Current Penetration, Completeness, and Representativeness of The Society of Thoracic Surgeons Adult Cardiac Surgery Database

Cardiac Surgery After Transcatheter Aortic Valve Replacement: Trends and Outcomes

BACKGROUND

Reports of cardiac operations after transcatheter aortic valve replacement (TAVR) and early TAVR explantation are increasing. The purpose of this report is to document trends and outcomes of cardiac surgery after initial TAVR.

METHODS

The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for all adult patients undergoing cardiac surgery after a previously placed TAVR between January 2012 and March 2023. This identified an overall cohort and 2 subcohorts: nonaortic valve operations and surgical aortic valve replacement (SAVR) after previous TAVR. Cohorts were examined with descriptive statistics, trend analyses, and 30-day outcomes.

RESULTS

Of 5457 patients who were identified, 2485 (45.5%) underwent non-SAVR cardiac surgery, and 2972 (54.5%) underwent SAVR. The frequency of cardiac surgery after TAVR increased 4235.3% overall and 144.6% per year throughout the study period. The incidence of operative mortality and stroke were 15.5% and 4.5%, respectively. Existing The Society of Thoracic Surgeons risk models performed poorly, because observed-to-expected mortality ratios were significantly >1.0. Among those undergoing SAVR after TAVR, increasing preoperative surgical urgency, age, dialysis, need for SAVR, and concomitant procedures were associated with increased mortality, whereas type of TAVR explant was not.

CONCLUSIONS

The need for cardiac surgery, including redo SAVR after TAVR, is increasing rapidly. Risks are higher, and outcomes are worse than predicted. These data should closely inform heart team decisions if TAVR is considered at lowering age and risk profiles in the absence of longitudinal evidence.

Superlative performance in cardiovascular surgery

Achieving excellence in surgery is an ongoing endeavor, gained through experience, observation, and practice. It is difficult to evaluate enterprise excellence, but attempts include the ratings of the Society of Thoracic Surgeons. The surgery team at Baylor University Medical Center has achieved three-star ratings for 9 of the past 10 evaluations for coronary artery bypass. This accomplishment is a result of many factors, including teamwork, multidisciplinary conferences, application of the latest evidence, continuous efforts at quality improvement, and effective governance. Some aspects of the latter include individual excellence, enjoying the work, being bold, having psychological safety, and employing meritocracy. Discernment of contemporary issues, a clear vision of the common good, and virtuous service to all must be attained while preserving the highest level of patient-centered service to patients and the institution.

Outcomes of Isolated Tricuspid Valve Surgery: A Society of Thoracic Surgeons Analysis and Risk Model

BACKGROUND

To provide patients and surgeons with clinically relevant information, The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried to develop a risk model for isolated tricuspid valve (TV) operations.

METHODS

All patients in the STS Adult Cardiac Surgery Database who had undergone isolated TV repair or replacement (N = 13,587; age 48.3 ± 18.4 years) were identified (July 2017 to June 2023). Multivariable logistic regression accounting for TV replacement vs repair was used to model 8 operative outcomes: mortality, morbidity or mortality or both, stroke, renal failure, reoperation, prolonged ventilation, short hospital stay, and prolonged hospital stay. Model discrimination (C-statistic) and calibration were assessed using 9-fold cross-validation.

RESULTS

The isolated TV study population included 41.1% repairs (N = 5,583; age 52.6 ± 18.1 years) and 58.9% replacements (N = 8,004; age 45.3 ± 18.0 years). The overall predicted risk of operative mortality was 5.6%, and it was similar in TV repairs and replacements (5.5% and 5.7%, respectively), as was the predicted risk of composite morbidity and mortality (28.2% and 26.8%). TV replacements were generally performed in younger patients with a higher endocarditis prevalence than TV repairs (45.7% vs 21.1%). The model yielded a C-statistic of 0.81 for mortality and 0.76 for the composite of morbidity and mortality, with excellent observed-to-expected calibration that was comparable in all subcohorts and predicted risk decile groups.

CONCLUSIONS

An STS risk model has been developed for isolated TV surgery. The current mortality of isolated TV operations is lower than previously observed. This risk prediction model and these contemporary outcomes provide a new benchmark for current and future isolated TV interventions.

Surgical versus transcatheter aortic valve replacement in low-risk Medicare beneficiaries

OBJECTIVE

Recent approval of transcatheter aortic valve replacement (TAVR) in patients at low surgical risk has resulted in a rapid real-world expansion of TAVR in patients not otherwise examined in recent low-risk trials. We sought to evaluate the outcomes of surgical aortic valve replacement (SAVR) versus TAVR in low-risk Medicare beneficiaries.

METHODS

Using the US Centers for Medicare and Medicaid Services claims database, we evaluated all beneficiaries undergoing isolated SAVR (n = 33,210) or TAVR (n = 77,885) (2018-2020). International Classification of Diseases 10th revision codes were used to define variables and frailty was defined by the validated Kim index. Doubly robust risk adjustment was performed with inverse probability weighting and multilevel regression models, as well as competing-risk time to event analysis. A low-risk cohort was identified to simulate recent low-risk trials.

RESULTS

A total of 15,749 low-risk patients (8144 SAVR and 7605 TAVR) were identified. Comparison was performed with doubly robust risk adjustment accounting for all factors. TAVR was associated with lower perioperative stroke (odds ratio, 0.62; P < .001) and hospital mortality (odds ratio, 0.16; P < .001) compared with SAVR. However, risk-adjusted longitudinal analysis demonstrated TAVR was associated with higher late risk of stroke (hazard ratio, 1.65; P < .001), readmission for valve reintervention (hazard ratio, 1.88; P < .001), and all-cause mortality (hazard ratio, 1.54; P < .001) compared with SAVR.

CONCLUSIONS

Among low-risk Medicare beneficiaries younger than age 75 years undergoing isolated AVR, SAVR was associated with higher index morbidity and mortality but improved 3-year risk-adjusted stroke, valve reintervention, and survival compared with TAVR.

Multiarterial vs Single-Arterial Coronary Surgery: 10-Year Follow-up of 1 Million Patients

BACKGROUND

Although many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG.

METHODS

All patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit.

RESULTS

A total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m2 had superior survival with SAG.

CONCLUSIONS

Multiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m2.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Perioperative acetaminophen is associated with reduced acute kidney injury after cardiac surgery

BACKGROUND

Cardiac surgery-associated acute kidney injury (AKI) is associated with increased postoperative morbidity and mortality. Evidence suggests an association between perioperative acetaminophen administration and decreased incidence of postoperative AKI in pediatric cardiac surgery patients; however, an effect in adults is unknown.

METHODS

All patients (n = 6192) undergoing coronary and/or valve surgery with a recorded Society of Thoracic Surgeons (STS) risk score at our institution between 2010 and 2018 were stratified by acetaminophen exposure on the day of surgery using institutional pharmacy records. AKI was determined using the Kidney Disease: Improving Global Outcomes (KDIGO) staging criteria. Logistic regression was used to analyze the association between perioperative acetaminophen and postoperative kidney injury or STS major morbidity. A sensitivity analysis using propensity score matching on the STS predicted risk of renal failure and cardiopulmonary bypass time was performed to account for time bias.

RESULTS

Perioperative acetaminophen exposure was associated with lower odds of stage 1 to 3 acute kidney injury (odds ratio [OR], 0.68; 95% CI, 0.56-0.83; P < .001) and decreased prolonged postoperative ventilation (OR, 0.53; 95% CI, 0.37-0.76; P < .001). A sensitivity analysis provided well-balanced (standard mean difference <0.10) groups of 401 pairs, in which acetaminophen was associated with a decreased incidence of postoperative AKI (OR, 0.7; 95% CI, 0.52-0.94; P = .016).

CONCLUSIONS

Exposure to acetaminophen on the day of surgery was associated with a decreased incidence of AKI in our patients undergoing cardiac surgery. These data serve as a measure of effect size to further explore the therapeutic potential of acetaminophen to reduce postoperative AKI after cardiac surgery and to elucidate the mechanisms involved.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2023 Update on Procedure Data and Research

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database is one of the largest and most comprehensive contemporary clinical databases in use. It now contains >9 million procedures from 1010 participants and 3651 active surgeons. Using audited data collection, it has provided the foundation for multiple risk models, performance metrics, health policy decisions, and a trove of research studies to improve the care of patients in need of cardiac surgical procedures. This annual report provides an update on the current status of the database and summarizes the development of new risk models and the STS Online Risk Calculator. Further, it provides insights into current practice patterns, such as the change in the demographics among patients undergoing aortic valve replacement, the use of minimally invasive techniques for valve and bypass surgery, or the adoption of surgical ablation and left atrial appendage ligation among patients with atrial fibrillation. Lastly, an overview of the research conducted using the STS Adult Cardiac Surgery Database and future directions for the database are provided.

Quality and Impact of Manuscripts Using The Society of Thoracic Surgeons National Databases

BACKGROUND

The Society of Thoracic Surgeons (STS) National Databases contain the largest and most comprehensive cardiac, thoracic, and congenital surgery data available. In this analysis characteristics of manuscripts that used the STS National Databases were examined to evaluate the quality and impact of these publications.

METHODS

Manuscripts published from 2010 to 2020 that used the STS National Databases (Adult Cardiac, General Thoracic, and Congenital Heart Surgery) were examined. The number of times cited per published manuscript, journal of publication, and journal CiteScore were assessed. Author characteristics, including institutional association and h-index, were evaluated for first and last authors.

RESULTS

Of 539 published manuscripts, 179 (33.2%) used the Adult Cardiac Surgery, 128 (23.7%) the Congenital Heart Surgery, 85 (15.8%) the General Thoracic Surgery, and 136 (25.2%) used unspecified STS National Databases. Collectively the analyzed manuscripts were cited 18,943 times, with a mean of 35.1 (range, 0-528) citations per manuscript. Manuscripts were published in 97 journals with a mean year-adjusted CiteScore of 5.6 (range, 0.1-60.2). Authors associated with 361 institutions contributed to published manuscripts. The mean h-index of first authors was 24.6 (range, 0-100) and of last authors was 44.1 (range, 0-164). From 2010 to 2020 first authors wrote a mean of 1.6 (range, 1-31) and last authors wrote a mean of 1.9 (range, 1-29) STS National Databases publications.

CONCLUSIONS

The STS National Databases are some of the most robust data collection sources available to cardiothoracic surgeons. These data have enabled valuable research in respected journals from authors of varying experience levels.

Benchmarking Outcomes of Surgical Aortic Valve Replacement in Patients With Bicuspid Aortic Valves

BACKGROUND

The relative roles for transcatheter and surgical aortic valve replacement (SAVR) for bicuspid aortic valve (AV) stenosis are debated. This study analyzes the 5-year longitudinal outcomes of isolated SAVR in bicuspid vs tricuspid AV patients, particularly in low-risk patients.

METHODS

All patients undergoing isolated index SAVR at 1146 United States hospitals in The Society of Thoracic Surgeons (STS) Adult Cardiac database between July 1, 2011, and December 31, 2018, with linkage to Medicare claims, were analyzed.

RESULTS

A total of 65,687 patients were analyzed, including of 9131 bicuspid patients (13.9%). Compared with tricuspid patients, bicuspid patients were significantly younger (median 70 vs 74 years, P < .001) with lower Society of Thoracic Surgeons predicted risk of mortality scores (mean 1.6% vs 2.3%, P < .001) and lower risk profile. Risk-adjusted 30-day mortality and major morbidity were similar, but risk-adjusted 5-year mortality was significantly lower in the bicuspid patients (adjusted hazard ratio, 0.72; 95% CI, 0.66-0.77), specifically in low-risk patients (adjusted hazard ratio, 0.69; 95% CI, 0.64-0.76). Additionally, the bicuspid cohort had a lower 5-year readmission risk of heart failure, stroke, bleeding, or other cardiovascular causes (all P < .05).

CONCLUSIONS

In this nationally representative study, 30-day mortality was similar, but risk-adjusted 5-year mortality was significantly lower in bicuspid patients undergoing isolated SAVR compared with tricuspid patients, specifically low-risk and normal left ventricular ejection fraction patients. This analysis provides a much-needed 5-year longitudinal national-level benchmark to better inform the discussion of transcatheter vs SAVR in bicuspid patients.

Long-term Outcomes and Anticoagulation in Mitral Valve Surgery-A Report From The Society of Thoracic Surgeons Database

BACKGROUND

Anticoagulation after bioprosthetic mitral valve (MV) replacement (BMVR) and repair (MVrep) is controversial. We explore outcomes among BMVR and MVrep patients in The Society of Thoracic Surgeons Adult Cardiac Surgery Database based on discharge anticoagulation status.

METHODS

BMVR and MVrep patients aged ≥65 years in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were linked to the Centers for Medicare and Medicaid Services claims database. Long-term mortality, ischemic stroke, bleeding, and a composite of the primary end points were compared as a function of anticoagulation. Hazard ratios (HRs) were calculated using multivariable Cox regression.

RESULTS

A total of 26,199 BMVR and MVrep patients were linked to the Centers for Medicare and Medicaid Services database; of these, 44%, 4%, and 52% were discharged on warfarin, non-vitamin K-dependent anticoagulant (NOAC), and no anticoagulation (no-AC; reference), respectively. Warfarin was associated with increased bleeding in the overall study cohort (HR, 1.38; 95% CI 1.26-1.52) and in the BMVR (HR, 1.32; 95% CI, 1.13-1.55) and MVrep subcohorts (HR, 1.42; 95% CI, 1.26-1.60). Warfarin was associated with decreased mortality only among BMVR patients (HR, 0.87; 95% CI, 0.79-0.96). Stroke and the composite outcome did not differ across cohorts with warfarin. NOAC use was associated with increased mortality (HR, 1.33; 95% CI 1.11-1.59), bleeding (HR, 1.37; 95% CI, 1.07-1.74), and the composite outcome (HR, 1.26; 95% CI, 1.08-1.47).

CONCLUSIONS

Anticoagulation was used in fewer than half of mitral valve operations. In MVrep patients, warfarin was associated with increased bleeding and was not protective against stroke or mortality. In BMVR patients, warfarin was associated with a modest survival benefit, increased bleeding, and equivalent stroke risk. NOAC was associated with increased adverse outcomes.

Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and The Society of Thoracic Surgeons (STS)

PREAMBLE

The finalized document was endorsed by the EACTS Council and STS Executive Committee before being simultaneously published in the European Journal of Cardio-thoracic Surgery (EJCTS) and The Annals of Thoracic Surgery (The Annals) and the Journal of Thoracic and Cardiovascular Surgery (JTCVS).

A comparison of the National Surgical Quality Improvement Program and the Society of Thoracic Surgery Cardiac Surgery preoperative risk models: a cohort study

BACKGROUND

Cardiac surgery prediction models and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) have not been reported. The authors sought to develop preoperative prediction models and estimates of postoperative outcomes for cardiac surgery using the ACS-NSQIP and compare these to the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD).

METHODS

In a retrospective analysis of the ACS-NSQIP data (2007-2018), cardiac operations were identified using cardiac surgeon primary specialty and sorted into cohorts of coronary artery bypass grafting (CABG) only, valve surgery only, and valve+CABG operations using CPT codes. Prediction models were created using backward selection of the 28 non-laboratory preoperative variables in ACS-NSQIP. Rates of nine postoperative outcomes and performance statistics of these models were compared to published STS 2018 data.

RESULTS

Of 28 912 cardiac surgery patients, 18 139 (62.8%) were CABG only, 7872 (27.2%) were valve only, and 2901 (10.0%) were valve+CABG. Most outcome rates were similar between the ACS-NSQIP and STS-ACSD, except for lower rates of prolonged ventilation and composite morbidity and higher reoperation rates in ACS-NSQIP (all P <0.0001). For all 27 comparisons (9 outcomes × 3 operation groups), the c-indices for the ACS-NSQIP models were lower by an average of ~0.05 than the reported STS models.

CONCLUSIONS

The ACS-NSQIP preoperative risk models for cardiac surgery were almost as accurate as the STS-ACSD models. Slight differences in c-indexes could be due to more predictor variables in STS-ACSD models or the use of more disease- and operation-specific risk variables in the STS-ACSD models.

Lessons learned from linking two complementary databases: the Society of Thoracic Surgeons Congenital Heart Surgery Database and The Vermont Oxford Network Expanded Database

The Society of Thoracic Surgeons Congenital Heart Surgery Database and the Vermont Oxford Network Expanded Database are both large, international, well-established quality and outcomes databases with high penetration in their respective fields of congenital heart surgery and neonatology. Previous studies have shown the value of combining large databases for research purposes. Our aim was to examine the feasibility and value of combining these databases on a local level.We included patients from both databases, cared for at our centre and born from 2015-2020, who had cardiac surgery as neonates or during the birth hospitalisation. We examined the number of patients from each database and overlap between the two. We compared cardiac diagnoses, surgeries performed, pre-operative factors, mortality, and length of stay between databases.Of the 255 patients meeting criteria, 209 (81.9%) had records in both databases. The most common diagnoses in both were hypoplastic left heart syndrome, coarctation, and transposition of the great arteries. Surgical data were incompletely recorded in Vermont Oxford. Gestational age, birth weight, multiple gestation, mortality, and length of stay did not differ significantly between the databases, while the percentage of patients with an extracardiac malformation or genetic syndrome recorded was higher in the Society for Thoracic Surgeons group.Larger-scale matching and comparison studies using these databases are feasible and desirable; for some variables, a record with data from both databases may be more complete. Specific attention should be given to inclusion criteria, reconciling different schema of diagnoses, and formulating questions relying on each database's relative strengths.

Operative Outcomes of Women Undergoing Coronary Artery Bypass Surgery in the US, 2011 to 2020

Importance

It has been reported that women undergoing coronary artery bypass have higher mortality and morbidity compared with men but it is unclear if the difference has decreased over the last decade.

Objective

To evaluate trends in outcomes of women undergoing coronary artery bypass in the US from 2011 to 2020.

Design, Setting, and Participants

This retrospective cohort study at hospitals contributing to the Adult Cardiac Surgery Database of the Society of Thoracic Surgeons included 1 297 204 patients who underwent primary isolated coronary artery bypass from 2011 to 2020.

Exposure

Coronary artery bypass.

Main Outcomes and Measures

The primary outcome was operative mortality. The secondary outcome was the composite of operative mortality and morbidity (including operative mortality, stroke, kidney failure, reoperation, deep sternal wound infection, prolonged mechanical ventilation, and prolonged hospital stay). The attributable risk (the association of female sex with coronary artery bypass grafting outcomes) for the primary and secondary outcomes was calculated.

Results

Between 2011 and 2020, 1 297 204 patients underwent primary isolated coronary artery bypass grafting with a mean age of 66.0 years, 317 716 of which were women (24.5%). Women had a higher unadjusted operative mortality (2.8%; 95% CI, 2.8-2.9 vs 1.7%; 95% CI, 1.7-1.7; P < .001) and overall unadjusted incidence of the composite of operative mortality and morbidity compared with men (22.9%; 95% CI, 22.7-23.0 vs 16.7%; 95% CI, 16.6-16.8; P < .001). The attributable risk of female sex for operative mortality varied from 1.28 in 2011 to 1.41 in 2020, with no significant change over the study period (P for trend = 0.38). The attributable risk for the composite of operative mortality and morbidity was 1.08 in both 2011 and 2020 with no significant change over the study period (P for trend = 0.71).

Conclusions and Relevance

Women remain at significantly higher risk for adverse outcomes following coronary artery bypass grafting and no significant improvement has been seen over the course of the last decade. Further investigation into the determinants of operative outcomes in women is urgently needed.

Incidence and Impact of a Single-Unit Red Blood Cell Transfusion: Analysis of The Society of Thoracic Surgeons Database 2010-2019

BACKGROUND

As the adverse effects of blood transfusions are better understood, recommendations support single-unit red blood cell (RBC) transfusions (SRBCT). However, an isolated SRBCT across the entire index admission suggests even the single unit may be avoidable. We sought to identify the characteristics of cardiac surgery patients receiving an isolated SRBCT and analyze the impact on outcomes.

METHODS

The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for the period between January 1, 2010, and December 31, 2019. Patients aged >18 years undergoing isolated coronary artery bypass grafting or isolated aortic valve replacement were included. A total of 2,151,430 encounters were analyzed.

RESULTS

Of the 847,442 patients (39.3%) receiving any RBC transfusion during their index admission, 206,555 (24.4%) received only 1 unit. Propensity-matching analysis determined SRBCT patients were significantly older (67.26 vs 64.02 years; odds ratio [OR], 1.02; P < .001), female (39.1% vs 17.8%; OR, 1.57; P < .001), non-White (18.2% vs 13.1%; OR, 0.81; P < .001), and had a smaller body surface area (1.94 vs 2.07 m2; OR, 0.20; P < .001). They also had higher mortality (1.4% vs 1.0%, P < .001), stroke (1.7% vs 1.2%, P < .001), prolonged ventilation (6.4% vs 3.4%, P < .001), renal failure (1.8% vs 0.9%, P < .001), and reoperations (1.3% vs. 0.5%, P < .001) than patients who received 0 RBCs.

CONCLUSIONS

SRBCT is a common occurrence in adult cardiac surgery. This low-volume transfusion is strongly associated with higher morbidity, even after controlling for preoperative risk factors.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2022 Update on Outcomes and Research

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is the most mature and comprehensive cardiac surgery database. It is one of the most respected clinical data registries in health care, providing accurate risk-adjusted benchmarks, a foundation for quality measurement and improvement activities, and the ability to perform novel research. This report encompasses data from the years 2020 and 2021 and is the seventh in a series of reports that provide updated volumes, outcomes, database-related developments, and research summaries using the Adult Cardiac Surgery Database.

Risk of Surgical Mitral Valve Repair for Primary Mitral Regurgitation

BACKGROUND

Risk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity. The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR).

METHODS

A novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately.

RESULTS

Event rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4746; 8.88%), and CONV (n = 3399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (interquartile range: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality.

CONCLUSIONS

This etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.

Risk of Surgical Mitral Valve Repair for Primary Mitral Regurgitation

BACKGROUND

Risk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity.

OBJECTIVES

The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR).

METHODS

A novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately.

RESULTS

Event rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4,746; 8.88%), and CONV (n = 3,399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (IQR: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality.

CONCLUSIONS

This etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.

Comparing Consumer-Directed Hospital Rankings With STS Adult Cardiac Surgery Database Outcomes

BACKGROUND

Public interest in stratifying hospital performance has led to the proliferation of commercial, consumer-oriented hospital rankings. In cardiac surgery, little is known about how these rankings correlate with clinical registry quality ratings.

METHODS

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried for isolated coronary artery bypass grafting or coronary artery bypass grafting/valve patients at hospitals among the top 100 U.S. News & World Report (USNWR) Cardiology & Heart Surgery rankings from 2016 to 2020. Hospitals were grouped into deciles by risk-adjusted observed/expected (O/E) ratios for morbidity and mortality using the STS 2018 risk models. Agreement between STS Adult Cardiac Surgery Database and USNWR ranked deciles was calculated by Bowker symmetry test. The association between each center's annual change in STS O/E ratio and change in USNWR ranking was modeled in repeated measures regression analysis.

RESULTS

Inclusion criteria were met by 524 393 patients from 149 hospitals that ranked in USNWR top 100 at least once during the study period. There was no agreement between USNWR ranking and STS major morbidity and mortality O/E ratio (P > .50 for all years). Analysis of patients undergoing surgery at the 65 hospitals that were consistently ranked in the top 100 during the study period demonstrated no association between annual change in hospital ranking and change in O/E ratio (P all > .3).

CONCLUSIONS

There was no agreement between annual USNWR hospital ranking and corresponding risk-adjusted STS morbidity or mortality. Furthermore, annual changes in USNWR rankings could not be accounted for using clinical outcomes. These findings suggest that factors unrelated to key surgical outcomes may be driving consumer-directed rankings.

Development of a Novel Society of Thoracic Surgeons Adult Congenital Mortality Risk Model

BACKGROUND

Operative mortality risk models for adults with congenital heart disease (ACHD) undergoing cardiac operations are essential, given the growing population of these patients, yet they are currently unavailable. Existing adult Society of Thoracic Surgeons (STS) models exclude congenital procedures, whereas existing congenital models exclude operations for acquired disease. We aimed to develop an STS mortality risk model for ACHD patients undergoing cardiac operations.

METHODS

Leveraging a comprehensive list of diagnostic and procedure codes, ACHD patients who underwent cardiac operations were identified from the STS Adult Cardiac Surgery Database (versions: v2.73, v2.81, and v2.9) between 2011 and 2019. The model was developed and validated in the ACHD population using a 60/40 development/validation split. Univariate analyses and clinical expertise informed the addition of ACHD-relevant procedure and diagnosis variables to existing STS adult risk model variables. Model performance was assessed overall and in 38 subgroups based on patient demographics, procedures, and diagnoses.

RESULTS

Forty-seven procedure and diagnosis variables relevant to ACHD were added to existing STS adult risk model variables. The derived ACHD model for operative mortality was well calibrated within demographic, procedural, and diagnosis subgroups and the overall ACHD population, and discrimination in the validation cohort was excellent (C statistic, 0.815) compared with the model using only existing STS adult risk model variables (C statistic, 0.79; P < .0001).

CONCLUSIONS

A novel, high-performing STS ACHD mortality risk model has been developed on the basis of contemporary patient data. The ACHD risk model represents an important expansion of the STS portfolio. Implementation with an online risk calculator is planned.