STS: 6.1%; ANZ: 42.6%), followed by BITA: (STS: 4.1%; ANZ: 4.3%), while ≥3 (BITA + RA) was rare in the STS (0.5%), but more common in ANZ (5.9%). In the STS, between 2004 and 2014, SABG rates systematically increased from 85.2% to 91.7%, BITA grafting was essentially unchanged from 3.6% to 4.3%, while RA use decreased systematically from 10.5% to 3.7%. In the ANZ, SABG rates increased from 17.3% to 51.4%, BITA grafting decreased from 6.3% to 3.6%, while RA grafting decreased from 65.8% to 39.0%. Compared with SABG patients, BITA patients were younger (STS: median age 59 vs 66, P 0.001; ANZ: mean age 62 vs 68, P 0.001), predominately male (STS: 84% vs 73%, P 0.001; ANZ: 86% vs 79%, P 0.001), less obese (body mass index 30 kg/m

Background Among patients with congenital heart disease (CHD), the coexistence of noncardiac congenital anatomic abnormalities (NC), genetic abnormalities (GA), and syndromes (S) may influence therapeutic strategies and outcomes. The appreciated prevalence of these abnormalities has risen because increased screening and improved diagnostic precision enable identification of these comorbidities in a larger fraction of neonates with CHD. We examined the contemporary prevalence and distribution of NC/GA/S across diagnostic groups among neonates undergoing cardiac operations using a large nationally representative clinical registry. Methods The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) was queried to identify neonates (≤30 days) who underwent index cardiac operations from 2010 to 2013. The fundamental cardiac diagnosis was used to identify 10 diagnostic groups. The prevalence of NC/GA/S was reported across each group. Results The cohort included 15,376 index neonatal operations from 112 centers. Overall, 18.8% (2,894 of 15,376) of operations were performed in neonates with NC/GA/S. Patients with atrioventricular septal defect (212 of 357 [59.4%]), interrupted aortic arch (248 of 567 [43.7%]), truncus arteriosus (204 of 554 [36.8%]), and tetralogy of Fallot (417 of 1,383 [30.2%]) had the highest prevalence of NC/GA/S abnormalities, whereas those with transposition of the great arteries (111 of 2,778 [4.0%]) had the lowest prevalence. The most commonly identified NC/GA/S included heterotaxy (597 of 15,376 [3.9%]), DiGeorge syndrome or 22q11 deletion (550 of 15,376 [3.6%]), Down syndrome or trisomy 21 (318 of 15, 376 [2.1%]), intestinal malrotation (220 of 15,376 [1.4%]), and Turner syndrome or 45XO (189 of 15,376 [1.2%]). Conclusions The prevalence of NC/GA/S varies widely across CHD diagnostic groups. This information may be useful for patient counseling, recommendations for screening for anomalies and genetic disorders, and perioperative management.

Robotic technology is one of the most recent technological changes in coronary artery bypass graft (CABG) operations. The current analysis was conducted to identify trends in the use and outcomes of robotic-assisted CABG (RA-CABG).A retrospective analysis was performed using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2006 and 2012. Patient and site-level characteristics were compared between traditional CABG and RA-CABG. Operative death, postoperative length of stay, and postoperative complications were compared between the two groups.The number of sites using RA-CABG remained relatively constant during the study period (from 148 in 2006 to 151 in 2012). The volume of RA-CABG as a percentage of the total CABG procedures increased slightly from 0.59% (872 RA-CABG of 127,717 total CABG) in 2006 to 0.97% (1,260 RA-CABG of 97,249 total CABG) in 2012. The RA-CABG patients were significantly younger (64 vs 65 years, p0.0001), had fewer comorbidities, and had lower rates of cardiopulmonary bypass use (22.4% vs 80.4%, p0.0001). RA-CABG patients had significantly lower unadjusted major complication rates (10.2% vs 13.5%, p0.0001), including postoperative renal failure (2.2% vs 2.9%, p 0.0001), and shorter length of stay (4 vs 5 days, p 0.0001). The difference in operative death was not significant (odds ratio, 1.10; 95% confidence interval, 0.92 to 1.30, p = 0.29).RA-CABG use remained relatively stagnant during the analysis period despite lower rates of major perioperative complications and no difference in operative deaths. Additional analysis is needed to fully understand the role that robotic technology will play in CABG operations in the future.

Information concerning tracheostomy after operations for congenital heart disease has come primarily from single-center reports. We aimed to describe the epidemiology and outcomes associated with postoperative tracheostomy in a multi-institutional registry.The Society of Thoracic Surgeons Congenital Heart Database (2000 to 2014) was queried for all index operations with the adverse event "postoperative tracheostomy" or "respiratory failure, requiring tracheostomy." Patients with preoperative tracheostomy or weighing less than 2.5 kg undergoing isolated closure of patent ductus arteriosus were excluded. Trends in tracheostomy incidence over time from January 2000 to June 2014 were analyzed with a Cochran-Armitage test. The patient characteristics associated with operative mortality were analyzed for January 2010 to June 2014, including deaths occurring up to 6 months after transfer of patients to long-term care facilities.From 2000 to 2014, the incidence of tracheostomy after operations for congenital heart disease increased from 0.11% in 2000 to a high of 0.76% in 2012 (p 0.0001). From 2010 to 2014, 648 patients underwent tracheostomy. The median age at operation was 2.5 months (25th, 75th percentile: 0.4, 7). Prematurity (n = 165, 26%), genetic abnormalities (n = 298, 46%), and preoperative mechanical ventilation (n = 275, 43%) were common. Postoperative adverse events were also common, including cardiac arrest (n = 131, 20%), extracorporeal support (n = 87, 13%), phrenic or laryngeal nerve injury (n = 114, 18%), and neurologic deficit (n = 51, 8%). The operative mortality was 25% (n = 153).Tracheostomy as an adverse event of operations for congenital heart disease remains rare but has been increasingly used over the past 15 years. This trend and the considerable mortality risk among patients requiring postoperative tracheostomy support the need for further research in this complex population.

Aim: To assess the utility of using external databases for quality improvement (QI) evaluations in the context of an innovative QI collaborative aimed to reduce three infections and improve patient safety across the cardiac surgery service line. Methods: We compared changes in each outcome between 15 intervention hospitals (infection reduction protocols plus safety culture intervention) and 52 propensity score-matched hospitals (feedback only). Results: Improvement trends in several outcomes among the intervention hospitals were not statistically different from those in comparison hospitals. Conclusion: Using external databases such as those of professional societies may permit comparative effectiveness assessment by providing concurrent comparison groups, additional outcome measures and longer follow-up. This can better inform evaluation of continuous QI in healthcare organizations.

OBJECTIVESMulti-arterial bypass grafting with bilateral internal thoracic (BITA-MABG) or radial (RA-MABG) arteries improves long-term survival, but its increased complexity raises perioperative safety concerns. We compared perioperative outcomes of RA-MABG and BITA-MABG using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD).METHODSWe analysed the 2004–2015 BITA-MABG and RA-MABG experience in STS-ACSD. Primary end points were operative mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios [AOR (95% confidence interval)] were derived via multivariable logistic regression. Sensitivity analyses were done in patient sub-cohorts and based on institutional BITA-utilization rates (40%).RESULTSEighty-five thousand nine hundred five RA-MABG (82.5% men; 61 years) and 61 336 BITA-MABG (85.1% men; 59 years) patients were analysed; 41.6% of BITA-MABG and 27.3% of RA-MABG cases came from institutions with low MABG utilization rates (20% of all cases for OM and ≥40% for DSWI.CONCLUSIONSThis analysis of the STS-ACSD showed that RA-MABG is a generally safer form of multi-arterial coronary artery bypass grafting surgery. However, this advantage is mitigated at institutions with substantial BITA experience.

There has not been a multicenter investigation to elucidate the prevalence and impact of congenital diaphragmatic hernia (CDH) on children undergoing cardiac surgery. We investigated the prevalence of CDH across congenital cardiac diagnostic and procedural groups and its impact on outcomes. The STS Congenital Heart Surgery Database was queried to identify children undergoing cardiac surgery who also had CDH. Baseline perioperative characteristics and postoperative outcomes were compared between groups. Subgroup analyses were performed based on case complexity as determined by STAT Categories. Overall 426 of 157,419 (0.27%) pediatric patients undergoing an index cardiac operation had a diagnosis of CDH including 89 neonates (0.25% of all neonatal index operations), 217 infants (0.39%), and 120 children (0.18%). The frequency of concomitant CDH varied across diagnostic groups and, in neonates and infants, was highest for tetralogy of Fallot (0.45%, n = 41), coarctation (0.39%, n = 27) and complete atrioventricular septal defects (0.31%, n = 19). For neonates and infants outcomes were generally worse in CDH vs no-CDH patients across the various procedural strata. For example, STAT ≥3 operative mortality was 34.4% vs 10.3% ( P0.001) for neonates, and 24.2% vs 5.3% ( P0.001) for infants with vs without CDH, respectively. In older children, outcomes disparities were less clear cut with no significant differences in mortality, and variable differences for complication and length of stay outcomes. CDH occurs in a small percentage of patients born with congenital heart disease. Concomitant diagnosis of CDH portends increased morbidity and mortality in infants and neonates undergoing cardiac surgery.

In adults undergoing cardiopulmonary bypass surgery, oral intubation is typically preferred over nasal intubation due to reduced risk of sinusitis and infection. In children, nasal intubation is more common and sometimes preferred due to perceived benefits of less postoperative sedation and a lower risk for accidental extubation. This study sought to describe the practice of nasal intubation in the pediatric population undergoing cardiopulmonary bypass surgery and assess the risks/benefits of a nasal route against an oral one.Patients18 years of age in the Society of Thoracic Surgeons Congenital Heart Surgery Database between January 2010 and December 2015 were included. Patients with a preoperative endotracheal tube, tracheostomy, or known airway anomalies were excluded. Multivariable modeling was used to assess the association between route of tracheal intubation and a composite measure of infection risk (wound infection, mediastinitis, septicemia, pneumonia, and endocarditis). Covariates were included to adjust for important patient characteristics (eg, weight, age, comorbidities), case complexity, and center effects. Secondary outcomes included length of intubation, hospital length of stay, and airway complications including accidental extubations. We also performed a subanalysis in children12 months of age in high-volume centers (100 cases/y) examining how infection risk may change with age at the time of surgery.Nasal intubation was used in 41% of operations in neonates, 38% in infants, 15% in school-aged children, and 2% in adolescents. Nasal intubation appeared protective for accidental extubation only in neonates (P = .02). Multivariable analysis in infants and neonates showed that the nasal route of intubation was not associated with the infection composite (relative risk [RR], 0.84; 95% CI, 0.59-1.18) or a shorter length of stay (RR, 0.992; 95% CI, 0.947-1.039), but was associated with a shorter intubation length (RR, 0.929; 95% CI, 0.869-0.992). Restricting to high-volume centers showed a significant interaction between age and intubation route with a risk change for infection occurring between approximately 6-12 months of age (P = .003).While older children undergoing nasal intubation trend similar to the adult population with an increased risk of infection, nasal intubation in neonates and infants does not appear to carry a similar risk. Nasal intubation in neonates and infants may also be associated with a shorter intubation length but not a shorter length of stay. Prospective studies are required to better understand these complex associations.

Since 2010, 460+ hospital mergers have occurred in the United States, rerouting historical coronary artery bypass graft (CABG) referral patterns. The goals of this study were: (1) to compare risk-adjusted CABG outcomes between single-center versus multicenter surgeons; and (2) for multicenter surgeons, to evaluate the risk-adjusted outcomes between their home (primary) versus satellite (secondary) hospitals.Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, nonemergent, first-time CABG procedures (n = 543,403) performed in the US between 2011 and 2014 were extracted across 1,120 centers and for 2,676 surgeons. Surgeons were classified as multicenter if they performed operations at two separate hospitals for ≥ 2 consecutive quarters; their home hospital was identified as their highest volume center. Observed-to-expected outcome ratios were reported using approved multivariable risk models for 30-day operative mortality and major morbidity.Of 2,676 cardiac surgeons, 668 (25.0%) operated at multiple centers. The observed-to-expected mortality ratios were 1.06 (95% confidence interval [CI], 1.01 to 1.12) and 0.97 (95% CI, 0.94 to 1.00) for multi- and single-center surgeons (p0.001). For multicenter surgeons, the observed-to-expected mortality ratios were 1.17 (95% CI, 1.09 to 1.27) versus 1.01 (95% CI, 0.96 to 1.07), p 0.001, for their satellite versus home facilities, respectively.Single-center surgeons performing CABG had lower risk-adjusted outcome rates compared with multicenter surgeons, who performed better at their home versus satellite hospitals. To improve future quality of care, surgeons, health care networks, and health policy makers should now more closely scrutinize their single versus multicenter performance.

Background— Surgeon experience concerns both families of children with congenital heart disease and medical providers. Relationships between surgeon seniority and patient outcomes are often assumed, yet there are little data. Methods and Results— This national study used linked data from the American Medical Association Physician Masterfile and the Society of Thoracic Surgeons-Congenital Heart Surgery Database to examine associations between surgeon years since medical school and major morbidity/mortality for children undergoing cardiac surgery. Sensitivity analyses explored the effects of patient characteristics, institutional/surgeon volumes, and various measures of institutional surgeon team experience. In secondary analyses, major morbidity and mortality were examined as separate end points. We identified 206 congenital heart surgeons from 91 centers performing 62 851 index operations (2010–2014). Median time from school was 25 years (range 9–55 years). A major morbidity/mortality occurred in 11.5% of cases. In multivariable analyses, the odds of major morbidity/mortality were similar for early-career ( Conclusions— In this study of >200 congenital heart surgeons, we found patient outcomes for surgeons with the fewest years of experience to be comparable to those of their midcareer and senior colleagues, within the context of existing referral and support practices. Very senior surgeons had higher risk-adjusted odds of major morbidity/mortality. Contemporary approaches to training, referral, mentoring, surgical planning, and other support practices might contribute to the observed outcomes of junior congenital heart surgeons being comparable to those of more experienced colleagues. Understanding and disseminating these practices might benefit the medical community at large.

ObjectiveControversy surrounds the effect of hypothermia on operative mortality during cardiac surgery. The present study accessed a large clinical database of coronary artery bypass graft operations to address the issue.MethodsA retrospective review of the Society of Thoracic Surgeons Adult Cardiac Surgery Database identified patients treated with isolated, nonemergency, on-pump coronary artery bypass grafting from July 2011 to December 2012. The patients were divided into 3 groups according to their lowest core temperature during the procedure: moderate hypothermia (≤34°C), mild hypothermia (>34°C but ≤36°C), and normothermia (>36°C). The primary endpoint of the study was operative mortality, defined according to the Database criteria.ResultsDuring the study period, 142,541 patients were available for analysis; 94,777 (66.5%) received moderate hypothermia, 42,750 (30.3%) mild hypothermia, and 5014 (3.5%) normothermia. Operative mortality occurred in 1394 patients (1.5%) in the moderate hypothermia, 534 (1.3%) in the mild hypothermia, and 105 (2.1%) in the normothermia group. Multivariate analysis identified hypothermia (both mild [odds ratio, 0.66; 95% confidence interval, 0.54-0.81; P

Background Performance assessment in congenital heart surgery is challenging due to the wide heterogeneity of disease. We describe current case mix across centers, evaluate methodology inclusive of all cardiac operations versus the more homogeneous subset of Society of Thoracic Surgeons benchmark operations, and describe implications regarding performance assessment. Methods Centers (n = 119) participating in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 through 2014) were included. Index operation type and frequency across centers were described. Center performance (risk-adjusted operative mortality) was evaluated and classified when including the benchmark versus all eligible operations. Results Overall, 207 types of operations were performed during the study period (112,140 total cases). Few operations were performed across all centers; only 25% were performed at least once by 75% or more of centers. There was 7.9-fold variation across centers in the proportion of total cases comprising high-complexity cases (STAT 5). In contrast, the benchmark operations made up 36% of cases, and all but 2 were performed by at least 90% of centers. When evaluating performance based on benchmark versus all operations, 15% of centers changed performance classification; 85% remained unchanged. Benchmark versus all operation methodology was associated with lower power, with 35% versus 78% of centers meeting sample size thresholds. Conclusions There is wide variation in congenital heart surgery case mix across centers. Metrics based on benchmark versus all operations are associated with strengths (less heterogeneity) and weaknesses (lower power), and lead to differing performance classification for some centers. These findings have implications for ongoing efforts to optimize performance assessment, including choice of target population and appropriate interpretation of reported metrics.

Background: Regional cerebral perfusion (RCP) is used as an adjunct or alternative to deep hypothermic circulatory arrest (DHCA) for neonates and infants undergoing aortic arch repair. Clinical studies have not demonstrated clear superiority of either strategy, and multicenter data regarding current use of these strategies are lacking. We sought to describe the variability in contemporary practice patterns for use of these techniques. Methods: The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010-2013) was queried to identify neonates and infants whose index operation involved aortic arch repair with cardiopulmonary bypass. Perfusion strategy was classified as isolated DHCA, RCP (with less than or equal to ten minutes of DHCA), or mixed (RCP with more than ten minutes of DHCA). Data were analyzed for the entire cohort and stratified by operation subgroups. Results: Overall, 4,523 patients (105 centers) were identified; median age seven days (interquartile range: 5.0-13.0). The most prevalent perfusion strategy was RCP (43%). Deep hypothermic circulatory arrest and mixed perfusion accounted for 32% and 16% of cases, respectively. In all, 59% of operations involved some period of RCP. Regional cerebral perfusion was the most prevalent perfusion strategy for each operation subgroup. Neither age nor weight was associated with perfusion strategy, but reoperations were less likely to use RCP (31% vs 45%, P < .001). The combined duration of RCP and DHCA in the RCP group was longer than the DHCA time in the DHCA group (45 vs 36 minutes, P < .001). Conclusion: There is considerable variability in practice regarding perfusion strategies for arch repair in neonates and infants. In contemporary practice, RCP is the most prevalent perfusion strategy for these procedures. Use of DHCA is also common. Further investigation is warranted to ascertain possible relative merits of the various perfusion techniques.

Patients undergoing coronary artery bypass grafting (CABG) are at risk for a variety of infections. Investigators have focused on predictors of these adverse sequelae, but less attention has been focused on characterizing hospital-level variability in these outcomes.Between July 2011 and December 2013, The Society of Thoracic Surgeons Adult Cardiac Surgery Database shows 365,686 patients underwent isolated CABG in 1,084 hospitals. Hospital-acquired infections (HAIs) were defined as pneumonia, sepsis/septicemia, deep sternal wound infection/mediastinitis, vein harvest/cannulation site infection, or thoracotomy infection. Hospitals were ranked by their HAI rate as low (≤ 10th percentile), medium (10th to 90th percentile), and high (90th percentile). Differences in perioperative factors and composite morbidity and mortality end points across these groups were determined using the Wilcoxon rank sum and χ(2) tests.HAIs occurred among 3.97% of patients overall, but rates varied across hospital groups (low:0.84%, medium: 0.84% to 8.41%, high:8.41%). Pneumonia (2.98%) was the most common HAI, followed by sepsis/septicemia (0.84%). Patients at high-rate hospitals more often smoked, had diabetes, chronic lung disease, New York Heart Association Functional Classification III to IV, and received blood products (p0.001); however, they less often were prescribed the appropriate antibiotics (p0.001). Major morbidity and mortality occurred among 12.3% of patients, although this varied by hospital group (low: 8.6%, medium: 12.3%, high: 17.9%; p0.001).Substantial hospital-level variation exists in postoperative HAIs among patients undergoing CABG, driven predominantly by pneumonia. Given the relatively small absolute differences in comorbidities across hospital groups, our findings suggest factors other than case mix may explain the observed variation in HAI rates.

Background As less invasive alternatives to surgical pulmonary valve replacement (PVR) are being refined and evaluated, there is a need for benchmark data concerning outcomes from surgical PVR. Methods We examined in-hospital outcomes from surgical PVR in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and Adult Cardiac Surgery Database (STS-ACSD) between 2007 and 2013, with a focus on patients likely to be eligible for transcatheter PVR (ie, ≥ 5 years age and ≥ 30 kg). Patient characteristics, morbidity, and mortality were described. Results The STS-CHSD included 6,431 eligible patients with a median age of 17 years (interquartile range [IQR], 14–25 years). Preoperative comorbidities were uncommon: arrhythmia (1.7%), renal failure (0.1%), endocarditis (0.3%), neurologic deficit (0.8%), and diabetes (0.5%). In-hospital mortality was 0.9%. A major complication occurred in 2.2%. The STS-ACSD included 3,352 eligible patients; the median age was 41 years (IQR, 30–55 years). Preoperative comorbidities were more common: arrhythmia (24.3%), renal failure (3.8%), endocarditis (12.2%), cerebrovascular disease (7.9%), and diabetes (10.9%). In-hospital mortality was 4.1%. A major complication occurred in 20.9%. Conclusions Contemporary outcomes from surgical PVR include a low risk of in-hospital death or major complications. Patients in the STS-ACSD are older and have an increased prevalence of preoperative factors, which may contribute to higher morbidity and mortality.

Background Ebstein's malformation is a rare congenital cardiac anomaly. Available data are limited to individual reports demonstrating highly variable approaches. We sought to understand the spectrum of surgical treatment of Ebstein's anomaly across institutions. Methods A retrospective review of surgical procedures performed on patients with primary diagnosis of Ebstein's malformation (2002 through 2009) in The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) was conducted. Results A total of 595 operations on 498 patients with Ebstein's anomaly were included: 116 on neonates (19%), 122 on infants (21%), 264 on children (44%), and 93 on adults (16%). Average annual institutional case volumes were low (median, 1 per year; range, 0 to 8 per year). Neonates had a high rate of palliative procedures: systemic-to-pulmonary artery shunts with or without tricuspid valve closure (43; 37.1%) and tricuspid valve closure (10; 8.6%); Ebstein's repair or tricuspid valvuloplasty was performed in 32%. The most common procedures among infants were superior cavopulmonary connections (62; 50.8%) and systemic-to-pulmonary shunt (10; 8.2%). Among older patients, procedures were primarily in three categories: tricuspid valve surgery (children, 54.5%; adults, 68.8%), arrhythmia procedures (children, 8.7%; adults, 17.3%), and Fontan (children, 14.8%). In-hospital mortality was high in neonatal patients (23.4%) in comparison with infants (4.1%), children (0.7%), and adults (1.1%). Conclusions Surgery for Ebstein's anomaly consists of a wide range of procedures, with low individual institutional volumes. Mortality is highest among neonates. A prospective multicenter inception cohort study would be valuable to better define indications for specific strategies of surgical management.

ObjectivesAnalyses of mechanical circulatory support (MCS) in pediatric heart surgery have primarily focused on single-center outcomes or narrow applications. We describe the patterns of use, patient characteristics, and MCS-associated outcomes across a large multicenter cohort.MethodsPatients (aged 70% for some operations. Future studies aimed at better understanding the appropriate indications, optimal timing, and management of MCS could help to reduce the variation in MCS use across hospitals and improve outcomes.