Background: This study investigated the impact of transplanting center donor acceptance patterns on usage of extended-criteria donors (ECDs) and posttransplant outcomes following orthotopic heart transplantation (OHT). Methods: The Scientific Registry of Transplant Recipients was queried to identify heart donor offers and adult, isolated OHT recipients in the United States from 1/1/2013-10/17/2018. Centers were stratified into 3 equal-size terciles based on donor heart acceptance rates (<13.7%, 13.7%-20.2%, >20.2%). Overall survival was compared between recipients of ECDs (≥40 years, left ventricular ejection fraction <60%, distance ≥500 miles, hepatitis B, hepatitis C or human immunodeficiency virus, or ≥50 offers) and recipients of traditional-criteria donors, and among transplanting terciles. Results: A total of 85,505 donor heart offers were made to 133 centers with 15,264 (17.9%) accepted for OHT. High-acceptance programs (>20.2%) more frequently accepted donors with LVEF <60%, HIV, HCV, and/or HBV, ≥50 offers, or distance >500 miles from the transplanting center (each p<0.001). Posttransplant survival was comparable across all three terciles (p=0.11). One- and five-year survival were also similar across terciles when examining recipients of all five ECD factors. Acceptance tier and increasing acceptance rate were not found to have any impact on mortality in multivariable modeling. Of ECD factors, only age ≥40 years was found to have increased hazards for mortality (HR 1.33, 95% CI 1.22-1.46, p<0.001). Conclusions: Of recipients of ECD hearts, outcomes are similar across center-acceptance terciles. Educating less aggressive programs to increase donor acceptance and ECD utilization may yield higher national rates of OHT without major impact on outcomes.
Background: This study evaluated outcomes of cardiac operations with very prolonged cardiopulmonary bypass (CPB) times. Methods: This was a retrospective study of cardiac surgical procedures with very-long CBP times (≥300 minutes) performed at a single institution. Primary outcomes of operative (≤30-day) and one-year mortality were evaluated, and secondary outcomes included use of mechanical support and postoperative complications. A probability analysis was also conducted to identify the correlation between operative mortality and CPB time. Results: 293 patients were included with a Society of Thoracic Surgeons predicted risk of mortality of 2.51% (IQR 1.32%- 4.70%), and median CPB time of 340 minutes (IQR 315.0-385.0). Preoperative mechanical support included intra-aortic balloon pump (IABP, n=4, 1.4%), Impella (n=0), or extracorporeal membrane oxygenation (ECMO, n=2, 0.7%). Intraoperative and operative mortality were 5.1% and 22.5%, respectively. Intraoperative or postoperative mechanical support were utilized in 90 (30.7%) cases, including IABP (n=65, 22.2%), Impella (n=2, 0.68%), or ECMO (n=23, 7.8%). Postoperative complications included prolonged mechanical ventilation (n=121, 41.3%), renal failure (n=71, 24.2%), stroke (n=20, 6.8%), and reoperation (n=95, 32.4%). One-year survival for the overall cohort was 61.4%. Probability analysis identified a CPB time of 446 minutes to be associated with 50% odds of operative mortality. Conclusions: Cardiac operations requiring very-long CPB times are associated with high rates of operative mortality and morbidity, with a 50% operative mortality rate predicted for those with a CPB time of 446 minutes or longer. Nonetheless, the majority of patients survive at least 1 year, and these cases should not be considered futile.
Background: This study evaluates the impact of peak preoperative troponin level on outcomes of coronary artery bypass grafting (CABG) for non-ST-elevation myocardial infarction (NSTEMI). Methods: This was a retrospective review of patients undergoing isolated CABG from 2011-2018 with presentation of NSTEMI. Patients were stratified into low- and high-risk groups based on median preoperative peak troponin (1.95ng/dL). Major cardiac and cerebrovascular events (MACCE) and mortality were compared. Multivariable analysis was performed to model risk factors for MACCE and mortality. Results: This study included 1,211 patients, 607 low- (≤1.95ng/dL) and 604 high-risk (>1.95ng/dL). Patients were well-matched with respect to age and comorbidity. High-risk patients had lower median preoperative ejection fraction (46.5% [IQR 35.0%-55.0%] vs 53.0% [IQR 40.0%-58.0%]) and higher incidence of preoperative intra-aortic balloon pump (15.9% vs 8.73%). Intensive care unit (47 hours [IQR 26-82] vs 43 hours [IQR 25-69]) and hospital lengths of stay (10 days [IQR 8-13] vs 9 days [IQR 8-12]) were longer in the high-risk group (each P<0.05). Postoperative complications and thirty-day, one- and five-year rates of both MACCE and survival were similar between groups. Peak troponin >1.95ng/dL was not associated with increased hazards for MACCE, mortality, or readmission in multivariable modeling. In sub-analyses, neither increasing troponin as a continuous variable nor peak troponin >10.00ng/mL were associated with increased hazards for these outcomes. Conclusions: Higher preoperative troponin levels are associated with longer lengths of stay but not MACCE or mortality following CABG. Dictating timing of CABG for NSTEMI based on peak troponin does not appear to be warranted.
Background: Cardiogenic shock is a known risk factor for early mortality following conventional cardiac surgery, however its impact on longitudinal outcomes is less established. This study evaluated longer-term outcomes of conventional cardiac surgery in patients with cardiogenic shock. Methods: This was a retrospective review of conventional cardiac operations performed in patients presenting with cardiogenic shock between 2010 and 2020. The primary outcome was survival, and secondary outcomes included postoperative complications, and rates of heart failure readmission. Multivariable Cox proportional hazards modeling was conducted to identify risk-adjusted predictors of mortality. Results: 604 patients were included, representing 4% of all cardiac cases. Median follow up was 4.3 (IQR 0.3-6.8) years. Aortic root repair/replacement (31.6%) was most commonly performed. 11.1% of patients required preoperative cardiopulmonary resuscitation. Bridging modalities included intravenous inotropes (35.4%), intra-aortic balloon pump (33.4%), Impella (0.5%), or venoarterial extracorporeal membrane oxygenation (3.3%). Operative mortality was 21.5%. Complications included reoperation (24.3%), stroke (15.9%) renal failure (19.2%), and prolonged ventilation (47.9%). Unadjusted 1- and 5-year survival were 71.7% and 62.1%. Risk-adjusted preoperative predictors for mortality included peripheral vascular disease (HR 1.75, 95% CI 1.23-2.49), dialysis dependency (HR 6.30, 95% CI 3.77–10.51) and increasing age (HR 1.02, 95% CI 1.02–1.04). Three patients eventually underwent ventricular assist device implantation and no patients underwent heart transplantation. Conclusions: Despite high initial rates of morbidity and mortality following conventional cardiac surgery in patients presenting with cardiogenic shock, 62% survive to 5 years and most do not require heart failure readmission or advanced heart failure surgical therapy.
Background: The purpose of this study was to investigate the incidence, predictors, and long-term impact of gastrointestinal (GI) complications following adult cardiac surgery. Methods: Index Society of Thoracic Surgeons (STS) adult cardiac operations performed between January 2010 and February 2018 at a single institution were included. Patients were stratified by the occurrence of postoperative GI complications. Outcomes included early and late survival as well as other associated major postoperative complications. A sub-analysis of propensity score matched patients was also performed. Results: 10,285 patients were included, and the overall rate of GI complications was 2.4% (n=246). Predictors of GI complications included dialysis dependency, intra-aortic balloon pump, congestive heart failure, chronic obstructive pulmonary disease, and longer aortic cross-clamp times. Thirty-day (2.6% vs 24.8%), one- (6.3% vs 41.9%), and three-year (11.1% vs 48.4%) mortality were substantially higher in patients who experienced GI complications (all P<0.001). GI complication was associated with a three-fold increased hazard for mortality (HR 3.1, 95% CI 2.6-3.7) after risk adjustment, and there was an association between the occurrence of GI complications and increased rates of renal failure (39.4% vs 2.5%), new dialysis dependency (31.3% vs 1.5%), multisystem organ failure (21.5% vs 1.0%), and deep sternal wound infections (2.6% vs 0.2%)(all P<0.001). These results persisted in propensity-matched analysis. Conclusions: GI complications are infrequent but have a profound impact on early and late survival, and often occur in association with other major complications. Risk factor modification, heightened awareness, and early detection and management of GI complications appears warranted.
BACKGROUND Prior studies have suggested that LVAD implantation technique and positioning may be associated with subsequent thromboembolic complications. This study evaluated the impact of inflow cannula positioning of the HeartWare LVAD (HVAD) on clinical outcomes. METHODS Adults undergoing primary HVAD implantation between 2009-2018 at a single center were reviewed. HVAD position parameters were calculated from plain chest radiographs and included cannula angle, pump depth, and pump area. These were measured at the day of HVAD implant, at 1 month post-HVAD, and at 6 months post-HVAD. Changes in these parameters over time were measured. Multivariable analysis was also conducted to evaluate associations between pump position parameters on the day of implant and one-year composite outcome of thromboembolic complication (embolic stroke or pump thrombosis) and death. RESULTS 159 HVAD recipients were included with a median follow up of 2.6 years (IQR 1.3 - 4.8 years). Pump area decreased from immediate post-HVAD implantation to one-month follow up (-0.7 cm2; p=0.002), but no significant changes were noted with other position parameters. Increasing preoperative serum creatinine level (HR 1.46, 95% CI 1.03 - 2.08, p=0.034) was associated with increased hazards for the composite outcome in multivariable analysis. Cannula angle, pump depth, nor pump area were associated with the one-year composite outcome, readmission, or other one-year complications including thromboembolic events or mortality when separately modeled. CONCLUSION This review of HVAD recipients demonstrates device position as assessed by chest X-ray does not have significant predictive associations with one-year outcomes.
Background: The predictive value of preoperative pulmonary function testing (PFT) in left ventricular assist device (LVAD) patients remains unknown. This study evaluates the relationship between abnormal PFTs and postimplant outcomes in LVAD patients. Methods: LVAD implants from January 2004 to December 2018 at a single institution were included. Patients were stratified based on presence of abnormal preoperative PFTs, and the primary outcome was respiratory adverse events (AE). Secondary outcomes included one-year overall postimplant survival, and complications including bleeding, renal failure, thromboembolism, and device malfunction. Results: 333 patients underwent LVAD implant, 46.5% (n=155) with normal PFTs and 53.5% (n=178) with abnormal PFTs. Patients with abnormal PFTs were noted to have higher rates of respiratory AEs (25.9% vs 15.1%, p=0.049). In multivariable analysis, the impact of PFTs was most significant when FEV1/FVC ratio was <0.5 (HR 16.32, 95% CI 1.70, 156.78). The rates of other AEs including bleeding, renal failure, right heart failure, and device malfunction were similar. One-year overall postimplant survival was comparable between the groups (56.8% vs 68.8%, p=0.3183), though patients in the lowest strata of FEV1 (<60% predicted) and FEV1/FVC (<0.5) had elevated risk-adjusted hazards for mortality (HR 2.63 95% CI 1.51, 4.60 and HR 18.92, 95% CI 2.10, 170.40, respectively). Conclusions: The presence of abnormal preoperative PFTs is not prohibitory for LVAD implantation although it can be used for risk stratification for respiratory AEs and mortality, particularly in patients with severely reduced metrics. The importance of careful patient selection should be underscored in this higher risk patient subset.