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To compare frailty, QOL and 90-day cost of treatment between patients who underwent surgery or SBRT for early stage NSCLC and identify objective parameters that could aide treatment selection and shared decision-making. Data from treatment naïve adult patients newly diagnosed with early stage NSCLC was collected prospectively. Combined decision on treatment option was based on multidisciplinary clinical assessment and patient preference. Demographics, PFT, NSQIP risk scores were collected. Frailty index score ≥3 was considered frail. Cancer specific QOL questionnaires QLQ-C30/QLQ-LC13/mMRC were administered. Patients were more likely to undergo SBRT if frail (OR-4.92), required functional assistance (IADL, OR-5.01), had pre-clinical morbidity/disability (OR-3.48), worse mobility (TUG test, OR-4.04) or poor nutritional status (MNA, OR- 2.18). Multivariate modeling demonstrated that an increase in NSQIP estimated risk of death (OR=12.60), higher frailty index (OR - 4.80) and decreasing FEV1% increased the probability of receiving SBRT. More surgery patients had complications (41% vs 17%, p<0.05). OS estimates at six months, one and two-years for surgery was 99.1%, 97.3% and 90.7% vs 95.7%, 86.2 and 70.1% for SBRT (p<0.05), respectively. RFS at one and two-year for surgery was 95.1% and 81.5% vs 88.2% and 64.8% for SBRT (p<0.05). Among QOL measures in the surgical cohort, the change in physical functioning, fatigue and dyspnea scores declined over the two-year period from baseline. There was no change from baseline in QOL measures with SBRT. At two-years the change in QOL measure was similar between the cohorts, except change in role functioning was significantly lower in SBRT patients. Median 90-day treatment-related Medicare/Medicaid costs were lower in SBRT $11,188 vs surgery $15,018 (p<0.05). In patients without major complications, treatment related costs were similar between SBRT and surgery ($11,188 vs $11,846, p<0.05). Frailty assessment, when used as part of a multifactorial risk model inclusive of increased comorbidities, higher pack year history, poor pulmonary function, and increased NSQIP risk, helped to identify patients selected for SBRT. While QOL did not differ, OS and RFS declined significantly with SBRT at 2 years in this unmatched comparison. Future longitudinal registries with long-term follow-up are needed to provide better discriminatory ability regarding the treatment impact on QOL and to develop robust treatment selection criteria. [ABSTRACT FROM AUTHOR]

Purpose: We assessed low-dose computed tomography (LDCT) screening for lung cancer using a proactive patient education/recruitment program., Methods: We identified patients aged 55-80 years from a family medicine group. In the retrospective phase (March-August, 2019), patients were categorized as current/former/never smokers, and screening eligibility was determined. Patients who underwent LDCT in the past year, along with outcomes, were documented. In the prospective phase (2020), patients in the same cohort who did not undergo LDCT were proactively contacted by a nurse navigator to discuss eligibility and prescreening. Eligible and willing patients were referred to their primary care physician., Results: In the retrospective phase, of 451 current/former smokers, 184 (40.8%) were eligible for LDCT, 104 (23.1%) were ineligible, and 163 (36.1%) had an incomplete smoking history. Of those eligible, 34 (18.5%) had LDCT ordered. In the prospective phase, 189 (41.9%) were eligible for LDCT (150 [79.4%] of whom had no prior LDCT or diagnostic CT), 106 (23.5%) were ineligible, and 156 (34.6%) had an incomplete smoking history. The nurse navigator identified an additional 56/451 (12.4%) patients as eligible after contacting patients with incomplete smoking history. In total, 206 patients (45.7%) were eligible, an increase of 37.3% compared with the retrospective phase (150). Of these, 122 (59.2%) verbally agreed to screening, 94 (45.6%) met with their physician, and 42 (20.4%) were prescribed LDCT., Conclusions: A proactive education/recruitment model increased eligible patients for LDCT by 37.3%. Proactive identification/education of patients desiring to pursue LDCT was 59.2%. It is essential to identify strategies that will increase and deliver LDCT screening among eligible and willing patients., (© 2023 Annals of Family Medicine, Inc.)

Background: The objective of this single-blind randomized study is to compare local infiltration of bupivacaine or liposomal bupivacaine (LipoB) in narcotic naïve patients undergoing minimally invasive lobectomy for early stage lung cancer., Methods: Adult patients without previous lung surgery undergoing minimally invasive lobectomy (robotic or thoracoscopic) for early stage lung cancer were randomly assigned to bupivacaine (with epinephrine 0.25%, 1:200 000) or LipoB 1.3%. Pain level was documented using the visual analog scale and morphine equivalents for narcotic pain medications. Inhospital treatment cost and pharmacy cost were compared., Results: The study enrolled 50 patients (bupivacaine, 24; LipoB, 26). The mean age of patients was 66 years, 94% were non-Hispanic white, and 48% were male. There was no difference in baseline characteristics and comorbidities. Duration of surgery (105 vs 137 minutes, P = .152), chest tube duration (49 vs 55 hours, P = .126), and length of stay (2.45 vs 3.28 days, P = .326) were similar between treatments. Inhospital morphine equivalents were 42.7 mg vs 48 mg (P = .714), and the median pain score was 5.2 vs 4.75 (P = .602) for bupivacaine vs LipoB, respectively. There was no difference in narcotic use at 2 to 4 weeks (57.1% [12 of 21] vs 54.5% [12 of 22], P = 1.00), and at 6 months (5.9% [1 of 17] vs 9.5% [2 of 21], P = 1.00) after surgery. The overall cost ($20 252 vs $22 775, P = .225) was similar; however, pharmacy cost for LipoB was higher ($1052 vs $596, P = .0001)., Conclusions: In narcotic naïve patients undergoing minimally invasive lobectomy, short-term narcotic use, postoperative pain scores, length of stay, and long-term narcotic use were similar between bupivacaine and LipoB., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Historically, pulmonary hypertension (PH) has been considered as one of the contraindications for lung volume reduction surgery (LVRS). Newer studies have shown that LVRS is successful in select emphysema patients with PH., Methods: In-hospital and 1-year functional and quality of life (QOL) outcomes were studied in patients with PH post-LVRS. PH was defined as pulmonary artery pressure (PAP) exceeding 35 mm Hg by right heart catheterization (RHC), where available, or else exceeding 35 mm Hg by echocardiogram., Results: Of 124 patients who underwent LVRS, 56 (45%) had PH (mean PAP, 41 mm Hg) with 48 mild to moderate and 8 severe PH. In-hospital outcomes were similar between patients with and without PH: hours of artificial ventilation (1.8 vs 0.06, P = .882), days in intensive care (4 vs 6, P = .263), prolonged air leak (12% vs 19%, P = .402), and days of hospital stay (13 vs 16, P = .072). Lung function improved significantly at the 1-year follow-up in patients with PH: forced expiratory volume in 1 second % predicted (26 vs 38, P = .001), forced vital capacity % (62 vs 90, P = .001), residual volume % predicted (224 vs 174, P = .001), diffusion capacity of the lung for carbon monoxide % predicted (36 vs 43, P = .001), 6-minute walk distance test (1104 vs 1232 feet, P = .001), and QOL utility scores (0.67 vs 0.77, P = .001). There were no differences in in-hospital, baseline, and follow-up functional and QOL outcomes between patients with and without PH., Conclusions: In this small, single-institution cohort, outcomes of patients undergoing LVRS for emphysema with PH were similar to those of patients without PH. LVRS may be a potential option for select emphysema patients with PH., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Air leaks are common after lobectomy, segmentectomy, and lung volume reduction surgery (LVRS). This can increase post-operative morbidity, cost, and hospital length of stay. The management of post-pulmonary resection air leaks remains challenging. Minimally invasive effective interventions are necessary. The Spiration Valve System (SVS, Olympus/Spiration Inc., Redmond, WA, US) is approved by the FDA under humanitarian use exemption for management of prolonged air leaks., Methods: This is a prospective multicenter registry of 39 patients with air leaks after lobectomy, segmentectomy, and LVRS managed with an intention to use bronchoscopic SVS to resolve air leaks., Results: Bronchoscopic SVS placement was feasible in 82.1% of patients (32/39 patients) and 90 valves were placed with a median of 2 valves per patient (mean of 2.7 ± 1.5 valves, range of 1 to 7 valves). Positive response to SVS placement was documented in 76.9% of all patients (30/39 patients) and in 93.8% of patients when SVS placement was feasible (30/32 patients). Air leaks ultimately resolved when SVS placement was feasible in 87.5% of patients (28/32 patients), after a median of 2.5 days (mean ± SD of 8.9 ± 12.4 days). Considering all patients with an intention to treat analysis, bronchoscopic SVS procedure likely contributed to resolution of air leaks in 71.8% of patients (28/39 patients). The post-procedure median hospital stay was 4 days (mean 6.0 ± 6.1 days)., Conclusions: This prospective registry adds to the growing body of literature supporting feasible and effective management of air leaks utilizing one-way valves.

Background: Lung volume reduction surgery (LVRS) is the definitive treatment for patients with severe emphysema. There is still a need for long-term data concerning the outcomes of this procedure. This study presents long-term longitudinal data on LVRS including correlation of quality of life (QOL) with pulmonary function testing metrics and includes additional analysis of patients with heterogeneous and homogeneous emphysema., Methods: Retrospective analysis of data collected from patients undergoing LVRS over a 9-year period at a single center was performed (N = 93). Pulmonary function and 6-minute walk tests as well as QOL questionnaires were administered before and 1 year after surgery. Descriptive statistics were reported for clinical outcomes and QOL indices. Wilcoxon signed-rank tests were used to examine changes from baseline to end of 1-year follow-up. Spearman correlation coefficients were used to evaluate relationships between clinical and QOL outcomes., Results: At 1-year post surgery, mean forced vital capacity (46%, P ≤ .0001), forced expiratory volume (43%, P ≤ .0001), diffusing capacity of the lungs for carbon monoxide (16%, P ≤ .0001), and 6-minute walk distance (20%, P ≤ .0001) were increased from baseline, while residual volume decreased (23%, P ≤ .0001). There was a positive correlation between changes in QOL and forced expiratory volume, forced vital capacity, and, 6-minute walk distance. Patients having heterogeneous disease had greater improvements in forced expiratory volume, forced vital capacity, residual volume, and diffusing capacity of the lungs for carbon monoxide, and greater QOL compared with patients with homogeneous disease., Conclusions: LVRS continues to be a valuable treatment option for patients with advanced emphysema with reproducible improvements in clinical and QOL metrics. Careful patient selection and optimization prior to surgery are crucial to successful outcomes., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: Lung volume reduction surgery (LVRS) has been shown to improve lung function, but also improve the overall quality of life (QOL). The aim of this study is to compare two QOL questionnaires-EuroQol Questionnaire (EQ-5D-3L) and 36-item Short Form Health Survey (SF-36) in patients post-LVRS., Methods: All patients undergoing LVRS for severe chronic obstructive pulmonary disease (COPD) at a single center of excellence were analyzed (n = 94). Baseline demographic and clinical outcomes were characterized. Both EQ-5D-3L and SF-36 questionnaires were administered to all patients at baseline (n = 94) and at the end of 1 year (n = 89) post-surgery. SF-36 was converted to Short Form six-dimensions (SF-6D) using standard algorithm. Correlation, discrimination, responsiveness and differences across the two questionnaires were examined., Results: The mean age of patients enrolled in the cohort was 66 years. There was significant increase in forced expiratory volume (FEV1, 43%), forced vital capacity (FVC 46%), diffusion capacity (DLCO 15%), 6 min walk distance test (6MWD 21%) and a significant decrease in residual volume (RV 23%) at the end of 1-year follow-up. The overall mean utility index significantly improved for both SF-6D and EQ-5D-3L questionnaires at the end of follow-up (p = 0.0001). However, the magnitude of percentage increase was higher with EQ-5D-3L compared to SF-6D (32% vs. 13%). Stronger correlations confirmed convergent validity at the end of 1-year follow-up between similar domains. Both questionnaires failed to discriminate between different levels of disease severity post-LVRS in patients with severe COPD., Conclusions: Both questionnaires responded similarly in patients with COPD post-LVRS. Combining results from QOL questionnaire(s) along with symptoms of disease and history of exacerbation may be a possible solution for identifying disease severity in old and sick patients unwilling/unable to come to hospital for a pulmonary function test post-LVRS.

Rationale: This is the first multicenter randomized controlled trial to evaluate the effectiveness and safety of Zephyr Endobronchial Valve (EBV) in patients with little to no collateral ventilation out to 12 months., Objectives: To evaluate the effectiveness and safety of Zephyr EBV in heterogeneous emphysema with little to no collateral ventilation in the treated lobe., Methods: Subjects were enrolled with a 2:1 randomization (EBV/standard of care [SoC]) at 24 sites. Primary outcome at 12 months was the ΔEBV-SoC of subjects with a post-bronchodilator FEV 1 improvement from baseline of greater than or equal to 15%. Secondary endpoints included absolute changes in post-bronchodilator FEV 1 , 6-minute-walk distance, and St. George's Respiratory Questionnaire scores., Measurements and Main Results: A total of 190 subjects (128 EBV and 62 SoC) were randomized. At 12 months, 47.7% EBV and 16.8% SoC subjects had a ΔFEV 1 greater than or equal to 15% (P < 0.001). ΔEBV-SoC at 12 months was statistically and clinically significant: for FEV 1 , 0.106 L (P < 0.001); 6-minute-walk distance, +39.31 m (P = 0.002); and St. George's Respiratory Questionnaire, -7.05 points (P = 0.004). Significant ΔEBV-SoC were also observed in hyperinflation (residual volume, -522 ml; P < 0.001), modified Medical Research Council Dyspnea Scale (-0.8 points; P < 0.001), and the BODE (body mass index, airflow obstruction, dyspnea, and exercise capacity) index (-1.2 points). Pneumothorax was the most common serious adverse event in the treatment period (procedure to 45 d), in 34/128 (26.6%) of EBV subjects. Four deaths occurred in the EBV group during this phase, and one each in the EBV and SoC groups between 46 days and 12 months., Conclusions: Zephyr EBV provides clinically meaningful benefits in lung function, exercise tolerance, dyspnea, and quality of life out to at least 12 months, with an acceptable safety profile in patients with little or no collateral ventilation in the target lobe. Clinical trial registered with www.clinicaltrials.gov (NCT 01796392).

Background and Aim of the Study: Large-scale data of heart failure (HF) readmission after aortic valve replacement (AVR) are limited., Methods: A total of 40,751 Medicare beneficiaries >65 years who underwent primary isolated AVR between 2000 and 2004 were included in the study. Preoperative HF was defined using ICD-9-CM diagnostic codes from the index admission and any hospitalization during the preceding year. Cumulative readmission incidences over five years were computed for those patients with and without preoperative HF, while adjusting for propensity scores., Results: The median patient age was 76 years. At 30 days, all-cause readmission was 21.5% and HF readmission was 3.9%. Patients with preoperative HF had higher postoperative HF readmission rates compared to those without (30 days, 6.3% versus 2.2%; one year, 13.9% versus 4.4%; five years, 6.6% versus 10.3%, p = 0.0001). The incremental risk of HF on readmission was >2 following adjustment. In patients with preoperative HF, the number of admissions was associated with increased postoperative HF readmissions. At 30 days, patients with no preoperative HF admissions had a HF readmission rate of 5.3%, while those with one, two, three and four or more preoperative HF admissions had rates of 8.2%, 11.9%, 13.8% and 17.4%, respectively. This trend persisted over the five-year follow up period., Conclusions: Postoperative HF readmission accounted for about one-fifth of all-cause readmissions after AVR in Medicare beneficiaries. Preoperative HF significantly contributed to postoperative readmission, both all-cause and HF-specific, which likely limits the symptomatic benefit of surgery. These data support early aortic valve intervention prior to the development of clinically apparent HF.

Background: This study was designed to examine the effect of hospital procedural volume on outcomes in aortic valve replacement (AVR) in the elderly., Methods: The study included 277,928 Medicare beneficiaries who underwent AVR from 2000 through 2009 at one of 1,255 participating hospitals. Operative mortality and the use of mechanical prostheses were analyzed according to hospital annual procedural volume. Annual AVR volume was divided into 5 different categories: the smallest volume group with less than 10 AVRs per year to the largest group averaging more than 70 AVRs per year., Results: The overall observed operative mortality rate was 7.3%; for isolated AVR it was 5.5%. Lower-volume hospitals exhibited increased adjusted operative mortality: 10 cases or fewer per year--odds ratio (OR), 1.55; 95% confidence interval (CI), 1.39 to 1.72; 11 to 20 cases per year--OR, 1.35; 95% CI, 1.23 to 1.47; 21 to 40 cases per year--OR, 1.15; 95% CI, 1.06 to 1.25; 41 to 70 cases per year--OR, 1.10; 95% CI, 1.01 to 1.20 relative to those hospitals performing more than 70 cases per year. The discrepancy in operative mortality between low- and high-volume hospitals diverged during the study. Mechanical valve use decreased with increasing hospital volume (p = 0.0001). Mechanical valves were used in 64.5% of AVRs in hospitals with an annual AVR volume less than 10 in contrast to only 25.4% in hospitals with an annual AVR volume more than 70. After adjustment, the use of mechanical valves was independently associated with increased operative mortality (OR, 1.15; 95% CI, 1.11-1.19)., Conclusions: Low-volume centers were characterized by increased adjusted operative mortality and greater use of mechanical prostheses, a trend that persisted during the 10-year course of the study. These data would support the center-of-excellence concept for AVR and may be particularly relevant in the elderly population., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Accurate risk assessment in patients presenting for aortic valve replacement (AVR) after prior coronary artery bypass grafting (CABG) is essential for appropriate selection of surgical versus percutaneous therapy., Methods: We included 6,534 patients in The Society for Thoracic Surgeons (STS) Adult Cardiac Surgery Database (October 2009 through December 2013) who underwent elective, isolated reoperative AVR for aortic stenosis after prior CABG. Case-specific PROM was calculated and observed-to-expected ratios were inspected across the spectrum of risk. A cohort-specific recalibration equation was derived using logistic regression: = expit(-0.6453+0.6147*logit(PROM) -0.0709*logit(PROM)(ˆ)2), where PROM is the predicted risk of mortality. The proportion of patients reclassified as low (PROM < 4%), intermediate (4% to < 8%), high (8% to < 12%), and very high risk (≥ 12%) was calculated using the recalibration equation. The performance of the cohort-specific recalibration equation was then compared with the generic recalibration for quarterly STS reports., Results: The STS online risk calculator overestimates risk for low, intermediate, and high risk categories. Using the recalibrated risk equation, a substantial proportion of patients were reclassified as the following: 25.5% from intermediate to low risk; 39.7% from high to intermediate risk; and 41.5% from very high to high risk. Comparison of the cohort-specific recalibration equation to the generic quarterly STS recalibration demonstrated very similar results., Conclusions: In patients presenting for AVR after prior CABG, the STS online risk calculator overestimates risk for all but the highest risk patients. Using a cohort-specific recalibration equation, a substantial proportion of patients would be downgraded to lower risk categories. The cohort-specific recalibration correlates well with the existing generic quarterly STS recalibration. The findings of this study support recommendations for periodic recalibration of the online risk calculator in order to facilitate clinical decision making in real time., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In patients with severe aortic stenosis, the development of heart failure (HF) prior to aortic valve replacement (AVR) is associated with worse prognosis. We sought to quantify the effect of progressive HF on mortality during AVR in the Medicare population over a 10-year period., Methods: Medicare beneficiaries 65 or greater years of age who underwent primary isolated AVR from 2000 through 2009 were included (n = 114,135). Logistic regression and Cox proportional hazards were used to model adjusted operative mortality (OM) and long-term survival, according to the presence of preoperative HF and its duration (≤ 3 vs > 3 months)., Results: The incidence of preoperative comorbidities was high, and it was higher in patients with preoperative HF, compared with those without. Preoperative HF dramatically increased adjusted OM, odds ratio (OR) 1.57 (95% confidence interval [CI], 1.48 to 1.67). Preoperative HF greater than 3 months conferred a significant increase in adjusted OM compared with HF 3 months or less, OR 1.43 (95% CI, 1.32 to 1.55). Similarly, preoperative HF increased the likelihood of long-term mortality by 50%, hazard ratio (HR) 1.48 (95% CI, 1.45 to 1.51). Long-term mortality was higher for patients with longer duration of preoperative HF as compared with those without preoperative HF, HR 1.81 (95% CI, 1.75 to 1.87) and compared with patients with HF 3 months or less, HR 1.26 (95% CI, 1.23 to 1.30)., Conclusions: The magnitude of the negative impact of preoperative HF on operative mortality and long-term survival of elderly patients undergoing primary isolated AVR is significant with 50% increased likelihood of adverse outcome. Duration of preoperative HF is also significantly related to mortality. These data support AVR in the elderly prior to the development of HF., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The volume-outcome relationship has been suggested as a quality metric in mitral valve surgery and would be particularly relevant in the elderly because of their greater burden of comorbidities and higher perioperative risk., Methods and Results: The study included 1239 hospitals performing mitral valve surgery on Medicare beneficiaries from 2000 through 2009. Only 9% of hospitals performed more than 40 mitral operations per year, 29% performed 5 or less, and 51% performed 10 or less. Mitral repair rates were low; 22.7% of hospitals performed 1 or less, 65.1% performed 5 or less, and only 5.6% performed more than 20 mitral repairs per year in those aged 65 years or more. Repair rates increased with increasing volume of mitral operations per year: 5 or less, 30.5%; 6 to 10, 32.9%; 11 to 20, 34.9%; 21 to 40, 38.8%; and more than 40, 42.0% (P = .0001). Hospitals with lower volume had significantly higher adjusted operative mortality compared with hospitals performing more than 40 cases per year: 5 or less cases per year, odds ratio (OR) 1.58 (95% confidence interval [CI], 1.40-1.78); 6 to 10 cases per year, OR 1.29 (95% CI, 1.17-1.43); 11 to 20 cases per year, OR 1.17 (95% CI, 1.07-1.28); 21 to 40 cases per year, OR 1.15 (95% CI, 1.05-1.26). Hospitals with lower mitral repair rates had an increased likelihood of operative mortality relative to the top quartile: lowest quartile, OR 1.31 (95% CI, 1.20-1.44); second quartile, OR 1.18 (95% CI, 1.09-1.29); and third quartile, OR 1.14 (95% CI, 1.05-1.24). Long-term mortality beyond 6 months was also higher in low-volume hospitals: 5 or less cases year, hazard ratio (HR) 1.11 (95% CI, 1.06-1.18); 6 to 10 cases per year, OR 1.06 (95% CI, 1.02-1.10) compared with hospitals performing more than 40 cases per year., Conclusions: Most hospitals perform few mitral valve operations on elderly patients. Greater volume of mitral procedures was associated with higher repair rates. Both greater volume of mitral procedures and increasing mitral repair rates were associated with decreased mortality., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Readmission rates are well established as a quality indicator for heart failure (HF). We analyzed HF readmission rates after mitral valve repair (MVP) and replacement (MVR)., Methods: We included 21,138 Medicare beneficiaries with primary isolated MVP (n=6,896) or MVR (n=14,242) from 2000 through 2004. Readmission rates were identified using MedPar records subsequent to the index procedure during a 5-year follow-up. Treating death as a competing risk, cumulative readmission incidences were analyzed and stratified by presence or absence of preoperative HF., Results: Preoperative HF was present in 61.0% of the patients. All-cause readmission rates were 24.9% at 30 days and 78.0% at 5 years. The cumulative incidence of readmission for HF remained almost 3 times higher in patients with preoperative HF compared with those without for MVP (2.1% vs 5.9% in 30 days and 10.3% vs 26.3% in 5 years) and 2 times higher for MVR (3.6% vs 7.4% in 30 days and 15.8% vs 30.4% in 5 years). Regardless of procedure type, patients without preoperative HF had significantly lower HF readmission rates (3.0% vs 7.0% in the first 30 days and 13.6% vs 29.2% after 5 years) (p=0.0001)., Conclusions: Hospital readmission after mitral surgery is high. Preoperative heart failure is associated with higher postoperative readmission rates. Because admission for heart failure accounts for a significant proportion of these readmissions, close follow-up of patients with known mitral valve disease and referral to surgery prior to development of heart failure may decrease postoperative readmission rates., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Elderly patients are under-represented in most surgical series of mitral valve surgery. The impact of preoperative heart failure (HF) on the outcomes of this subset has not been extensively studied., Methods and Results: The study included 45,082 Medicare beneficiaries who underwent primary isolated mitral valve repair (MVP) (n=16,850) or replacement (MVR) (n=28,232) from 2000 to 2009. Medicare claims from the year before and the year of the index hospitalization were reviewed for documentation of HF to examine the operative mortality and long-term survival of patients with and without preoperative HF. Preoperative HF was present in 52.5% and 64.8% of patients who underwent repair and replacement, respectively. Duration of HF greater than 3 months was present in a significant proportion of patients (18.2% for MVP and 22.7% for MVR). Adjusted operative mortality was higher for patients with preoperative HF (MVP odds ratio [OR], 1.46; 95% confidence interval [CI], 1.21-1.78; MVR OR, 1.36; 95% CI, 1.23-1.51). Patients without preoperative HF had better long-term survival (MVP hazard ratio [HR], 2.23 [95% CI, 2.09-2.36]; MVR HR, 1.80 [95% CI, 1.73-1.86]). After adjustment, a preoperative HF diagnosis was still associated with 52% and 36% increased risk of death over the 10-year follow-up period for patients who underwent MVP and MVR, respectively. Preoperative HF duration greater than 3 months conferred an excess 28% higher risk of death on long-term follow-up compared with patients with HF less than 3 months., Conclusions: Preoperative HF is present in a large number of elderly patients undergoing primary isolated mitral valve surgery and adversely affects their short-term and long-term survival, irrespective of procedure type (repair or replacement). The study supports the early identification of elderly patients with mitral valve disease and referral to surgery before the onset of HF., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the likelihood of mitral valve repair among dialysis patients and the influence of mitral procedure selection on surgical outcomes in this cohort., Methods: Among patients undergoing isolated primary mitral valve surgery in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2002-2010), we used logistic regression models to evaluate the following: (1) the likelihood of attempted and successful mitral repair among dialysis patients (2008-2010), and (2) the impact of mitral procedural selection on surgical mortality and composite mortality/major morbidity experienced by dialysis patients (2002-2010). Patients with endocarditis and those undergoing emergent or major concomitant surgeries were excluded., Results: The study cohort consisted of 86,563 patients, of whom 1480 (1.7%) required preoperative dialysis. Dialysis patients had a high comorbid burden, including a high prevalence of congestive heart failure, stroke, diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, and prior myocardial infarction. Dialysis-dependent patients had a lower propensity for mitral repair (44.6% vs 61.5%; P = .0010; adjusted odds ratio [OR], 0.69; 95% confidence interval [CI], 0.61-0.78); although the odds of successful repair (when attempted) were similar for dialysis versus nondialysis patients (OR, 0.87; 95% CI, 0.65-1.17). Compared with nondialysis patients, dialysis patients experienced a higher mortality rate (9.3% vs 2.3%; P < .0001; adjusted OR, 3.91; 95% CI, 3.17-4.81) and composite mortality or major morbidity (40.9% vs 15.9%; P < .0001; adjusted OR, 2.72; 95% CI, 2.41-3.07); however, adjustment for procedure selection did not substantially attenuate this effect (2.3% and 2.1% change-in-estimate for mortality and composite mortality/major morbidity, respectively)., Conclusions: Dialysis patients undergo mitral repair less frequently, although repair success is equally likely when attempted among dialysis versus nondialysis patients. Dialysis-dependent renal failure is associated strongly with early mortality and major morbidity. However, procedure selection (repair vs replacement) does not appear to have a clinically meaningful impact on these short-term outcomes., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Gender disparities in outcomes have been documented in cardiac surgery. Gender differences in long-term survival after mitral valve operations, especially in the elderly, are less well studied., Methods: Using Centers for Medicare and Medicaid Services data, we identified 183,792 Medicare beneficiaries aged 65 years and older who underwent mitral valve repair or replacement from 2000 through 2009. The final study population included 47,602 Medicare fee-for-service beneficiaries undergoing isolated mitral valve operations. The outcomes studied were gender-specific operative mortality and long-term survival., Results: Women were less likely to receive mitral valve repair (31.9% vs 44.0%, p < 0.0001). The hospital mortality rate was 7.7% for women vs 6.1% for men (p < 0.0001), reflective of a worse preoperative profile. Women undergoing repair had worse long-term survival than men (p = 0.0020) but survival was similar after risk adjustment (hazard ratio, 0.97; 95% confidence interval, 0.92 to 1.02, p = 0.2106). Compared with the United States population matched for age and sex, mitral repair restored life expectancy for men but not for women. Unadjusted and adjusted long-term survival was similar for men and women undergoing mitral valve replacement (p = 0.3653; hazard ratio, 0.99; 95% confidence interval, 0.96 to 1.02; p = 0.4847)., Conclusions: In this large comparative study of gender differences in mitral valve operations, elderly women had higher operative mortality and lower long-term survival. These differences appeared to be driven largely because women present for mitral valve operations later in the disease process. Mitral repair appeared to restore normal life expectancy for men but not for women. Future studies should examine the factors that influence physician referral to mitral valve operations for men and women., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Despite the established superiority of mitral repair over replacement, its adoption in the treatment of elderly patients has not been uniform, partly because of a lack of robust long-term survival data. We present the long-term survival of Medicare fee-for-service beneficiaries undergoing mitral valve repair and replacement over a 10-year period., Methods and Results: We used the Medicare database to identify 47 279 fee-for-service beneficiaries ≥65 years of age undergoing primary isolated mitral valve repair or replacement from 2000 to 2009. Operative mortality and long-term survival are presented for repair and replacement. Operative mortality was 3.9% for patients undergoing repair and 8.9% for patients undergoing replacement. The 1-, 5-, and 10-year Kaplan-Meier survival estimates for patients undergoing repair were 90.9%, 77.1%, and 53.6%. The 1-, 5-, and 10-year Kaplan-Meier survival estimates for patients undergoing replacement were 82.6%, 64.7%, and 37.2%. Important predictors of mitral repair included younger age (odds ratio, 1.10; 95% confidence interval, 1.05-1.14), elective admission status (odds ratio, 1.34; 95% confidence interval, 1.27-1.41), and annual mitral procedure volume >40 cases per year (odds ratio, 1.57; 95% confidence interval, 1.36-1.81). Female sex and the presence of comorbidities were associated with a lower likelihood of repair., Conclusions: Mitral valve surgery in the Medicare population carries less risk than previously reported. Given the favorable outcomes of elderly patients undergoing mitral valve surgery, especially mitral valve repair, an approach of earlier identification and surgical referral appears justified regardless of age.

Background: The superiority of mitral valve (MV) repair is well established with respect to long-term survival, preservation of ventricular function, and valve-related complications. The relationship between patient income level and the selection of MV procedure (repair versus replacement) has not been studied., Methods: The 2005 to 2007 Nationwide Inpatient Sample database was searched for patients ≥ 30 years old with MV repair or replacement; patients with ischemic and congenital MV disease were excluded. Patients were stratified into quartiles according to income level (quartile 1, lowest; quartile 4, highest). We used univariate and multivariate models to compare patients with respect to baseline characteristics, selection of MV procedure, and hospital mortality., Results: The preoperative profiles of the income quartiles differed significantly, with more risk factors occurring in the lower income quartiles. Unadjusted hospital mortality decreased with increasing income quartile. The percentage of patients receiving MV repair increased with increasing income (35.6%, 39.6%, 48.2%, and 55.8% for quartiles 1, 2, 3, and 4, respectively; P = .0001). Following adjustment for age, race, sex, urban residency, admission status, primary payer, Charlson comorbidity index, and hospital location and teaching status, the income quartiles had similar hospital death rates, whereas the highly significant relationship between valve repair and income level persisted (P = .0008)., Conclusions: Significant disparity exists among patients in the different income quartiles with respect to the likelihood of receiving MV repair. MV repair is performed less frequently in patients with lower incomes, even after adjustment for differences in baseline characteristics. The higher unadjusted mortality rate for less affluent patients appears mostly related to their worse preoperative profiles.

Background and Aim of the Study: Cardiovascular disease is a frequent cause of death in patients with rheumatoid arthritis (RA). Valvular involvement is common, most frequently affecting the mitral valve. Whether RA is an additional risk factor for patients undergoing mitral surgery has not been studied. The study aim was to examine procedure selection and outcome in patients with RA compared to that in patients without RA., Methods: The 2005-2008 NIS database was searched to identify patients aged > or = 18 years undergoing isolated mitral valve repair or replacement. Patients with and without RA were compared on their baseline characteristics and hospital outcomes. Within the subset of patients with RA, patients undergoing repair and replacement were compared., Results: RA patients comprised 1.0% (710/70,969) of the population, and were older, more likely to be female, and had a higher Charlson comorbidity index. The repair rate for RA patients was lower (37.6% versus 45.5%, p = 0.0401). The hospital length of stay (OR = 1.27, 95% CI 0.88-1.82, p = 0.1946) and hospital mortality (OR = 0.57, 95% CI 0.19-1.72, p = 0.3081) were similar for patients with and without RA. Baseline characteristics were similar between mitral valve repair and replacement subsets. The median LOS was higher for replacement (10 days versus 7 days, p = 0.0242). Hospital mortality was similar for repair versus replacement (OR = 1.17, 95% CI 0.10-13.46, p = 0.8983)., Conclusion: RA does not appear to be an additional risk factor for adverse outcome following isolated mitral valve surgery. Although repair rates were lower for patients with RA, hospital mortality was similar to that in patients without RA. Within the RA subset, hospital mortality rates between mitral valve repair and replacement were similar.

Background: Within the field of cardiac surgery, several strategies have been adopted in an effort to address contributors to increasing health care costs. Limited data are available on cost analysis within the field of mitral valve surgery. The purpose of our investigation was to analyze cost differences between mitral valve repair and replacement., Methods: The analysis was based on the subset of patients with isolated mitral valve repair or replacement (International Classification of Diseases, ninth revision, clinical codes 35.12, 35.23, and 35.24) using data from the 2005 to 2008 Nationwide Inpatient Sample database, which is the largest all-payer database in the United States. We examined the selective contribution of patient demographics, hospital characteristics, and postoperative complications to cost by using hierarchical linear mixed models. We used mixed effects logistic regression models to identify factors that influence extreme cost expenditures in patients undergoing mitral valve surgery., Results: Independent predictors of increased cost for both repair and replacement on multivariable analysis included increased age, prior myocardial infarction, heart failure, neurologic deficit, renal disease, emergent status, and Medicare or Medicaid insurance type. The presence of postoperative complications also predicted increased costs. However, the model for repair only yielded a reduction in variability of 13%, while the model for replacement produced a reduction of 22%., Conclusions: In this analysis, the most important contributors to cost for mitral valve repair and replacement are preoperative patient comorbidities, most notably history of myocardial infarction and heart failure, emergent admission status, and postoperative complications. The variables in our model failed to account for a large proportion of the variability in cost. This would suggest that future analyses exploring differential procedure costs between hospitals must look for factors beyond patient baseline characteristics and postoperative outcomes., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to examine the trends in tricuspid valve surgery over time., Methods: We used 10 years (1999-2008) of NIS data to examine the population of patients undergoing tricuspid valve repair or replacement (ICD-9-CM codes 35.14, 35.27, and 35.28)., Results: We identified 28,726 admissions for tricuspid valve surgery. The total number of tricuspid procedures more than doubled over the 10- year period (1712 cases in 1999 vs 4072 cases in 2008). Although the absolute number of repairs and replacements increased over time, the tricuspid repair rate increased whereas there was a corresponding decrease in tricuspid replacement rate. Isolated tricuspid valve surgery accounted for 20% of the total tricuspid cases, whereas tricuspid surgery as a concomitant procedure to other cardiac operations accounted for the remaining 80%. There was a trend toward increased use of tissue over mechanical valves for tricuspid replacement. Overall hospital mortality was 10.6%. Over time, mortality decreased significantly for both repair and replacement. Concomitant tricuspid replacement was associated with significantly higher hospital mortality than was isolated tricuspid replacement (16.1% vs 10.1%; P = .0001)., Conclusions: There has been a dramatic increase in tricuspid interventions over time. This has been associated with an increase in tricuspid repair rates as well as use of bioprostheses for tricuspid replacement. The majority of tricuspid operations are performed concomitantly to other cardiac procedures. Mortality for tricuspid valve surgery remains considerable and significantly higher for replacement than for repair., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background and Aim of the Study: The aim of this investigation was to examine the impact of hospital annual mitral volume on mitral valve (MV) repair rates and mortality., Methods: The 2005-2008 Nationwide Inpatient Sample (NIS) database was searched to identify patients who had undergone either MV repair (ICD-9-CM code 35.12) or MV replacement (ICD-9-CM codes 35.23 and 35.24). The hospitals were stratified into five categories based on the annual volume of all mitral procedures (< 10, 10-20, 21-40, 41-79, and > or = 80 cases/year). The relationship between hospital annual mitral procedure volume and MV repair rates, as well as hospital mortality for MV repair, was then examined for patients undergoing isolated MV surgery (excluding those aged < 30 years and those with congenital heart disease, concomitant coronary revascularization, ventricular aneurysm excision, heart transplant and other valvular interventions, except tricuspid). Chi-square tests of independence were used to test for differences between the mitral volume categories, and Cochran-Armitage tests to check for trends across the years., Results: The sample included a total of 12,857 patients from 603 hospitals. Mitral repair rates increased as a function of hospital mitral volume, ranging from 34% for hospitals with < 10 mitral cases/year to 53% for hospitals with > or = 80 mitral cases/year. Follow up comparisons revealed that an annual mitral volume of > 40 cases/year was associated with a significantly higher rate of MV repair (p < 0.005). There was a significant trend of increasing MV repair rates over time for hospitals with annual mitral volumes of 20-40 and 41-79 cases/year (p = 0.0001). The MV repair mortality ranged from 1.33% to 2.29%, and did not differ among hospitals as a function of the annual mitral volume (p = 0.2982)., Conclusion: Mortality after MV repair was low, and independent of the hospital annual mitral volume. A hospital annual mitral volume of fewer than 40 cases per year was associated with a lower rate of MV repair. Addressing the factors responsible for this finding constitutes an important area for future improvement in the care of patients with MV disease.

A 25-year-old woman with a history of chronic bronchitis since age 12 and 3-4 previous episodes of pneumonia presented to the emergency room with cough and shortness of breath. A CT scan of her chest revealed findings consistent with Morgagni hernia with herniation of omental fat, causing near complete compressive atelectasis of the right middle lobe. The diaphragmatic defect was successfully treated with a laparoscopic repair. The patient was discharged home on the first postoperative day after tolerating regular diet.

Background and Aim of the Study: There is paucity of data relating to the geographic variation in mitral valve (MV) repair trends and outcomes of patients undergoing MV surgery., Methods: Using the 2005-2008 Nationwide Inpatient Sample (NIS) Database, the four geographic regions of the US (Northeast, Midwest, South, and West) were compared with respect to baseline characteristics, mitral procedure selection, and hospital mortality of patients undergoing either MV repair (ICD-9CM code 35.12) or replacement (ICD-9-CM codes 35.23 and 35.24)., Results: Patient age was similar across regions. The Midwest had the highest proportion of whites, while patients in the South were the least affluent. The Northeast had the highest proportion of patients presenting non-electively. The West and Midwest had more women and patients with private insurance compared to the South, but the proportion of patients on Medicaid was similar across all regions. The Northeast and the South had a higher Charlson Comorbidity Index compared to the West. The overall repair rate was 47%; the Midwest had the highest rate (50%), and the South the lowest (42%) (p = NS). Following adjustment for baseline characteristics, hospital mortality was similar among regions for patients undergoing MV replacement. For the subset undergoing MV repair, hospital mortality was more than 2.5-fold higher in the South than in the Northeast (OR = 2.88, 95% CI 1.45-5.71)., Conclusion: MV repair is utilized in less than half of all mitral procedures nationwide. Repair rates and hospital mortality are comparable across all four regions in the US. Hospital mortality for isolated MV surgery is low. The higher adjusted mortality for patients undergoing MV repair in the South identifies an important area for future improvement in the care of patients with valvular heart disease.

Background: The optimal surgical approach for patients with hypertrophic obstructive cardiomyopathy (HOCM) with concomitant mitral valve (MV) regurgitation has remained controversial. The purpose of this study was to use the largest all-payer database in the United States to examine the strategy most commonly used for the correction of mitral valve pathology in the setting of HOCM., Methods: The Nationwide Inpatient Sample (NIS) database was searched from 2005 to 2008 to identify patients with a diagnosis of HOCM (ICD-9-CM code 425.1) who underwent MV repair (ICD-9-CM code 35.12) or replacement (ICD-9-CM codes 35.23 and 35.24). HOCM patients who underwent MV repair and those who underwent MV replacement were compared with respect to baseline characteristics, repair rates, hospital mortality, and length of stay (LOS)., Results: MV repair was performed in 17.2% of cases (219/1255). Repair rates did not show a significantly increasing trend over time (P = .1419). The median LOS was significantly longer for replacement than for repair (11 days versus 7 days, P = .0001). The mortality rate for patients who underwent repair was 0.00%, compared with 11.18% for those who underwent replacement (P < .05)., Conclusions: The majority of patients with a HOCM diagnosis underwent MV replacement for the correction of MV pathology. Referral to centers with special expertise in treating patients with HOCM may positively affect the operative outcomes of this patient subset.

Background: There is a paucity of data on sex differences in procedure selection and outcomes of patients undergoing mitral valve surgery., Methods and Results: The National Inpatient Sample database from 2005 to 2008 was searched to identify patients ≥30 years of age who underwent mitral valve repair or replacement (ICD-9-CM codes 35.12, 35.23, and 35.24). Women constituted 51.6% of the patients, and they were older, were less affluent, had higher values for the Charlson comorbidity index, and more often presented on an urgent/emergent basis. Women underwent repair less often than men (37.9% versus 55.9%, P < .001) and more often underwent concomitant tricuspid surgery or a Maze procedure. After adjustment for propensity scores, women were more likely to undergo replacement (odds ratio, 1.78; 95% confidence interval, 1.64-1.93; P = .0001), they had longer lengths of stay, and less favorable disposition. Among the patients who underwent mitral valve repair, women had a higher hospital mortality (2.06% versus 1.36%, P = .0328). After adjustment for propensity scores and concomitant procedures, this relationship was no longer statistically significant., Conclusions: Women are less likely than men to receive mitral valve repair. Although the higher hospital mortality of women presenting for mitral valve surgery was accounted for by their worse preoperative profiles, this sex disparity reflects the current reality in surgical practice and identifies an important area for future improvement in the care of patients with valvular heart disease.