The STS Participant-Level, Multi-Procedural Composite Measure for Adult Cardiac Surgery

Robotic-Assisted Aortic Valve Replacement and Coronary Artery Bypass Grafting

PURPOSE

Left chest robotic left internal thoracic artery (LITA) to left anterior descending (LAD) coronary revascularization has been established. We describe robotic aortic valve replacement and coronary artery bypass grafting through a right lateral approach.

DESCRIPTION

A 73-year-old woman with severe aortic insufficiency, 70% LAD stenosis, and ejection fraction of 0.35 presented with recalcitrant symptoms. She sustained a stroke 1 year before surgery. She was frail, with a body mass index of 17 kg/m2. Her Society of Thoracic Surgeons predicted risk of mortality was 10%. Given minimal leaflet calcium, transcatheter options were declined, and she was referred for high-risk nonsternotomy surgical consideration.

EVALUATION

After informed consent, a single-incision 4-cm right lateral working incision facilitated on-pump arrested fully robotic 23-mm bioprosthetic aortic valve replacement and LITA-LAD grafting. The LITA harvest time was 43 minutes, and LAD anastomosis was 27 minutes. This frail patient recovered expectantly and was discharged home.

CONCLUSIONS

Robotic aortic valve replacement and coronary artery bypass grafting is feasible and may represent a viable future option for patients with concomitant aortic valve and coronary disease.

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.

Transcatheter vs Surgical Aortic Valve Replacement in Bicuspid Aortic Valves

BACKGROUND

Recent approval of transcatheter aortic valve replacement (TAVR) in patients at lower risk profiles has resulted in a real-world expansion in patients with bicuspid aortic valves (BAV), otherwise excluded from trials comparing TAVR with surgical aortic valve replacement (SAVR). This study compared perioperative and longitudinal outcomes between BAV patients undergoing TAVR vs SAVR.

METHODS

Using the United States Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all beneficiaries with BAV undergoing isolated SAVR or TAVR (2018-2022). Comorbidities and frailty were accounted for using validated metrics with doubly robust risk adjustment using inverse probability weighting, multilevel regression models, and competing-risk time to event analysis. Subgroup analysis evaluated patients <75 years with low surgical risk (<4%).

RESULTS

The study included 11,289 BAV patients (8123 SAVR and 3166 TAVR). Accounting for age, comorbidities, and frailty, TAVR was associated with lower procedural mortality (odds ratio, 0.40; P < .001) but higher pacemaker (12.4% vs 2.3%; odds ratio, 5.4; P < .001), longitudinal stroke (2.4% vs 1.5%; hazard ratio [HR], 1.35; P < .001), and all-cause mortality (8.8% vs 5.7%; HR, 1.49; P < .001) compared with SAVR. The young low-risk subgroup (5393 SAVR and 1731 TAVR) highlighted similar findings, with TAVR associated with higher longitudinal stroke (2.1% vs 1.7%; HR, 1.22; P = .017) and composite stroke, valve reintervention, or death (8.1% vs 5.9%; HR, 1.37; P < .001) compared with SAVR.

CONCLUSIONS

Among Medicare beneficiaries with BAV, TAVR was associated with lower index in-hospital mortality but also lower 5-year risk-adjusted freedom from longitudinal stroke compared with SAVR, even in the youngest low-risk patients.

Interprofessional teams with and without nurse practitioners and the level of adherence to best practice guidelines in cardiac surgery: A retrospective study

AIM

To examine the level of adherence to best-practice guidelines of interprofessional teams with acute care nurse practitioners (ACNPs) compared to interprofessional teams without ACNPs.

DESIGN

A retrospective observational study was conducted in 2023.

METHOD

A retrospective cohort was created including 280 patients who underwent a coronary artery bypass graft and/or a valve repair and hospitalised in a cardiac surgery unit of a university affiliated hospital in Québec (Canada) between 1 January 2019 to 31 January 2020. The level of adherence to best-practice guidelines was measured from a composite score in percentage. The composite score was created from a newly developed tool including 99 items across six categories (patient information, pharmacotherapy, laboratory tests, post-operative assessment, patient and interprofessional teams' characteristics). Multivariate linear and logistic regression models were computed to examine the effect of interprofessional teams with ACNPs on the level of adherence to best-practice guidelines.

RESULTS

Most of the patients of the cohort were male and underwent a coronary artery bypass graft procedure. Patients under the care of interprofessional teams with ACNP were 1.72 times more likely to reach a level of adherence higher than 80% compared to interprofessional teams without ACNPs and were 2.29 times more likely to be within the highest quartile of the scores for the level of adherence to best-practice guidelines of the cohort.

IMPACT

This study provides empirical data supporting the benefits of ACNP practice for patients, interprofessional teams and healthcare organisations.

RELEVANCE FOR PRACTICE

Our findings identify the important contributions of interprofessional teams that include ACNPs using a validated instrument, as well as their contribution to the delivery of high quality patient care.

REPORTING METHOD

This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for reporting observational studies guidelines.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

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.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: Intraoperative Echocardiography Reporting

OBJECTIVES

To identify trends in the reporting of intraoperative transesophageal echocardiographic (TEE) data in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) and the Adult Cardiac Anesthesiology (ACA) module by period, practice type, and geographic distribution, and to elucidate ongoing areas for practice improvement.

DESIGN

A retrospective study.

SETTING

STS ACSD.

PARTICIPANTS

Procedures reported in the STS ACSD between July 2017 and December 2021 in participating programs in the United States.

INTERVENTIONS

None MEASUREMENTS AND MAIN RESULTS: Intraoperative TEE is reported for 73% of all procedures in ACSD. Although the intraoperative TEE data reporting rate increased from 2017 to 2021 for isolated coronary artery bypass graft surgery, it remained low at 62.2%. The reporting of relevant echocardiographic variables across a wide range of procedures has steadily increased over the study period but also remained low. The reporting in the ACA module is high for most variables and across all anesthesia care models; however, the overall contribution of the ACA module to the ACSD remains low.

CONCLUSIONS

This progress report suggests a continued need to raise awareness regarding current practices of reporting intraoperative TEE in the ACSD and the ACA, and highlights opportunities for improving reporting and data abstraction.

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.

Articulation of postsurgical patient discharges: coordinating care transitions from hospital to home

BACKGROUND

Cardiac surgery patients are at high risk for readmissions after hospital discharge- few of these readmissions are preventable by mitigating barriers underlying discharge care transitions. An in-depth evaluation of the nuances underpinning the discharge process and the use of tools to support the process, along with insights on patient and clinician experiences, can inform the design of evidence-based strategies to reduce preventable readmissions.

OBJECTIVE

The study objectives are 3-fold: elucidate perceived factors affecting the postsurgical discharge care transitions of cardiac surgery patients going home; highlight differences among clinician and patient perceptions of the postsurgical discharge experiences, and ascertain the impact of these transitions on patient recovery at home.

METHODS

We conducted a prospective multi-stakeholder study using mixed methods, including general observations, patient shadowing, chart reviews, clinician interviews, and follow-up telephone patient and caregiver surveys/interviews. We followed thematic and content analyses.

FINDINGS

Participants included 49 patients, 6 caregivers, and 27 clinicians. We identified interdependencies between the predischarge preparation, discharge education, and postdischarge follow-up care phases that must be coordinated for effective discharge care transitions. We identified several factors that could lead to fragmented discharges, including limited preoperative preparation, ill-defined discharge education, and postoperative plans. To address these, clinicians often performed behind-the-scenes work, including offering informal preoperative preparation, tailoring discharge education, and personalizing postdischarge follow-up plans. As a result, majority of patients reported high satisfaction with care transitions and their positive impact on their home recovery.

DISCUSSION AND CONCLUSIONS

Articulation work by clinicians (ie, behind the scenes work) is critical for ensuring safety, care continuity, and overall patient experience during care transitions. We discuss key evidence-based considerations for re-engineering postsurgical discharge workflows and re-designing discharge interventions.

The Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations

BACKGROUND

The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures.

METHODS

Using July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration.

RESULTS

C-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample.

CONCLUSIONS

New STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.

Failure to Rescue: A New Society of Thoracic Surgeons Quality Metric for Cardiac Surgery

BACKGROUND

Failure to rescue (FTR) focuses on the ability to prevent death among patients who experience postoperative complications. The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed a new, risk- adjusted FTR quality metric for adult cardiac surgery.

METHODS

The study population was taken from 1118 STS Adult Cardiac Surgery Database participants including patients who underwent isolated CABG, aortic valve replacement +/- CABG, or mitral valve repair/replacement, +/- CABG between January, 2015 and June, 2019. The FTR analysis was derived from patients who experienced ≥ 1 of the following complications: prolonged ventilation, stroke, reoperation, and renal failure. Data were randomly split into 70% training (n=89,059) and 30% validation samples (n=38,242),Risk variables included STS predicted risk of mortality, operative procedures, and intraoperative variables (cardiopulmonary bypass and cross-clamp times, unplanned procedures, need for circulatory support, and massive transfusion).

RESULTS

Overall mortality for the for patients undergoing any of the index operations during the study period was 2.6% (27,045/1,058,138), with mortality of 0.9% (8,316/930,837), 8.0% (7,618/94,918), 30.6% (8,247/26,934), 51.9%(2,661/5,123), and 62.3% (203/326) among patients suffering none, one, two, three or four complications. FTR risk model calibration was excellent, as were model discrimination (c-statistic 0.806) and the Brier score (0.102). Using 95% Bayesian credible intervals, 62 (5.6%) participants performed worse and 53 (4.7%) participants performed better than expected.

CONCLUSIONS

A new risk-adjusted FTR metric has been developed which complements existing STS performance measures. The metric specifically assesses institutional effectiveness of postoperative care, allowing hospitals to target quality improvement efforts.