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Objective: The influence of socioeconomic determinants of health on failure to rescue (mortality after a postoperative complication) after cardiac surgery is unknown. We hypothesized that increasing Distressed Communities Index, a comprehensive socioeconomic ranking by ZIP code, would be associated with higher failure to rescue., Methods: Patients undergoing Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) who developed a failure to rescue complication were included. After excluding patients with missing ZIP code or Society of Thoracic Surgeons predicted risk of mortality, patients were stratified by Distressed Communities Index scores (0-no distress, 100-severe distress) based on education level, poverty, unemployment, housing vacancies, median income, and business growth. The upper 2 quintiles of distress (Distressed Communities Index >60) were compared to all other patients. Hierarchical logistic regression analyzed the association between Distressed Communities Index and failure to rescue., Results: A total of 4004 patients developed 1 or more of the defined complications across 17 centers. Of these, 582 (14.5%) experienced failure to rescue. High socioeconomic distress (Distressed Communities Index >60) was identified among 1272 patients (31.8%). Before adjustment, failure to rescue occurred more frequently among those from socioeconomically distressed communities (Distressed Communities Index >60; 16.9% vs 13.4%, P = .004). After adjustment, residing in a socioeconomically distressed community was associated with 24% increased odds of failure to rescue (odds ratio, 1.24; confidence interval, 1.003-1.54; P = .044)., Conclusions: Increasing Distressed Communities Index, a measure of poor socioeconomic status, is associated with greater risk-adjusted likelihood of failure to rescue after cardiac surgery. These findings highlight that current quality metrics do not account for socioeconomic status, and as such underrepresent procedural risk for these vulnerable patients., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Lay Abstract: A nationwide survey was done in Bangladesh to assess autism spectrum disorder prevalence in 16- to 30-month-old children at urban-rural distribution and to determine the association with socioeconomic and demographic conditions. A three-stage cluster sampling method was used where districts from all divisions were selected in the first stage, census enumeration areas as blocks of households were selected in the second stage and households (within the blocks) were selected in the third stage. Thereby, it included 38,440 children from 37,982 households (71% rural, 29% urban) aged 16-30 months from 30 districts of eight divisions of Bangladesh. Screening was done with a 'Red Flag' tool and Modified Checklist for Toddlers and a final diagnosis using Diagnostic and Statistical Manual of Mental Disorders, 5th Edition for autism spectrum disorder. Autism spectrum disorder prevalence was 17 per 10,000 young children - in other words, one in 589 young children. Boys were found at higher risk of autism (one in 423 boys; one in 1026 girls). Prevalence of autism spectrum disorder was higher in urban environments than in rural ones - 25/10,000 and 14/10,000, respectively. More autism spectrum disorder children were found in advanced age groups of parents, especially mothers, and in households with a higher wealth quintile. This survey is significant as it covers both urban and rural areas and specifically targets very young children. The involvement of the Bangladesh Bureau of Statistics, as well as support from the entire healthcare system infrastructure, makes this survey more representative on a national level. Its results will form a database to support the development of an effective early intervention programme in Bangladesh. We hope it will prove useful for researchers, clinicians and frontline healthcare workers, and inform the decisions of policymakers and funders in Bangladesh., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Infective endocarditis affects patients of all socioeconomic status. We hypothesized that the Distressed Communities Index (DCI), a comprehensive assessment of socioeconomic status, would be associated with risk-adjusted mortality for patients with endocarditis. All patients with endocarditis (2001-2017) in a regional Society of Thoracic Surgeons database were analyzed. DCI scores range from 0 (no socioeconomic distress) to 100 (severe distress) and account for unemployment, poverty rate, median income, housing vacancies, education level, and business growth by zip code. The most distressed patients (top quartile, DCI > 75) were compared to all other patients. Hierarchical logistic regression modeled the association between DCI and mortality. A total of 2,075 patients were included (median age 55 years, 65.2% urgent/emergent cases, 42.7% self-pay). Major morbidity was 32.8% and operative mortality was 9.5%. Tricuspid/pulmonic valve endocarditis was present in 12.5% of cases, with significantly worse mean DCI compared to patients with left-sided endocarditis (median 55.3, IQR 20.3-77.6 vs 46.8, IQR 17.3-74.2, P = 0.016). High socioeconomic distress (DCI > 75) was associated with higher rates of major morbidity, operative mortality, increased length of stay, and higher total cost. After risk-adjustment, DCI was independently predictive of higher operative mortality for patients with endocarditis (OR 1.24 per DCI quartile increase, 95% CI 1.06-1.45, P < 0.001). Increasing DCI, an indicator of poor socioeconomic status, independently predicts increased risk-adjusted mortality and resource utilization for patients with endocarditis. Accounting for socioeconomic status allows for more accurate risk prediction and resource allocation for patients with endocarditis., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Data showing the efficacy and safety of the transplantation of hearts obtained from donors after circulatory death as compared with hearts obtained from donors after brain death are limited., Methods: We conducted a randomized, noninferiority trial in which adult candidates for heart transplantation were assigned in a 3:1 ratio to receive a heart after the circulatory death of the donor or a heart from a donor after brain death if that heart was available first (circulatory-death group) or to receive only a heart that had been preserved with the use of traditional cold storage after the brain death of the donor (brain-death group). The primary end point was the risk-adjusted survival at 6 months in the as-treated circulatory-death group as compared with the brain-death group. The primary safety end point was serious adverse events associated with the heart graft at 30 days after transplantation., Results: A total of 180 patients underwent transplantation; 90 (assigned to the circulatory-death group) received a heart donated after circulatory death and 90 (regardless of group assignment) received a heart donated after brain death. A total of 166 transplant recipients were included in the as-treated primary analysis (80 who received a heart from a circulatory-death donor and 86 who received a heart from a brain-death donor). The risk-adjusted 6-month survival in the as-treated population was 94% (95% confidence interval [CI], 88 to 99) among recipients of a heart from a circulatory-death donor, as compared with 90% (95% CI, 84 to 97) among recipients of a heart from a brain-death donor (least-squares mean difference, -3 percentage points; 90% CI, -10 to 3; P<0.001 for noninferiority [margin, 20 percentage points]). There were no substantial between-group differences in the mean per-patient number of serious adverse events associated with the heart graft at 30 days after transplantation., Conclusions: In this trial, risk-adjusted survival at 6 months after transplantation with a donor heart that had been reanimated and assessed with the use of extracorporeal nonischemic perfusion after circulatory death was not inferior to that after standard-care transplantation with a donor heart that had been preserved with the use of cold storage after brain death. (Funded by TransMedics; ClinicalTrials.gov number, NCT03831048.)., (Copyright © 2023 Massachusetts Medical Society.)

Introduction: Pulmonary hypertension (PHT) is a known risk factor for coronary artery bypass grafting (CABG), though less well understood for valve operations. We hypothesized PHT is associated with lower risk during mitral valve operations compared to CABG., Methods: Patients undergoing isolated mitral valve or CABG operations (2011-2019) in a regional Society of Thoracic Surgeons (STS) database were stratified by pulmonary artery systolic pressure (PASP). The association of PASP by procedure type was assessed by hierarchical regression modeling, adjusting for STS predicted risk scores., Results: Of the 2542 mitral and 11,059 CABG patients, the mitral population had higher mean STS risk of mortality (3.6% versus 2.4%, P < 0.0001) and median PASP (42 mmHg versus 32 mmHg, P < 0.0001). PASP was independently associated with operative mortality and major morbidity in both mitral and CABG patients. However, for mitral patients a 10-mmHg increase in PASP was associated with lower odds of morbidity (odds ratio: 1.06 versus 1.13), mortality (odds ratio: 1.11 versus 1.18) and intensive care unit time (4.3 versus 7.6 h) compared with CABG patients (interaction terms P < 0.0001). Among mitral patients, median PASP was higher in stenotic versus regurgitant disease (57 mmHg versus 40 mmHg, P < 0.0001). However, there was no differential association of PASP on morbidity or mortality (interaction terms P > 0.05)., Conclusions: Although mitral surgery patients tend to have higher preoperative pulmonary artery pressures, PHT was associated with a lower risk for mitral outcomes compared with CABG. Further research on the management and optimization of patients with PHT perioperatively is needed to improve care for these patients., (Published by Elsevier Inc.)

Introduction: We describe a case report of metabolic alkalosis that occurred during veno-arterial extracorporeal membrane oxygenation (VA ECMO) that was corrected during cardiopulmonary bypass (CPB) using zero balance ultrafiltration with normal saline (NS) 0.9%., Case Report: A 67-year-old male received a heart transplant 6 days after being placed on VA ECMO. During VA ECMO the patient developed metabolic alkalosis. During CPB, zero balance ultrafiltration with NS 0.9% was used to correct metabolic alkalosis., Discussion: Metabolic alkalosis during CPB is rare. To our knowledge, this is the first reported case of the use of zero balance ultrafiltration to effectively correct metabolic alkalosis., Conclusion: Metabolic alkalosis during CPB may be corrected using zero balance ultrafiltration with NS 0.9%.

Background: Racial disparities in outcomes after cardiac surgery are well reported. We sought to determine whether variation by race exists in controllable practices during coronary artery bypass graft surgery (CABG). We hypothesized that racial disparities exist in CABG quality metrics, but have improved over time., Methods: All patients undergoing isolated CABG (2000 to 2019) in a multiple state database were stratified into three eras by race. Analysis included propensity matched White Americans and Black Americans. Primary outcomes included left internal mammary artery use, multiple arterial grafting, revascularization completeness, and guideline-directed medication prescription., Results: Of 72 248 patients undergoing CABG, Black American patients (n = 10 270, 15%) had higher rates of diabetes mellitus, hypertension, prior stroke, and myocardial infarction. After matching, 19 806 patients (n = 9903 per group) were well balanced. Left internal mammary artery use was significantly different early (era 1, Black Americans 84.7% vs White Americans 86.6%; P = .03), but equalized over time. Importantly, multiarterial grafting differed between Black Americans and White Americans over the entire study (9.1% vs 11.5%, P < .001) and within each era. Black Americans had more incomplete revascularization during the study period (14% vs 12.8%, P = .02) driven by a large disparity in era 1 (9.5% vs 7.2%, P < .001). Despite similar rates of preoperative use, Black Americans were more often discharged on a regimen of β-blockers (91.8% vs 89.6%, P < .001)., Conclusions: Coronary artery bypass graft surgery metrics of left internal mammary artery use and optimal medical therapy have improved over time and are similar despite patient race. Black Americans undergo less frequent multiarterial grafting and greater discharge β-blocker prescription. Identifying changes in controllable CABG quality practices across races supports a continued focus on standardizing such efforts., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Rheumatic mitral valve disease is often viewed as a historic disease in North America with limited contemporary data. We hypothesized that rheumatic pathology remains common and has worse short-term outcomes and higher resource utilization compared to other mitral valve pathologies., Method: All patients undergoing mitral valve repair or replacement (2011-2019) were extracted from a regional Society of Thoracic Surgeons database. Resource utilization metrics included inflation-adjusted hospital costs. Patients were stratified by mitral valve pathology for univariate analysis., Result: Out of the 6625 mitral valve procedures, 835 (12.6%) were from rheumatic disease, a proportion that incrementally increased over time (+0.39% per year, p = .032). Among 19 hospitals, there was high variability in number of rheumatic mitral operations (median: 22, interquartile range [IQR]: 5-80) and rate of rheumatic repairs (median: 3%, IQR: 0%-6%). Rheumatic patients were younger (62 vs. 65, p < .0001), more often female (75% vs. 43%, p < .001) and with greater burden of heart failure, multi-valve disease, and lung disease, but less coronary disease. There were no differences in operative mortality (5.2% vs. 5.0%, p = .85) or major morbidity (22.2% vs. 21.8%, p = .83). However, resource utilization was higher for rheumatic patients, including more frequent transfusions (43% vs. 39%, p = .012), longer ICU (73 vs. 64 h, p < .0001) and postoperative length of stay (8 vs. 7 days, p < .0001)., Conclusions: Rheumatic mitral disease accounts for a meaningful (12%) and rising percentage of mitral valve operations in the region, with high variability among hospitals. Rheumatic mitral surgery yielded similar short-term outcomes compared to nonrheumatic pathology, but required greater resource utilization., (© 2022 The Authors. Journal of Cardiac Surgery published by Wiley Periodicals LLC.)

Objective: To assess the outcomes of a single-center experience with percutaneous left ventricular assist device (LVAD) decommissioning., Background: Patients with LVADs may eventually require their removal, either due to recovery of left ventricular function or recurrent complications. Traditionally, withdrawal of LVAD support has been managed with surgical device explantation, which carries significant procedural risks. Transcatheter LVAD decommissioning, with outflow graft occlusion and driveline transection, has recently been described as an alternative to surgical removal., Methods: Here, we report on a retrospective cohort of five consecutive cases treated with transcatheter LVAD decommissioning., Results: The procedure was effective in all cases, and no patient experienced procedure-related complications. At midterm follow-up, the three patients who had myocardial function recovery were alive and had not experienced heart failure-related symptoms or complications., Conclusion: Percutaneous LVAD decommissioning appears to be a safe and effective approach to LVAD treatment discontinuation., (© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Global vaccination coverage is an urgent need to recover the recent pandemic COVID-19. However, people are concerned about the safety and efficacy of this vaccination program. Thus, it has become crucial to examine the knowledge, attitude, and hesitancy towards the vaccine. An online cross-sectional survey was conducted among university students of Bangladesh. Total of 449 university students participated. Most of these students used the internet (34.74%), social media (33.41%), and electronic media (25.61%) as a source of COVID-19 vaccine information. Overall, 58.13% and 64.81% of university students reported positive knowledge and attitude towards the COVID-19 vaccine. 54.34% of these students agreed that the COVID-19 vaccine is safe and effective. 43.88% believed that the vaccine could stop the pandemic. The Spearman's Rank correlation determined the positive correlation between knowledge and attitude. The negative correlation was determined between positive knowledge and hesitancy, and positive attitude and hesitancy. University students with positive knowledge and attitude showed lower hesitancy. Multiple logistic regression analyses determined the university type and degree major as the predictors of knowledge, whereas only degree major was the predictor of attitudes. 26.06% of the study population showed their hesitancy towards the vaccine. University type and degree major were also determined as predictors of this hesitancy. They rated fear of side effects (87.18%) and lack of information (70.94%) as the most reasons for the hesitancy. The findings from this study can aid the ongoing and future COVID-19 vaccination plan for university students. The national and international authorities can have substantial information for a successful inoculation campaign., Competing Interests: The authors have declared that no competing interests exist.

Dhaka has become the worst affected city in Bangladesh regarding dengue fever (DF). A large number of university students are residing in this city with a high DF risk. This cross-sectional study was conducted to assess the DF status and responses among these students through their Knowledge, Attitude, and Practices (KAP) survey. A total of 625 students participated in an online self-reported survey. Statistical analyses were performed to assess the status and KAP regarding DF. University students from the city perceived their living places as moderately safe (45.28%) against DF, whereas about 20% reported their DF infection history. Some of these students had exemplary DF knowledge (66.72%), attitude (89.28%), and practices (68.32%). However, many of them were also observed with a lack of knowledge about this disease’s infectious behavior, recognizing Aedes mosquito breeding sites, multiple infection cases, and the risk of DF viral infection during pregnancy. Fair correlations (p < 0.001) were determined in the KAP domain. Gender, residential unit, major, and dengue-relevant subjects were found to be significant predictors (p < 0.05) of KAP level in the univariate analysis. Major subject and residential units remained significant predictors of overall KAP level in further multiple analysis. This study revealed the urgency of infectious disease-related subjects and the relevant demonstration into the university curriculum. The study’s findings can assist the university, government and non-governmental organizations, and the health and social workers to prepare a comprehensive dengue response and preparedness plan., Competing Interests: The authors declare no conflicts of interest.

Despite the public health concern, there is a dearth of research regarding perceived noise pollution and noise-related health status in Bangladesh. This study was carried out to evaluate the noise-related health status among Bangladesh's adult population. 1386 adult Bangladeshis participated in an online survey. A linear regression model was used to evaluate overall noise-related health status determinants. 91% of the survey population reported noisy environments in their neighborhood, with the majority reporting two types (34%) of noise pollution sources. Road vehicles (38%) and construction activities (24%) were identified as significant source of noise pollution. The Bangladeshis are primarily exposed to noise during school and office hours. Socio-demographic information, perceived noise pollution and individual views towards noise pollution were examined as determinants of noise-related health problems. Females were found to be more impacted than males, and young people also expressed concern about noise pollution's influence. Residents in mixed-unit buildings exhibited a significant level of noise-related health problems such as deafness, insomnia, heart disease, headache, stress, poor concentration, production loss, fatigue, irritability, heartburn, indigestion, ulcers, and high blood pressure. Noise pollution from road vehicles and industry has been shown to have a negative effect on people's health. Individuals affected by noise were interested in noise reduction efforts. The findings of this research may aid in the improvement of international, national, and local noise control efforts.

Introduction: COVID-19 has become a global public health concern. Safe and effective vaccines are required to control the pandemic. However, positive perception toward the vaccine is also necessary for a successful vaccination effort., Objective: A rapid online survey was conducted to evaluate the status and perception toward the newly administered COVID-19 vaccine among the adult population (18 years and above) of Bangladesh., Methods: A total of 850 adult people participated. χ 2 or Fisher's exact test was performed to determine the association between the first dose of vaccination and sociodemographic information. Logistic regression analyses were carried out to examine the predictors of knowledge, attitude, and hesitation toward the vaccine., Results: Exactly 24.12% of the study population received their first dose of COVID-19 vaccine, whereas 30.23% expressed hesitation about pursuing the vaccine. Older age groups (>70%), married people (49.62%), capital Dhaka city outsiders (32.76%), and high-income groups (>50%) received the vaccine much higher than their counter group. Age, marital status, educational attainment, monthly income, and prior COVID-19 positive status were all significantly associated with the knowledge regarding the vaccine. Only age (>55 years age group = aOR: 4.10; 95% CI: 1.30, 14.31) and level of knowledge (poor knowledge = aOR: 0.17; 95% CI: 0.12, 0.23) were significant determinants of attitudes. In case of hesitation, age group and monthly income were found as significant determinants. Fear of adverse consequences (86.67%) was the most common reason for hesitation, followed by insufficient information (73.85%)., Conclusion: This study sought to determine the status and perception of the newly administered COVID-19 vaccine to aid in the current inoculation campaign's effectiveness. Collaboration between academics, government officials, and communities is essential in developing a successful COVID-19 vaccination program for the entire population. The authority should develop effective strategies to ensure the implementation of its policy of widespread COVID-19 vaccination coverage., Competing Interests: The authors declare that they have no conflict of interest., (© 2021 The Authors. Health Science Reports published by Wiley Periodicals LLC.)

Background: LVADs provide life-sustaining treatment for patients with heart failure, but their complexity allows for complications. One complication, LVAD outflow graft obstruction, may be misdiagnosed as intraluminal thrombus, when more often it is extraluminal compression from biodebris accumulation. It can often be treated endovascularly with stenting. This case series describes diagnostic and procedural techniques for the treatment of left ventricular assist device (LVAD) outflow graft obstruction., Methods: We present four patients with LVADs who developed LVAD outflow graft obstruction within the bend relief-covered segment. All were initially diagnosed with computed tomographic angiography (CTA). All underwent invasive evaluation with intravascular ultrasound (IVUS), then were treated with stenting. After misdiagnosing a twist, we developed the technique of balloon "graftoplasty" to ensure suitability for stent delivery in subsequent cases., Results: All patients presented with low-flow alarms and symptoms of low output, and were diagnosed with outflow graft obstruction by CTA. In all four, IVUS confirmed an extraluminal etiology. Patient 1 was treated with stenting and had a good outcome. Patient 2's obstruction was from twisting, rather than biodebris accumulation, and had sub-optimal stent expansion and ultimately required surgery. Balloon "graftoplasty" was used in subsequent cases to ensure subsequent stent expansion. Patients 3 and 4 were successfully stented. All improved after treatment., Conclusions: In patients with LVAD outflow graft obstruction, IVUS can distinguish intraluminal thrombus from extraluminal compression. Balloon "graftoplasty" can ensure that the outflow graft will respond to stenting. Many cases of LVAD outflow graft obstruction should be amenable to endovascular treatment., (© 2021 Wiley Periodicals LLC.)

Background: Long-term outcomes of aortic valve replacement (AVR) are worse in patients with tricuspid regurgitation (TR), but the impact of concomitant tricuspid valve intervention remains unclear. The purpose of this study was to determine the effect of tricuspid intervention in patients with TR undergoing AVR., Methods: Patients undergoing AVR in a regional Society of Thoracic Surgeons database (2001-2017) were stratified by severity of TR and whether or not they underwent concomitant tricuspid intervention. Operative morbidity and mortality were compared between the 2 groups. Further analysis was performed using propensity score-matched pairs., Results: Among 17,483 patients undergoing AVR, 8984 (51%) had no TR, 7252 (41%) had mild TR, 1060 (6%) had moderate TR, and 187 (1%) had severe TR. Overall, more severe TR was associated with higher morbidity and mortality. Tricuspid intervention was performed in 104 patients (0.6%), including 0.2% of patients with mild TR, 2% of those with moderate TR, and 31% of those with severe TR. In the propensity score-matched analysis, there was not a statistically significant difference in operative mortality between the 2 groups (18% vs 9%; P = .16), but there was significantly higher composite major morbidity (51% vs 26%; P = .006) in the tricuspid intervention group compared with those without surgical TR correction., Conclusions: Increasing severity of TR is associated with higher rates of morbidity and mortality after AVR. Correction of TR at the time of surgical AVR is not associated with increased operative mortality and has been shown to improve long-term outcomes., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Limited multi-institutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raised concern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort., Methods: Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis., Results: Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P = .383) or major morbidity (7.9% open vs 7.2% MICS CABG, P = .795). However, open CABG patients received more blood products (22.2% vs 12.2%, P = .013), and had longer intensive care unit (45 vs 30 hours, P = .049) as well as hospital lengths of stay (7 vs 6 days, P = .005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P < .001) compared with MICS CABG., Conclusions: Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Organ transplantation remains the gold standard therapy for many end-organ diseases. The demand for donor organs continues to grow to far exceed supply. This review summarizes recent protocols, procedures, and ethics surrounding the increased utilization of donors after circulatory death for transplantation., Recent Findings: An increasing number of centers are utilizing donation after circulatory death, and outcomes are improving. Although outcomes from donors after brain death continue to be the primary source of donation, circulatory death outcomes continue to improve approaching the level of brain death donors., Summary: Donation after circulatory death offers a real opportunity to narrow the supply and demand issue with organ donation. Outcomes are improving, and protocols continue to evolve., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The prevalence of non-vitamin K oral anticoagulant use after cardiac surgery is unknown, particularly in patients with bioprosthetic valves. We sought to define the contemporary use and short-term safety of non-vitamin K oral anticoagulants after cardiac surgery., Methods: All patients undergoing bioprosthetic aortic valve replacement, bioprosthetic mitral valve replacement, or isolated coronary artery bypass grafting (2011-2018) were evaluated from a multicenter, regional Society of Thoracic Surgeons database. Patients were stratified by anticoagulant type (non-vitamin K oral anticoagulant vs vitamin K antagonist) and era (early [2011-2014] vs contemporary [2015-2018])., Results: Of 34,188 patients, 18% (6063) were discharged on anticoagulation, of whom 23% were prescribed non-vitamin K oral anticoagulants. Among those receiving anticoagulation, non-vitamin K oral anticoagulant use has significantly increased from 10.3% to 35.4% in contemporary practice (P < .01). This trend was observed for each operation type (coronary artery bypass grafting 0.86%/year, bioprosthetic aortic valve replacement: 2.15%/year, bioprosthetic mitral valve replacement: 2.72%/year, all P < .01). In patients with postoperative atrial fibrillation receiving anticoagulation, non-vitamin K oral anticoagulant use has increased from 6.3% to 35.4% and 12.3% to 40.3% after bioprosthetic valve replacement and isolated coronary artery bypass grafting, respectively (both P < .01). In patients receiving anticoagulation at discharge, adjusted 30-day mortality (odds ratio, 1.94; P = .12) and reoperation (odds ratio, 0.79; P = .34) rates were not associated with anticoagulant choice, whereas non-vitamin K oral anticoagulant use was associated with an adjusted 0.9-day decrease (P < .01) in postoperative length of stay., Conclusions: Non-vitamin K oral anticoagulant use after cardiac surgery has dramatically increased since 2011. This trend is consistent regardless of indication for anticoagulation including bioprosthetic valves. Short-term outcomes support their safety in the cardiac surgery setting with shorter postoperative hospital stays. Long-term studies on the efficacy of non-vitamin K oral anticoagulants after cardiac surgery are still necessary., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Continuation of dual antiplatelet therapy (DAPT) after coronary artery bypass grafting (CABG) after acute myocardial infarction is recommended by current guidelines. We sought to evaluate guideline adherence over time and factors associated with postoperative DAPT within a regional consortium., Methods: Isolated CABG patients from 2011 to 2017 who had a myocardial infarction within 21 days prior to surgery were included. Patients were stratified by DAPT prescription at discharge and by time period, early (2011-2014) vs late (2015-2017). Hierarchical regressions were then performed to evaluate factors influencing DAPT use after CABG., Results: A total of 7314 patients were included with an overall rate of DAPT utilization of 31.2% that increased from 29.6% in the early to 33.4% in the late era (P < .01). There was considerable variability in hospital rates of DAPT (range 9.5%-92.1%) and hospital level changes over time (26% increased, 11% decreased, and 63% remained stable). After adjustment for clinical factors, era was not associated with DAPT use but treating hospital remained significantly associated with DAPT use. Other clinical factors associated with increased DAPT utilization included off-pump surgery (odds ratio [OR] 4.48, P < .01) and prior percutaneous coronary intervention (OR 2.02, P < .01), and atrial fibrillation (OR 0.39, P < .01) was associated with decreased utilization., Conclusions: Dual antiplatelet use has increased between 2011 and 2017, driven primarily by evolving patient demographics. Significant hospital-level variability drives inconsistency in DAPT utilization. Efforts to promote DAPT use for patients treated with CABG after myocardial infarction in concordance with current guidelines should be targeted at the hospital level., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Readmissions cost an estimated $41 billion in the United States each year. To address this, a single institution recently developed a new risk model predictive of 30-day readmission after adult cardiac surgery. The purpose of this study is to validate and refine this new readmission risk model using a statewide database., Methods: A total of 19,964 patients were analyzed using a statewide Society of Thoracic Surgeons database (2014-2017). The aforementioned multivariate model was replicated (model 1): race, hospital length of stay, chronic lung disease, operation type, and renal failure. Model 2 also included discharge location. Thirty-day readmission risk scores and low-risk (0%-10%), moderate-risk (10%-13%), and high-risk (≥13%) categories were calculated., Results: The overall 30-day readmission rate was 11.1% with both models 1 and 2 predicting readmission (odds ratio, 1.09; 95% confidence interval, 1.08-1.11 vs odds ratio, 1.10; 95% confidence interval, 1.08-1.11). Statistically significant differences were observed across all risk categories in discharge location and total cost. For models 1 and 2, 86% of low-risk patients were discharged to home vs 66.9% and 42.9% of patients in high-risk groups, respectively (P < .001). The largest increases were observed with a hospice discharge location for both model 1 (from $37,930 to $89,285) and model 2 (from $37,930 to $89,230)., Conclusions: Both risk models significantly predicted 30-day readmission in our multiinstitutional dataset, confirming the score is valid and a generalizable quality improvement tool. The addition of discharge location and total cost adds valuable information of the ongoing efforts to identify patients at high risk for readmission., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: A weekend effect with increased mortality has previously been reported in surgical patients and those with acute myocardial infarction (MI). We hypothesized that a similar phenomenon may exist in coronary artery bypass grafting (CABG)., Methods: Patients undergoing non-elective isolated CABG (2011-2017) were included from a multicentre regional Society of Thoracic Surgeons database. Patients were stratified by weekend versus weekday operations and further analysed by specific day of the week., Results: A total of 14 374 patients underwent urgent or emergency isolated CABG with 410 (2.9%) operated on over the weekend. Weekend operations were more often emergency (36.1% vs 5.0%, P < 0.001) and more likely to be in the setting of MI (70.0% vs 51.2%, P < 0.001). Cardiopulmonary bypass times were similar [91 min (71-114) vs 94 min (74-117), P = 0.0749] and the frequency of complete revascularization equivalent (83.4% vs 85.3%, P = 0.284) between weekend and weekday operations. In risk-adjusted analyses, there was no increased odds for mortality in patients operated on over the weekend [odds ratio (OR) 1.07, P = 0.811]; however, there was an increased odds of major morbidity (OR 1.37, P = 0.034). Furthermore, compared with Monday, morbidity increased as the operative day approached the weekend (Tuesday 0.98, P = 0.828; Wednesday 1.07, P = 0.469; Thursday 1.12, P = 0.229; Friday 1.19, P = 0.041; weekend 1.47, P = 0.014)., Conclusions: While patients requiring surgery on the weekend are higher risk, there is no independent effect of weekend surgery on mortality. However, these patients are at increased risk for major morbidity, the causes of which require further investigation., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: With a rising emphasis on public reporting, we hypothesized that select hospitals are becoming increasingly risk-averse by avoiding high-risk operations. Further, we evaluated the association between risk-averse practices, outcomes, and publicly reported quality measures., Methods: Clinical data from 78,417 patients undergoing cardiac surgery (2002-2016) from a regional consortium was paired with publicly available reimbursement and quality data. High-risk surgery was defined as predicted risk of mortality ≥5%. Hospital risk aversion was defined as a significant decrease in both high-risk volume and proportion, with cases stratified by hospital risk aversion status for univariate analysis., Results: The rate of high-risk cases decreased from 17.9% in 2002 to 12.6% in 2016. Significant risk aversion was seen in 39% of hospitals, which had a 59% decrease in high-risk volume vs a 16% decrease at non-risk-averse hospitals. In the last 5 years, declining high-risk cases at risk-averse hospitals were driven by fewer cases from transfers (19.2% vs 28.1%, P < .001) and the emergency department (17.6% vs 19.2%, P = .001). Only non-risk-averse hospitals had mortality rates lower than expected (risk-averse: 0.97 [95% confidence interval, 0.91-1.03], P = .30; non-risk-averse: 0.88 [95% confidence interval, 0.83-0.94], P = .001). There were no differences by risk aversion status in reported ratings or financial incentives (all P > .05)., Conclusions: Over 60% of hospitals continue to operate on high-risk patients, with concentration of care driven by transfer patterns. These non-risk-averse hospitals are high-performing with better-than-expected outcomes, particularly in high-risk cases. Transparency and objectivity in reporting are essential to ensure continued access for these high-risk patients., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Transfer from hospital to hospital for cardiac surgery represents a large portion of some clinical practices. Previous literature in other surgical fields has shown worse outcomes for transferred patients. We hypothesized that transferred patients would be higher risk and demonstrate worse outcomes than those admitted through the emergency department., Methods: All patients undergoing cardiac operations with a Society of Thoracic Surgeons Predicted Risk of Mortality were evaluated from a multicenter, statewide Society of Thoracic Surgeons database. Only patients requiring admission before surgery were included. Patients were stratified by admission through the emergency department or in transfer. Transfers were further stratified by the cardiothoracic surgery capabilities at the referring center., Results: A total of 13,094 patients met the inclusion criteria of admission before surgery. This included 7582 (57.9%) transfers, of which 502 (6.6%) were referred from cardiac centers. Compared with emergency department admissions, transfers had increased hospital costs despite lower operative risk (Predicted Risk of Mortality 1.5% vs 1.6%, P < .01) and equivalent postoperative morbidity (15.6% vs 15.3% P = .63). In risk-adjusted analysis, transfer status was not independently associated with worse outcomes. Patients transferred from centers that perform cardiac surgery are higher risk than general transfers (Predicted Risk of Mortality 2.5% vs 1.5, P < .01), but specialized care results in excellent risk-adjusted outcomes (observed/expected: mortality 0.81; morbidity or mortality 0.90)., Conclusions: Transfer patients have similar rates of postoperative complications but increased resource use compared with patients admitted through the emergency department. Patients transferred from centers that perform cardiac surgery represent a particularly high-risk subgroup., (Copyright © 2019 The American Association for Thoracic Surgery. All rights reserved.)

Objectives: Outcomes in cardiac surgery are benchmarked against national Society of Thoracic Surgeons (STS) data and include patients undergoing elective, urgent, emergent, and salvage operations. This practice relies on accurate risk adjustment to avoid risk-averse behavior. We hypothesize that the STS risk calculator does not adequately characterize the risk of salvage operations because of their heterogeneity and infrequent occurrence., Methods: Data on all cardiac surgery patients with an STS predicted risk score (2002-2017) were extracted from a regional database of 19 cardiac surgery centers. Patients were stratified according to operative status for univariate analysis. Observed-to-expected (O:E) ratios for mortality and composite morbidity/mortality were calculated and compared among elective, urgent, emergent, and salvage patients., Results: A total of 76,498 patients met inclusion criteria. The O:E mortality ratios for elective, urgent, and emergent cases were 0.96, 0.98, and 0.93, respectively (all P values > .05). However, mortality rate was significantly higher than expected for salvage patients (O:E ratio, 1.41; P = .04). Composite morbidity/mortality rate was lower than expected in elective (O:E ratio, 0.81; P = .0001) and urgent (O:E ratio, 0.93; P = .0001) cases but higher for emergent (O:E ratio, 1.13; P = .0006) and salvage (O:E ratio, 1.24; P = .01). O:E ratios for salvage mortality were highly variable among each of the 19 centers., Conclusions: The current STS risk models do not adequately predict outcomes for salvage cardiac surgery patients. On the basis of these results, we recommend more detailed reporting of salvage outcomes to avoid risk aversion in these potentially life-saving operations., (Copyright © 2019. Published by Elsevier Inc.)

Background: Annular enlargement (AE) is a critical technique to avoid patient-prosthesis mismatch and may help facilitate future valve-in-valve (ViV) transcatheter replacement. We hypothesized that the addition of annular enlargement would increase risk of morbidity and mortality and that the number of annular enlargement procedures is increasing to accommodate future ViV procedures., Methods: Patients undergoing aortic valve replacement ± coronary surgery (2012 to 2017) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by annular enlargement and era, pre-ViV (2012 to 2014) vs ViV (2015 to 2017) for univariate analysis. Risk-adjusted outcomes were assessed by hierarchical regression modeling adjusting for predicted risk of mortality., Results: Of 6045 patients, the 300 (5.0%) who received an annular enlargement were younger and more commonly female. Patients receiving an annular enlargement had higher complication rates including operative mortality (4.7% vs 2.5%, P = .024). After risk adjustment, AE was independently associated with increased mortality (odds ratio, 2.06, P = .016) and major morbidity (odds ratio, 1.41, P = .042). The rate of enlargement increased from 3.9% pre-ViV to 6.3% ViV (P < .001). The use of ViV capable valves (bioprosthetic ≥23 mm) from 61% to 67% (P = .001), and more in AE patients (30% vs 11% non-AE). Alternatively, the rate of patient prosthesis mismatch declined from 23% to 16%., Conclusions: Increasing utilization of AE coincides with a decline in patient prosthesis mismatch and may facilitate future ViV transcatheter aortic valve replacement. However, AE was independently associated with increased morbidity and mortality. High variability in AE volume may be increasing risk and deserves further investigation., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Evidence in other surgical subspecialties suggests patients traveling farther to undergo surgery have worse outcomes. We sought to determine the impact of travel distance and travel beyond closest center on outcomes after valve surgery., Methods: Patients who underwent valve surgery ±CABG with a Society of Thoracic Surgeons (STS) predicted risk and zip code were extracted from a statewide STS database (2011-016). Patients were stratified by those receiving care greater than or equal to 20 miles from the closest surgical center (Traveler) or at the closest center (Non-Traveler). Multivariate logistic regression assessed the effects of travel distance and traveler status on mortality and major morbidity adjusted for STS predicted risk, median income by zip code, and payer status., Results: Median travel distance for all patients (n = 4765) was 19 miles and after risk-adjustment increasing distance was associated with reduced operative mortality (odds ratio [OR], 0.94 [0.89-1.00], P = .049) with no impact on major morbidity. Travelers (445 patients, 9.3%) had lower median income, higher self-pay and reoperative status, but similar urgent/emergent status and STS risk as Non-Travelers. Travelers had lower operative mortality (1.6% vs 4.3%, P = .005) which remained statistically lower after risk-adjustment (OR, 0.32 [0.14-0.75], P = .009). This mortality difference was particularly pronounced in patients with postoperative complications (3.1% vs 7.9%, P = .005)., Conclusions: Contrary to other surgical subspecialties, farther travel distance and bypassing the nearest surgical center were associated with lower rates of operative mortality and failure to rescue. Either referral patterns or financials reasons may result in Travelers ending up at high performing centers that prevent escalation of complications., (© 2019 Wiley Periodicals, Inc.)

Background: Limited prior studies suggest patients with acute type A aortic dissection (ATAAD) and prior cardiac surgery are at increased risk for major complications compared with those without a prior sternotomy. We sought to investigate the impact of prior cardiac surgery on ATAAD outcomes across a multicenter regional consortium., Methods: Patients undergoing surgical intervention for ATAAD in a regional Society of Thoracic Surgeons database between 2002 and 2017 were stratified by prior cardiac surgery (reoperative) status. Demographics, operative characteristics, outcomes and cost data were compared by univariate analysis. Multivariable regression models assessed risk-adjusted impact of reoperative status on outcomes., Results: A total of 1,332 patients underwent surgery for ATAAD, of whom 138 (10.4%) were reoperations. Reoperative patients were older (63 vs. 58 years, p < 0.01) with more comorbidities. These patients had longer median cardiopulmonary bypass times (218 vs 177 minutes, p < 0.01) and increased blood product utilization; however rates of aortic arch, root, and valve procedures were similar. On unadjusted analysis operative mortality was higher in reoperative patients (28% vs 15%, p < 0.01) with a longer total length of stay (13 vs 10 days, p = 0.02). Reoperative patients exhibited a trend toward decreased mortality at high-volume centers (25.7% vs 37.9%, p = 0.19). After risk adjustment reoperative status remained associated with mortality (odds ratio, 2.1; p < 0.01) as well as composite morbidity-mortality (odds ratio, 2.2; p < 0.01)., Conclusions: In this multicenter cohort undergoing repair of ATAAD prior cardiac surgery was associated with an increased morbidity and mortality. Centralization to high-volume centers and emerging technologies may improve outcomes in this high-risk population., (Copyright © 2019 The Society of Thoracic Surgeons. All rights reserved.)

Background: Left ventricular assist devices (LVADs) have revolutionized the treatment of advanced heart failure, but proliferation of device therapy has unmasked potential complications. Reports have emerged of outflow graft narrowing due to extrinsic compression., Methods and Results: The records of patients with LVADs that had been implanted at our institution were reviewed. Those who had postimplantation computed tomography angiographies sufficient to analyze the outflow graft lumen were identified, and the studies were analyzed to characterize the outflow graft lumen. We identified 241 patients; 110 (46%) had suitable computed tomography angiographies. Of those, 15 (14%) had evidence of outflow graft lumen narrowing, all in HeartMate devices and all within the portion covered by the bend relief. Of the 15, 3 underwent invasive examination, all without intraluminal thrombus but, rather, with biodebris between the bend relief and the outflow graft. Patients with HeartWare devices had a wide range of biodebris accumulation surrounding the outflow graft but no cases of lumen narrowing. On multivariable analysis, 1) time from device implant to scan, 2) nonischemic cardiomyopathy and 3) age at implant were significantly associated with higher risk of graft narrowing., Conclusion: Outflow graft narrowing can be seen in a number of patients with HeartMate LVADs within the portion covered by the bend relief. In the limited number of patients who underwent invasive evaluation, the narrowing was found to arise from extrinsic compression rather than intraluminal thrombus. The clinical significance of this requires further investigation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The effects of socioeconomic factors other than insurance status and race on outcomes after cardiac operations are not well understood. We hypothesized that the Distressed Communities Index (DCI), a comprehensive socioeconomic ranking by zip code, would predict operative mortality after coronary artery bypass grafting (CABG)., Methods: All patients who underwent isolated CABG (2010 to 2017) in the Virginia Cardiac Services Quality Initiative database were analyzed. The DCI accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies, with scores ranging from 0 (no distress) to 100 (severe distress). Patients were stratified by DCI quartiles (I: 0 to 24.9, II: 25 to 49.9, III: 50 to 74.9, IV: 75 to 100) and compared. Hierarchical linear regression modeled the association between the DCI and mortality., Results: A total of 19,756 CABG patients were analyzed, with mean predicted risk of mortality of 2.0% ± 3.5%. Higher DCI scores were associated with increasing predicted risk of mortality. Overall operative mortality was 2.1% (n = 424) and increased with increasing DCI quartile (I: 1.6% [n = 95], II: 2.1% [n = 77], III: 2.4% [n = 114], IV: 2.6% [n = 138]; p = 0.0009). The observed-to-expected ratio for mortality increased as level of socioeconomic distress increased. After risk adjustment for The Society of Thoracic Surgeons predicted risk of mortality, year of surgical procedure, and hospital, the DCI remained predictive of operative mortality after CABG (odds ratio, 1.14 for each 25-point increase in DCI; 95% confidence interval 1.04 to 1.26; p = 0.007)., Conclusions: The DCI independently predicts risk-adjusted operative mortality after CABG. Socioeconomic status, although not part of traditional risk calculators, should be considered when building risk models, evaluating resource utilization, and comparing hospitals., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although liver disease increases surgical risk, it is not considered in The Society for Thoracic Surgeons (STS) risk calculator. This study assessed the impact of Model for End-Stage Liver Disease (MELD) on outcomes after cardiac surgical procedures and the additional predictive value of MELD in the STS risk model., Methods: Deidentified records of 21,272 patients were extracted from a regional STS database. Inclusion criteria were any cardiac operation with a risk score available (2011-2016). Exclusion criteria included missing MELD (n = 2,895) or preoperative anticoagulation (n = 144). Patients were stratified into three categories, MELD < 9 (low), MELD 9 to 15 (moderate), and MELD > 15 (high). Univariate and multivariate logistic regression assessed risk-adjusted associations between MELD and operative outcomes., Results: Increasing MELD scores were associated with greater comorbid disease, mitral operation, prior cardiac operation, and higher STS-predicted risk of mortality (1.1%, 2.3%, and 6.0% by MELD category; p < 0.0001). The operative mortality rate increased with increasing MELD score (1.6%, 3.9%, and 8.4%; p < 0.0001). By logistic regression MELD score was an independent predictor of operative mortality (odds ratio, 1.03 per MELD score point; p < 0.0001) as were the components total bilirubin (odds ratio, 1.22 per mg/dL; p = 0.002) and international normalized ratio (odds ratio, 1.40 per unit; p < 0.0001). Finally, MELD score was independently associated with STS major morbidity and the component complications renal failure and stroke., Conclusions: Increasing MELD score, international normalized ratio, and bilirubin all independently increase risk of operative mortality. Because high rates of missing data currently limit utilization of MELD, efforts to simplify and improve data collection would help improve future risk models., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Expedient extubation after cardiac surgery has been associated with improved outcomes, leading to postoperative extubation frequently during overnight hours. However, recent evidence in a mixed medical-surgical intensive care unit population demonstrated worse outcomes with overnight extubation. This study investigated the impact of overnight extubation in a statewide, multicenter Society of Thoracic Surgeons database., Methods: Records from 39,812 patients undergoing coronary artery bypass grafting or valve operations (2008-2016) and extubated within 24 hours were stratified according to extubation time between 06:00 and 18:00 (day) or between 18:00 and 6:00 (overnight). Outcomes including reintubation, mortality, and composite morbidity-mortality were evaluated using hierarchical regression models adjusted for Society of Thoracic Surgeons predictive risk scores. To further analyze extubation during the night, a subanalysis stratified patients into 3 groups: 06:00 to 18:00, 18:00 to 24:00, and 24:00 to 06:00., Results: A total of 20,758 patients were extubated overnight (52.1%) and were slightly older (median age 66 vs 65 years, P < .001) with a longer duration of ventilation (4 vs 7 hours, P < .001). Day and overnight extubation were associated with equivalent operative mortality (1.7% vs 1.7%, P = .880), reintubation (3.7% vs 3.4%, P = .141), and composite morbidity-mortality (8.2% vs 8.0%, P = .314). After risk adjustment, overnight extubation was not associated with any difference in reintubation, mortality, or composite morbidity-mortality. On subanalysis, those extubated between 24:00 and 06:00 exhibited increased composite morbidity-mortality (odds ratio, 1.18; P = .001) but no difference in reintubation or mortality., Conclusions: Extubation overnight was not associated with increased mortality or reintubation. These results suggest that in the appropriate clinical setting, it is safe to routinely extubate cardiac surgery patients overnight., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Institutional studies suggest robotic mitral surgery may be associated with superior outcomes. The objective of this study was to compare the outcomes of robotic, minimally invasive (mini), and conventional mitral surgery., Methods: A total of 2300 patients undergoing non-emergent isolated mitral valve operations from 2011 to 2016 were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by approach: robotic (n=372), mini (n=576) and conventional sternotomy (n=1352). To account for preoperative differences, robotic cases were propensity score matched (1:1) to both conventional and mini approaches., Results: The robotic cases were well matched to the conventional (n=314) and mini (n=295) cases with no significant baseline differences. Rates of mitral repair were high in the robotic and mini cohorts (91%), but significantly lower with conventional (76%, P<0.0001) despite similar rates of degenerative disease. All procedural times were longest in the robotic cohort, including operative time (224 vs 168 min conventional, 222 vs 180 min mini; all P<0.0001). The robotic approach had comparable outcomes to the conventional approach except there were fewer discharges to a facility (7% vs 15%, P=0.001) and 1 less day in the hospital (P<0.0001). However, compared with the mini approach, the robotic approach had more transfusions (15% vs 5%, P<0.0001), higher atrial fibrillation rates (26% vs 18%, P=0.01), and 1 day longer average hospital stay (P=0.02)., Conclusion: Despite longer procedural times, robotic and mini patients had similar complication rates with higher repair rates and shorter length of stay metrics compared with conventional surgery. However, the robotic approach was associated with higher atrial fibrillation rates, more transfusions and longer postoperative stays compared with minimally invasive approach., Competing Interests: Competing interests: GA is a consultant for Abbott, Edwards, Medtronic, and Cephea. AS is a consultant on the Medtronic Cardiac Surgery Advisory Board., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Postoperative atrial fibrillation (POAF) is a known risk factor for morbidity and mortality after cardiac surgery but has not been investigated in the left ventricular assist device (LVAD) population. We hypothesize that POAF will increase morbidity and resource utilization after LVAD placement., Methods: Records were extracted for all patients in a regional database who underwent continuous-flow LVAD placement (n = 1064, 2009-2017). Patients without a history of atrial fibrillation (n = 689) were stratified by POAF for univariate analysis. Multivariable regression models calculated the risk-adjusted association of arrhythmias on outcomes and resource utilization., Results: The incidence of new-onset POAF was 17.6%, and patients who developed POAF were older and more likely to have moderate/severe mitral regurgitation, a history of stroke, and concomitant tricuspid surgery. After risk adjustment, POAF was not associated with operative mortality or stroke but was associated with major morbidity (odds ratio [OR] 2.5 P = .0004), prolonged ventilation (OR 2.7, P < .0001), unplanned right ventricular assist device (OR 2.9, P = .01), and a trend toward renal failure (OR 2.0, P = .06). In addition, POAF was associated with greater risk-adjusted resource utilization, including discharge to a facility (OR 2.2, P = .007), an additional 4.9 postoperative days (P = .02), and 88 hours in the intensive care unit (P = .01)., Conclusions: POAF was associated with increased major morbidity, possibly from worsening right heart failure leading to increased renal failure and unplanned right ventricular assist device placement. This led to patients with POAF having longer intensive care unit and hospital stays and more frequent discharges to a facility., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: A statewide database identified prolonged ventilation (PV) and acute renal failure (RF) as the biggest cost drivers after isolated coronary artery bypass grafting. Reducing these complications through regional collaboration should improve outcomes and lower health care costs., Methods: A total of 27,978 patients who underwent isolated coronary artery bypass grafting were divided into pre- and post-quality improvement initiative groups (early era: 2008 to 2011, n = 15,176; later era: 2012 to 2015, n = 12,802). Focused learning sessions on PV and postoperative RF were undertaken in the earlier era. Incidence of death, PV, and RF in the two groups was analyzed using one-way analysis of variance and Fisher exact tests., Results: The Society of Thoracic Surgeons (STS) predicted risk of mortality and predicted risk of mortality/morbidity were significantly higher in the later era (p < 0.01), as were STS predicted PV (10.1% vs 11.3%) and RF (3.4% vs 3.8%). Despite these increased risks, STS observed-to-expected ratios for mortality and mortality/morbidity fell. Observed rates for PV (10.5% vs 8.8%, p < 0.01) and RF (3.6% vs 2.3%, p < 0.01) were associated with STS observed-to-expected ratios of PV (1.04 vs 0.78) and RF (1.03 vs 0.60). Adjusting for case volume in the two eras, 271 cases of PV and 170 of RF were avoided, with estimated cost savings of $10,212,637 and $8,519,630, respectively., Conclusions: A regional collaboration using a statewide STS and an all-payor database with focused quality improvement is a powerful tool for change. Despite rising risks for mortality and morbidity, outcomes for PV and RF improved and produced significant cost savings. Applying these efforts nationally can enormously affect patient care and health care costs., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Reducing blood product utilization after cardiac surgery has become a focus of perioperative care as studies have suggested improved outcomes. The relative impact of preoperative anemia versus packed red blood cells (PRBC) transfusion on outcomes remains poorly understood, however. In this study, we investigated the relative association between preoperative hematocrit (Hct) level and PRBC transfusion on postoperative outcomes after coronary artery bypass grafting (CABG) surgery., Methods: Patient records for primary, isolated CABG operations performed between January 2007 and December 2017 at 19 cardiac surgery centers were evaluated. Hierarchical logistic regression modeling was used to estimate the relationship between baseline preoperative Hct level as well as PRBC transfusion and the likelihoods of postoperative mortality and morbidity, adjusted for baseline patient risk. Variable and model performance characteristics were compared to determine the relative strength of association between Hct level and PRBC transfusion and primary outcomes., Results: A total of 33,411 patients (median patient age, 65 years; interquartile range [IQR], 57-72 years; 26% females) were evaluated. The median preoperative Hct value was 39% (IQR, 36%-42%), and the mean Society of Thoracic Surgeons (STS) predicted risk of mortality was 1.8 ± 3.1%. Complications included PRBC transfusion in 31% of patients, renal failure in 2.8%, stroke in 1.3%, and operative mortality in 2.0%. A strong association was observed between preoperative Hct value and the likelihood of PRBC transfusion (P < .001). After risk adjustment, PRBC transfusion, but not Hct value, demonstrated stronger associations with postoperative mortality (odds ratio [OR], 4.3; P < .0001), renal failure (OR 6.3; P < .0001), and stroke (OR, 2.4; P < .0001). A 1-point increase in preoperative Hct was associated with decreased probabilities of mortality (OR, 0.97; P = .0001) and renal failure (OR, 0.94; P < .0001). The models with PRBC had superior predictive power, with a larger area under the curve, compared with Hct for all outcomes (all P < .01). Preoperative anemia was associated with up to a 4-fold increase in the probability of PRBC transfusion, a 3-fold increase in renal failure, and almost double the mortality., Conclusions: PRBC transfusion appears to be more closely associated with risk-adjusted morbidity and mortality compared with preoperative Hct level alone, supporting efforts to reduce unnecessary PRBC transfusions. Preoperative anemia independently increases the risk of postoperative morbidity and mortality. These data suggest that preoperative Hct should be included in the STS risk calculators. Finally, efforts to optimize preoperative hematocrit should be investigated as a potentially modifiable risk factor for mortality and morbidity., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

A microwave brain imaging system model is envisaged to detect and visualize tumor inside the human brain. A compact and efficient microstrip patch antenna is used in the imaging technique to transmit equivalent signal and receive backscattering signal from the stratified human head model. Electromagnetic band gap (EBG) structure is incorporated on the antenna ground plane to enhance the performance. Rectangular and circular EBG structures are proposed to investigate the antenna performance. Incorporation of circular EBG on the antenna ground plane provides an improvement of 22.77% in return loss, 5.84% in impedance bandwidth, and 16.53% in antenna gain with respect to the patch antenna with rectangular EBG. The simulation results obtained from CST are compared to those obtained from HFSS to validate the design. Specific absorption rate (SAR) of the modeled head tissue for the proposed antenna is determined. Different SAR values are compared with the established standard SAR limit to provide a safety regulation of the imaging system. A monostatic radar-based confocal microwave imaging algorithm is applied to generate the image of tumor inside a six-layer human head phantom model. S -parameter signals obtained from circular EBG loaded patch antenna in different scanning modes are utilized in the imaging algorithm to effectively produce a high-resolution image which reliably indicates the presence of tumor inside human brain.

Background: The surgical management of acute type A aortic dissection is evolving, and many aortic centers of excellence are reporting superior outcomes. We hypothesize that similar trends exist in a multiinstitutional regional consortium., Methods: Records for 884 consecutive patients who underwent aortic operations (2003 to 2015) for acute type A aortic dissection were extracted from a regional The Society of Thoracic Surgeons database. Patients were stratified into three equal operative eras. Differences in outcomes and risk factors for morbidity and mortality were determined., Results: Surgical procedures for type A aortic dissection are increasing in extent and complexity. Aortic root repair was performed in 16% of early era cases compared with 67% currently (p < 0.0001). Similarly, aortic arch repair increased from 27% to 37% cases (p < 0.0001). Cerebral perfusion is currently used in 85% of circulatory arrest cases, most frequently antegrade (57%). Total circulatory arrest times increased (29 minutes vs 31 minutes vs 36 minutes; p = 0.005), but times without cerebral perfusion were stable (12 minutes vs 6 minutes; p = 0.68). Although the operative mortality rate remained stable at 18.9% during the 3 operative eras, there were significant decreases in pneumonia and reoperations (p < 0.05). Predictors of operative mortality and major morbidity are age (odds ratio [OR], 1.04; p < 0.0001), previous stroke (OR, 2.09; p = 0.03), and elevated creatinine (OR, 1.31; p = 0.01). Importantly, the extent of aortic operation did not increase risk for morbidity or mortality., Conclusions: Operative morbidity and mortality remain significant for type A aortic dissection, but lower than historical outcomes. The extent of aortic surgery has increased, resulting in adaptive cerebral protection changes in contemporary "real-world" practice., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Two large, randomized trials are underway evaluating transcatheter aortic valve replacement (AVR) against conventional surgical AVR. We analyzed contemporary, real-world outcomes of surgical AVR in low-risk patients to provide a practical benchmark of outcomes and cost for evaluating current and future transapical AVR technology., Methods: From 2010 to 2015, 2,505 isolated AVR operations were performed for severe aortic stenosis at 18 statewide cardiac institutions. Of these, 2,138 patients had a Society of Thoracic Surgeons predicted risk of mortality of less than 4%, and 1,119 met other clinical and hemodynamic criteria as outlined in the PARTNER 3 (The Placement of Transcatheter Aortic Valves) protocol. Patients with endocarditis, end-stage renal disease, ejection fraction of less than 0.45, bicuspid valves, and previous valve replacements were excluded. Outcomes of interest included operative death and postoperative adverse events., Results: The median Society of Thoracic Surgeons predicted risk of mortality for the study-eligible patients was 1.44%, with a median age of 72 years (interquartile range [IQR], 65 to 78 years). Operative mortality was 1.3%, permanent stroke was 1.3%, and pacemaker requirement was 4.2%. The most common adverse events were transfusion of 2 or more units of red blood cells (18%) and atrial fibrillation (28%). The median length of stay was 6 days (IQR, 5 to 8 days). Median total hospital cost was $37,999 (IQR, $30,671 to $46,138). Examination of complications by age younger than 65 vs 65 or older demonstrated a significantly lower need for transfusion (11.2%, p < 0.001) and incidence of atrial fibrillation (17.1%, p < 0.001) but no difference in operative mortality (2.2% vs 0.9%, p = 0.1), major morbidity (10.4% vs 12.6%, p = 0.3), or total hospital costs., Conclusions: Low-risk patients undergoing surgical AVR in the current era have excellent results. The most common complications were atrial fibrillation and bleeding. These real-world results should provide additional context for upcoming transcatheter clinical trial data., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

As a disaster prone country, Bangladesh is regularly hit by natural hazards, including devastating cyclones, such as in 1970, 1991 and 2007. Although the number of cyclones' fatalities reduced from 0.3 million in 1970 to a few thousand or fewer in recent events, loss of lives and impact on livelihoods remains a concern. It depends on the meteorological characteristics of cyclone and the general vulnerability and capacity of the exposed population. In that perspective, a spatially explicit risk assessment is an essential step towards targeted disaster risk reduction. This study aims at analyzing the spatial variation of the different factors contributing to the risk for coastal communities at regional scale, including the distribution of the hazards, exposure, vulnerability and capacity. An exploratory factor analysis method is used to map vulnerability contrasts between local administrative units. Indexing and ranking using geospatial techniques are used to produce maps of exposure, hazard, vulnerability, capacities and risk. Results show that vulnerable populations and exposed areas are distributed along the land sea boundary, islands and major inland rivers. The hazard, assessed from the density of historical cyclone paths, is highest in the southwestern part of the coast. Whereas cyclones shelters are shown to properly serve the most vulnerable populations as priority evacuation centers, the overall pattern of capacity accounting for building quality and road network shows a more complex pattern. Resultant risk maps also provide a reasonable basis from which to take further structural measures to minimize loss of lives in the upcoming cyclones., Competing Interests: The authors declare no conflict of interest.

Background: Transcatheter aortic valve replacement (TAVR) represents a disruptive technology that is rapidly expanding in use. We evaluated the effect on surgical aortic valve replacement (SAVR) patient selection, outcomes, volume, and cost., Methods: A total of 11,565 patients who underwent SAVR, with or without coronary artery bypass grafting (2002 to 2015), were evaluated from the Virginia Cardiac Services Quality Initiative database. Patients were stratified by surgical era: pre-TAVR era (2002 to 2008, n = 5,113), early-TAVR era (2009 to 2011, n = 2,709), and commercial-TAVR era (2012 to 2015, n = 3,743). Patient characteristics, outcomes, and resource utilization were analyzed by univariate analyses., Results: Throughout the study period, statewide SAVR volumes increased with median volumes of pre-TAVR: 722 cases/year, early-TAVR: 892 cases/year, and commercial-TAVR: 940 cases/year (p = 0.005). Implementation of TAVR was associated with declining Society of Thoracic Surgeons predicted risk of mortality among SAVR patients (3.7%, 2.6%, and 2.4%; p < 0.0001), despite increasing rates of comorbid disease. The mortality rate was lowest in the current commercial-TAVR era (3.9%, 4.3%, and 3.2%; p = 0.05), and major morbidity decreased throughout the time period (21.2%, 20.5%, and 15.2%; p < 0.0001). The lowest observed-to-expected ratios for both occurred in the commercial-TAVR era (0.9 and 0.9, respectively). Resource utilization increased generally, including total cost increases from $42,835 to $51,923 to $54,710 (p < 0.0001)., Conclusions: At present, SAVR volumes have not been affected by the introduction of TAVR. The outcomes for SAVR continue to improve, potentially due to availability of transcatheter options for high-risk patients. Despite rising costs for SAVR, open approaches still provide a significant cost advantage over TAVR., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Hepatocyte transplantation partially corrects genetic disorders and has been associated anecdotally with reversal of acute liver failure. Monitoring for graft function and rejection has been difficult, and has contributed to limited graft survival. Here we aimed to use preparative liver-directed radiation therapy, and continuous monitoring for possible rejection in an attempt to overcome these limitations., Methods: Preparative hepatic irradiation was examined in non-human primates as a strategy to improve engraftment of donor hepatocytes, and was then applied in human subjects. T cell immune monitoring was also examined in human subjects to assess adequacy of immunosuppression., Results: Porcine hepatocyte transplants engrafted and expanded to comprise up to 15% of irradiated segments in immunosuppressed monkeys preconditioned with 10Gy liver-directed irradiation. Two patients with urea cycle deficiencies had early graft loss following hepatocyte transplantation; retrospective immune monitoring suggested the need for additional immunosuppression. Preparative radiation, anti-lymphocyte induction, and frequent immune monitoring were instituted for hepatocyte transplantation in a 27year old female with classical phenylketonuria. Post-transplant liver biopsies demonstrated multiple small clusters of transplanted cells, multiple mitoses, and Ki67 + hepatocytes. Mean peripheral blood phenylalanine (PHE) level fell from pre-transplant levels of 1343±48μM (normal 30-119μM) to 854±25μM (treatment goal ≤360μM) after transplant (36% decrease; p<0.0001), despite transplantation of only half the target number of donor hepatocytes. PHE levels remained below 900μM during supervised follow-up, but graft loss occurred after follow-up became inconsistent., Conclusions: Radiation preconditioning and serial rejection risk assessment may produce better engraftment and long-term survival of transplanted hepatocytes. Hepatocyte xenografts engraft for a period of months in non-human primates and may provide effective therapy for patients with acute liver failure., Lay Summary: Hepatocyte transplantation can potentially be used to treat genetic liver disorders but its application in clinical practice has been impeded by inefficient hepatocyte engraftment and the inability to monitor rejection of transplanted liver cells. In this study, we first show in non-human primates that pretreatment of the host liver with radiation improves the engraftment of transplanted liver cells. We then used this knowledge in a series of clinical hepatocyte transplants in patients with genetic liver disorders to show that radiation pretreatment and rejection risk monitoring are safe and, if optimized, could improve engraftment and long-term survival of transplanted hepatocytes in patients., (Copyright © 2016 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

The pathogenic bacterium Helicobacter pylori is a causative agent of gastric diseases in Bangladesh as well as throughout the world. This study aimed at analyzing the prevalence of H. pylori infection among dyspeptic patients in Chittagong, the second most populous city of Bangladesh, using 16S rRNA-based H. pylori -specific Polymerase Chain Reaction and Campylobacter -like organism test. We found that 67% of the population under study was positive for H. pylori infection. Gastric ulcer and duodenal ulcer disease showed statistically significant association with H. pylori infection; however, no association of H. pylori infection was observed in terms of age and gender. This study would play a crucial role in managing H. pylori -induced gastric diseases by understanding the current trend of H. pylori infection in the Chittagong region of Bangladesh., Competing Interests: Authors disclose no potential conflicts of interest.

Background: Insufficient data delineate outcomes for Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 patients with the total artificial heart (TAH)., Methods: We studied 66 consecutive patients implanted with the TAH at our institution from 2006 through 2012 and compared outcome by INTERMACS profile. INTERMACS profiles were adjudicated retrospectively by a reviewer blinded to clinical outcomes., Results: Survival after TAH implantation at 6 and 12 months was 76% and 71%, respectively. INTERMACS profile 1 patients had decreased 6-month survival on the device compared with those in profiles 2-4 (74% vs 95%, log rank: P = .015). For the 50 patients surviving to heart transplantation, the 1-year posttransplant survival was 82%. There was no difference in 1-year survival when comparing patients in the INTERMACS 1 profile with less severe profiles (79% vs 84%; log rank test P = .7; hazard ratio [confidence interval] 1.3 [0.3-4.8])., Conclusions: Patients implanted with the TAH as INTERMACS profile 1 had reduced survival to transplantation compared with less sick profiles. INTERMACS profile at the time of TAH implantation did not affect 1-year survival after heart transplantation., (Copyright © 2016 Elsevier Inc. All rights reserved.)