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Idrees JJ, Roselli EE, Blackstone EH, Lowry AM, Soltesz EG, Johnston DR, Tong MZ, Pettersson GB, Griffin B, Gillinov AM, Svensson LG. Risk of adding prophylactic aorta replacement to a cardiac operation. J Thorac Cardiovasc Surg 2020; 159:1669-1678.e10. [DOI: 10.1016/j.jtcvs.2019.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 04/02/2019] [Accepted: 05/13/2019] [Indexed: 01/25/2023]
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Dewan KC, Dewan KS, Idrees JJ, Navale SM, Rosinski BF, Svensson LG, Gillinov AM, Johnston DR, Bakaeen F, Soltesz EG. Trends and Outcomes of Cardiovascular Surgery in Patients With Opioid Use Disorders. JAMA Surg 2019; 154:232-240. [PMID: 30516807 DOI: 10.1001/jamasurg.2018.4608] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Importance Persistent opioid use is currently a major health care crisis. There is a lack of knowledge regarding its prevalence and effect among patients undergoing cardiac surgery. Objective To characterize the national population of cardiac surgery patients with opioid use disorder (OUD) and compare outcomes with the cardiac surgery population without OUD. Design, Setting, and Participants In this retrospective population-based cohort study, more than 5.7 million adult patients who underwent cardiac surgery (ie, coronary artery bypass graft, valve surgery, or aortic surgery) in the United States were included. Pregnant patients were excluded. Propensity matching was performed to compare outcomes between cardiac surgery patients with OUD (n = 11 359) and without OUD (n = 5 707 193). The Nationwide Inpatient Sample database was queried from January 1998 to December 2013. Data were analyzed in January 2018. Exposures Persistent opioid use and/or dependence. Main Outcomes and Measures In-hospital mortality, complications, length of stay, costs, and discharge disposition. Results Among the 5 718 552 included patients, 3 887 097 (68.0%) were male; the mean (SD) age of patients with OUD was 47.67 (13.03) years and of patients without OUD was 65.53 (26.14) years. The prevalence of OUD among cardiac surgery patients was 0.2% (n = 11 359), with an 8-fold increase over 15 years (0.06% [262 of 437 641] in 1998 vs 0.54% [1425 of 263 930] in 2013; difference, 0.48%; 95% CI of difference, 0.45-0.51; P < .001). Compared with patients without OUD, patients with OUD were younger (mean [SD] age, 48 [0.30] years vs 66 [0.05] years; P < .001) and more often male (70.8% vs 68.0%; P < .001), black (13.7% vs 4.8%), or Hispanic (9.1% vs 4.8%). Patients with OUD more commonly fell in the first quartile of median income (30.7% vs 17.1%; P < .001) and were more likely to be uninsured or Medicaid beneficiaries (48.6% vs 7.7%; P < .001). Valve and aortic operations were more commonly performed among patients with OUD (49.8% vs 16.4%; P < .001). Among propensity-matched pairs, the mortality was similar between patients with vs without OUD (3.1% vs 4.0%; P = .12), but cardiac surgery patients with OUD had an overall higher incidence of major complications (67.6% vs 59.2%; P < .001). Specifically, the risks of blood transfusion (30.4% vs 25.9%; P = .002), pulmonary embolism (7.3% vs 3.8%; P < .001), mechanical ventilation (18.4% vs 15.7%; P = .02), and prolonged postoperative pain (2.0% vs 1.2%; P = .048) were significantly higher. Patients with OUD also had a significantly longer length of stay (median [SE], 11 [0.30] vs 10 [0.22] days; P < .001) and cost significantly more per patient (median [SE], $49 790 [1059] vs $45 216 [732]; P < .001). Conclusions and Relevance The population of patients with persistent opioid use or opioid dependency undergoing cardiac surgery has increased over the past decade. Cardiac surgery in patients with OUD is safe but is associated with higher complications and cost. Patients should not be denied surgery because of OUD status but should be carefully monitored postoperatively for complications.
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Affiliation(s)
- Krish C Dewan
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Karan S Dewan
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Suparna M Navale
- Department of Population and Quantitative Health Sciences, Population Health and Outcomes Research Core, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Faisal Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Clifford AH, Arafat A, Idrees JJ, Roselli EE, Tan CD, Rodriguez ER, Svensson LG, Blackstone E, Johnston D, Pettersson G, Soltesz E, Hoffman GS. Outcomes Among 196 Patients With Noninfectious Proximal Aortitis. Arthritis Rheumatol 2019; 71:2112-2120. [DOI: 10.1002/art.40855] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 11/27/2018] [Indexed: 12/17/2022]
Affiliation(s)
- Alison H. Clifford
- Cleveland Clinic Foundation, Cleveland, Ohio, and University of Alberta Edmonton Alberta Canada
| | - Amr Arafat
- Cleveland Clinic Foundation, Cleveland, Ohio, and Tanta University Tanta Egypt
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Rosinski BF, Idrees JJ, Roselli EE, Germano E, Pasadyn SR, Lowry AM, Blackstone EH, Johnston DR, Soltesz EG, Navia JL, Desai MY, Mick SL, Bakaeen FG, Svensson LG. Cannulation strategies in acute type A dissection repair: A systematic axillary artery approach. J Thorac Cardiovasc Surg 2019; 158:647-659.e5. [DOI: 10.1016/j.jtcvs.2018.11.137] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Revised: 10/17/2018] [Accepted: 11/14/2018] [Indexed: 11/25/2022]
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Idrees JJ, Merath K, Gani F, Bagante F, Mehta R, Beal E, Cloyd JM, Pawlik TM. Trends in centralization of surgical care and compliance with National Cancer Center Network guidelines for resected cholangiocarcinoma. HPB (Oxford) 2019; 21:981-989. [PMID: 30591307 DOI: 10.1016/j.hpb.2018.11.013] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 11/12/2018] [Accepted: 11/19/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND A retrospective study was performed to characterize trends in centralization of care and compliance with National Comprehensive Cancer Network (NCCN) guidelines for resected cholangiocarcinoma (CCA), and their impact on overall survival (OS). METHODS Using the National Cancer Database (NCDB) 2004-2015 we identified patients undergoing resection for CCA. Receiver Operating Characteristic (ROC) analyses identified time periods and hospital volume groups for comparison. Propensity score matching provided case-mix adjusted patient cohorts. Cox hazard analysis identified risk factors for OS. RESULTS Among the 40,338 patients undergoing resection for CCA, the proportion of patients undergoing surgery at high volume hospitals increased over time (25%-44%, p < 0.001), while the proportion of patients undergoing surgery at low volume hospitals decreased (30%-15%, p < 0.001). Using ROC analyses, a hospital volume of 14 operations/year was the most sensitive and specific value associated with mortality. Surgery at high volume hospitals [HR] = 0.92, 95% CI: 0.88-0.97, p < 0.001) and receipt of care compliant with NCCN guidelines (HR = 0.87, 95% CI: 0.83-0.91, p < 0.001) were independently associated with improved OS. CONCLUSIONS Both centralization of surgery for CCA to high volume hospitals and increased compliance with NCCN guidelines were associated with significant improvements in overall survival.
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Affiliation(s)
- Jay J Idrees
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Faiz Gani
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Bagante
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Rittal Mehta
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Eliza Beal
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Idrees JJ, Bagante F, Gani F, Rosinski BF, Chen Q, Merath K, Dillhoff M, Cloyd J, Pawlik TM. Population level outcomes and costs of single stage colon and liver resection versus conventional two-stage approach for the resection of metastatic colorectal cancer. HPB (Oxford) 2019; 21:456-464. [PMID: 30266492 DOI: 10.1016/j.hpb.2018.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The objective of the current study was to compare outcomes among patients combined colon (CR) and liver resection (LR) for the treatment of simultaneous colorectal liver metastasis (CRLM) versus patients undergoing two-stage CR and LR. METHODS Patients undergoing surgery for CRLM between 2004 and 2014 were identified using the Nationwide Inpatient Sample (NIS). Propensity-score matching was used to compare patients undergoing CR + LR with patients undergoing two-stage CR and LR. RESULTS Among 83,410 patients, CR + LR was performed in 5659 (6.7%), stage C + LR was performed in 5659 (6.7%), while isolated CR and LR was performed in 70,177 (84.0%) and 7574 (9.3%) patients, respectively. The number of patients undergoing CR + LR increased from 423 in 2004 to 580 in 2014 (Δ = +37%). Patients undergoing CR + LR had lower postoperative morbidity (CR + LR vs. two-staged CR and LR: 38.5% vs. 61.2%), shorter LOS (median LOS: 8 days [IQR: 7-12] vs. 14 days [IQR: 10-21]), and lower postoperative mortality (3.1% vs. 5.9%) versus patients undergoing two-stage CR and LR. Compared with patients undergoing two-staged CR and LR, median hospital costs were $13,093 lower for patients undergoing CR + LR (median costs: $36,775 [IQR: 26,416-54,245] vs. $23,682 [IQR: 16,299-32,996]). CONCLUSION CR + LR was increasingly performed for treatment of CRLM. Compared with two-staged CR and LR, CR + LR was associated with improved outcomes and lower costs.
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Affiliation(s)
- Jay J Idrees
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Faiz Gani
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Brad F Rosinski
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Merath K, Chen Q, Bagante F, Sun S, Akgul O, Idrees JJ, Dillhoff M, Schmidt C, Cloyd J, Pawlik TM. Variation in the cost-of-rescue among medicare patients with complications following hepatopancreatic surgery. HPB (Oxford) 2019; 21:310-318. [PMID: 30266495 DOI: 10.1016/j.hpb.2018.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 07/06/2018] [Accepted: 08/12/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The relationship of expenditures related to rescuing patients from complications and hospital quality has not been well characterized. We sought to examine the relationship between payments for treating post-operative complications after liver and pancreas surgery and hospital quality. METHODS A retrospective cohort study of patients who underwent hepatopancreatic surgery was performed using claims data from 2013 to 2015 in the Medicare Provider Analysis and Review (MEDPAR) database. Medicare payments for index hospitalization and readmissions, as well as perioperative clinical outcomes were analyzed. Hospitals were stratified using average payments for patients who were rescued from complications (cost-of-rescue). RESULTS A total of 13,873 patients and 737 hospitals were included in the analyses. Patient characteristics were similar across hospitals. Risk-adjusted rates of overall complications were higher at the highest cost-of-rescue hospitals (relative risk [RR], 1.35, 95% confidence interval [CI] 1.16-1.58), as well as rates of serious complications (RR, 1.78, 95% CI 1.51-2.09), 30-day readmission (RR 1.21 95% CI 1.06-1.39), 90-day mortality (RR, 1.29, 95% CI 1.01-1.64), and rates of failure-to-rescue (RR, 1.50, 95% CI 1.14-1.97). CONCLUSION Highest cost-of-rescue hospitals demonstrated worse quality metrics, including higher rates of serious complications, failure-to-rescue, 30-day readmission, and 90-day mortality.
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Affiliation(s)
- Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Qinyu Chen
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Fabio Bagante
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA; Department of Surgery, University of Verona, Verona, Italy
| | - Steven Sun
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Ozgur Akgul
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jay J Idrees
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Carl Schmidt
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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Idrees JJ, Rosinski BF, Merath K, Chen Q, Bagante F, Pawlik TM. Readmission after pancreatic resection: causes, costs and cost-effectiveness analysis of high versus low quality hospitals using the Nationwide Readmission Database. HPB (Oxford) 2019; 21:291-300. [PMID: 30201297 DOI: 10.1016/j.hpb.2018.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/22/2018] [Accepted: 07/09/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Objectives were to determine the causes of readmission and assess the cost-effectiveness of high (HQ) and low quality (LQ) hospitals in performing pancreatic resection, by using readmission rates as the measure of quality. METHODS We identified 53,572 pancreatic resection cases from National Readmission Database from 2010 through 2014. Hospitals were risk adjusted and ranked based on readmission. Top 20% HQ hospitals having the lowest readmission rates were compared to the bottom 20% LQ hospitals with the highest readmission rates. RESULTS The 90-day readmission rate was 27.2% (HQ: 25.7%, LQ: 30.9%, p < 0.001). Compared to LQ, HQ hospitals had lower mortality (2.1% vs 10.2%, p < 0.001) and major complication (10.5% vs 53%, p < 0.001). Major complication during index operation was a major predictor of readmission (RR: 1.6, 95% CI: 1.6-1.7, p < 0.001). The optimal cut point of hospital volume associated with low mortality was 70 or more cases/year. Per year of survival benefit at HQ hospitals, the costs were lower by $9,293 with cost-savings of $6.98 million/year. CONCLUSION HQ hospitals were cost-effective at performing pancreatic resection and achieved substantial cost-savings by avoiding major complications during index operation and having lower rates of readmissions. Hospital readmission rate is a strong marker of quality of care.
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Affiliation(s)
- Jay J Idrees
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Brad F Rosinski
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH, USA.
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Aftab M, Cikach FS, Zhu Y, Idrees JJ, Rigelsky CM, Kalahasti V, Roselli EE, Svensson LG. Loeys-Dietz syndrome: Intermediate-term outcomes of medically and surgically managed patients. J Thorac Cardiovasc Surg 2019; 157:439-450.e5. [DOI: 10.1016/j.jtcvs.2018.03.172] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 03/21/2018] [Accepted: 03/29/2018] [Indexed: 12/23/2022]
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Merath K, Chen Q, Bagante F, Akgul O, Idrees JJ, Dillhoff M, Cloyd JM, Pawlik TM. Synergistic Effects of Perioperative Complications on 30-Day Mortality Following Hepatopancreatic Surgery. J Gastrointest Surg 2018; 22:1715-1723. [PMID: 29916105 DOI: 10.1007/s11605-018-3829-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 05/22/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND Data on the interaction effect of multiple concurrent postoperative complications relative to the risk of short-term mortality following hepatopancreatic surgery have not been reported. The objective of the current study was to define the interaction effect of postoperative complications among patients undergoing HP surgery on 30-day mortality. METHODS Using the ACS-NSQIP Procedure Targeted Participant Use Data File, patients who underwent HP surgery between 2014 and 2016 were identified. Hazard ratios (HRs) for 30-day mortality were estimated using Cox proportional hazard models. Two-way interaction effects assessing combinations of complications relative to 30-day mortality were calculated using the relative excess risk due to interaction (RERI) in separate adjusted Cox models. RESULTS Among 26,824 patients, 10,886 (40.5%) experienced at least one complication. Mortality was higher among patients who experienced at least one complication versus patients who did not experience a complication (3.0 vs 0.1%, p < 0.001). The most common complications were blood transfusion (16.9%, n = 4519), organ space infection (12.2%, n = 3273), and sepsis/septic shock (8.2%, n = 2205). Combinations associated with additive effect on mortality included transfusion + renal dysfunction (RERI 12.3, 95% CI 5.2-19.4), pulmonary dysfunction + renal dysfunction (RERI 60.9, 95% CI 38.6-83.3), pulmonary dysfunction + cardiovascular complication (RERI 144.1, 95% CI 89.3-199.0), and sepsis/septic shock + renal dysfunction (RERI 11.5, 95% CI 4.4-18.7). CONCLUSION Both the number and specific type of complication impacted the incidence of postoperative mortality among patients undergoing HP surgery. Certain complications interacted in a synergistic manner, leading to a greater than expected increase in the risk of short-term mortality.
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Affiliation(s)
- Katiuscha Merath
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Qinyu Chen
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Fabio Bagante
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.,Department of Surgery, University of Verona, Verona, Italy
| | - Ozgur Akgul
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jay J Idrees
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA. .,Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University, Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Chen Q, Bagante F, Olsen G, Merath K, Idrees JJ, Beal EW, Akgul O, Cloyd J, Dillhoff M, Schmidt C, White S, Pawlik TM. Time to Readmission and Mortality Among Patients Undergoing Liver and Pancreatic Surgery. World J Surg 2018; 43:242-251. [PMID: 30109390 DOI: 10.1007/s00268-018-4766-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Chen Q, Merath K, Olsen G, Bagante F, Idrees JJ, Akgul O, Cloyd J, Schmidt C, Dillhoff M, Beal EW, White S, Pawlik TM. Impact of Post-Discharge Disposition on Risk and Causes of Readmission Following Liver and Pancreas Surgery. J Gastrointest Surg 2018; 22:1221-1229. [PMID: 29569005 DOI: 10.1007/s11605-018-3740-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/05/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The relationship between the post-discharge settings and the risk of readmission has not been well examined. We sought to identify the association between discharge destinations and readmission rates after liver and pancreas surgery. METHODS The 2013-2015 Medicare-Provider Analysis and Review (MEDPAR) database was reviewed to identify liver and pancreas surgical patients. Patients were subdivided into three groups based on discharge destination: home/self-care (HSC), home with home health assistance (HHA), and skilled nursing facility (SNF). The association between post-acute settings, readmission rates, and readmission causes was assessed. RESULTS Among 15,141 liver or pancreas surgical patients, 60% (n = 9046) were HSC, 26.9% (n = 4071) were HHA, and 13.4% (n = 2024) were SNF. Older, female patients and patients with ≥ 2 comorbidities, ≥ 2 previous admissions, an emergent index admission, an index complication, and ≥ 5-day length of stay were more likely to be discharged to HHA or SNF compared to HSC (all P < 0.001). Compared to HSC, HHA and SNF patients had a 34 and a 67% higher likelihood of 30-day readmission, respectively. The HHA and SNF settings were also associated with a 33 and a 69% higher risk of 90-day readmission. There was no association between discharge destination and readmission causes. CONCLUSION Among liver and pancreas surgical patients, HHA and SNF patients had a higher risk of readmission within 30 and 90 days. There was no difference in readmission causes and discharge settings. The association between discharge setting and the higher risk of readmission should be further evaluated as the healthcare system seeks to reduce readmission rates after surgery.
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Affiliation(s)
- Qinyu Chen
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Katiuscha Merath
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Griffin Olsen
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Fabio Bagante
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
- Department of Surgery, University of Verona, Verona, Italy
| | - Jay J Idrees
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Ozgur Akgul
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan Cloyd
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Carl Schmidt
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Eliza W Beal
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Susan White
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
- Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Idrees JJ, Rosinski BF, Chen Q, Bagante F, Merath K, White S, Pawlik TM. Variation in Medicare Payments and Reimbursement Rates for Hepatopancreatic Surgery Based on Quality: Is There a Financial Incentive for High-Quality Hospitals? J Am Coll Surg 2018; 227:212-222.e2. [PMID: 29680412 DOI: 10.1016/j.jamcollsurg.2018.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/08/2018] [Accepted: 04/09/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND To better define the financial impact of high-quality care for payers and hospitals, we compared outcomes and Medicare payments between high-quality (HQ) and low-quality (LQ) hospitals after hepatopancreatic surgery. STUDY DESIGN Between 2013 through 2015, a total of 15,874 Medicare beneficiaries underwent hepatopancreatic surgery. Using the entire cohort, multivariable logistic regression was performed to categorize hospitals into quintiles based on the probability of experiencing a major complication; HQ (bottom 20%) and LQ (top 20%) hospitals were identified. Only HQ and LQ hospitals were included in the final propensity matching to compare payments. Major complication was defined as a complication associated with a length of stay of >75th percentile. Incremental payment and cost of complication were estimated using multivariable linear regression. RESULTS Major complications occurred in 9.7% (n = 309 of 3,182) at HQ hospitals compared with 20% (n = 625 of 3,130) at LQ hospitals (p < 0.001). The incremental increased payment associated with major complication was $29,640, which was lower than the incremental hospital cost of $42,935. The Medicare reimbursement rate was also 6% lower at both HQ and LQ hospitals when a major complication occurred vs not; however, HQ hospitals had a 3% higher reimbursement rate compared with LQ hospitals when a major complication did not occur (p = 0.002). Mean unadjusted Medicare payment was lower at HQ hospitals by $5,165 per patient vs LQ hospitals (p < 0.001), largely because HQ hospitals had a lower overall incidence of major complications (n = 315 vs n = 625). By having 310 fewer patients with a major complication, HQ hospitals collectively achieved $3.1 million/year in Medicare savings. CONCLUSIONS High-quality hospitals are able to achieve substantial Medicare savings by avoiding major complications. Occurrence of major complications was associated with lower Medicare reimbursement rates at both HQ and LQ hospitals vs when no complications occurred.
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Affiliation(s)
- Jay J Idrees
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH
| | - Brad F Rosinski
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH
| | - Qinyu Chen
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH
| | - Fabio Bagante
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH
| | - Katiuscha Merath
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH
| | - Susan White
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH.
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Roselli EE, Idrees JJ, Johnston DR, Eagleton MJ, Desai MY, Svensson LG. Zone zero thoracic endovascular aortic repair: A proposed modification to the classification of landing zones. J Thorac Cardiovasc Surg 2018; 155:1381-1389. [DOI: 10.1016/j.jtcvs.2017.11.054] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 10/19/2017] [Accepted: 11/16/2017] [Indexed: 11/28/2022]
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15
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Roselli EE, Idrees JJ, Bakaeen FG, Tong MZ, Soltesz EG, Mick S, Johnston DR, Eagleton MJ, Menon V, Svensson LG. Evolution of Simplified Frozen Elephant Trunk Repair for Acute DeBakey Type I Dissection: Midterm Outcomes. Ann Thorac Surg 2018; 105:749-755. [DOI: 10.1016/j.athoracsur.2017.08.037] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 07/26/2017] [Accepted: 08/21/2017] [Indexed: 11/16/2022]
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16
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Paredes AZ, Idrees JJ, Beal EW, Chen Q, Cerier E, Okunrintemi V, Olsen G, Sun S, Cloyd JM, Pawlik TM. Influence of English proficiency on patient-provider communication and shared decision-making. Surgery 2018; 163:1220-1225. [PMID: 29482884 DOI: 10.1016/j.surg.2018.01.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/31/2017] [Accepted: 01/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The number of patients in the United States (US) who speak a language other than English is increasing. We evaluated the impact of English proficiency on self-reported patient-provider communication and shared decision-making. METHODS The 2013-2014 Medical Expenditure Panel Survey database was utilized to identify respondents who spoke a language other than English. Patient-provider communication (PPC) and shared decision-making (SDM) scores from 4-12 were categorized as "poor" (4-7), "average" (8-11), and "optimal." The relationship between PPC, SDM, and English proficiency was analyzed. RESULTS Among 13,880 respondents, most were white (n = 10,281, 75%), age 18-39 (n = 6,677, 48%), male (n = 7,275, 52%), middle income (n = 4,125, 30%), and born outside of the US (n = 9,125, 65%). English proficiency was rated as "very well" (n = 7,221, 52%), "well" (n = 2,378, 17%), "not well" (n = 2,820, 20%), or "not at all" (n = 1,463, 10%). On multivariable analysis, patients who rated their English as "well" (OR 1.73, 95% CI 1.37-2.18) or "not well" (OR 1.53, 95% CI 1.10-2.14) were more likely to report "poor" PPC (both P < .01). Similarly, SDM was more commonly self-reported as "poor" among patients who reported English proficiency as "not well" (OR 1.31, 95% CI 1.04-1.65, P = .02). CONCLUSION Decreased English proficiency was associated with worse self-reported patient-provider communication and shared decision-making. Attention to patients' language needs is critical to patient satisfaction and improved perception of care.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jay J Idrees
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Eliza W Beal
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Qinyu Chen
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Emily Cerier
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Victor Okunrintemi
- Center for Healthcare Advancement and Outcomes, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA
| | - Griffin Olsen
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Steven Sun
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Wojnarski CM, Roselli EE, Idrees JJ, Zhu Y, Carnes TA, Lowry AM, Collier PH, Griffin B, Ehrlinger J, Blackstone EH, Svensson LG, Lytle BW. Machine-learning phenotypic classification of bicuspid aortopathy. J Thorac Cardiovasc Surg 2018; 155:461-469.e4. [DOI: 10.1016/j.jtcvs.2017.08.123] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 07/27/2017] [Accepted: 08/28/2017] [Indexed: 01/08/2023]
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18
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Gillinov AM, Mihaljevic T, Javadikasgari H, Suri RM, Mick SL, Navia JL, Desai MY, Bonatti J, Khosravi M, Idrees JJ, Lowry AM, Blackstone EH, Svensson LG. Early results of robotically assisted mitral valve surgery: Analysis of the first 1000 cases. J Thorac Cardiovasc Surg 2018; 155:82-91.e2. [DOI: 10.1016/j.jtcvs.2017.07.037] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 07/11/2017] [Accepted: 07/21/2017] [Indexed: 02/07/2023]
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19
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Aftab M, Idrees JJ, Cikach F, Navia JL, Hammer D, Roselli EE. Open Distal Fenestration of Chronic Dissection Facilitates Endovascular Elephant Trunk Completion: Late Outcomes. Ann Thorac Surg 2017; 104:1960-1967. [DOI: 10.1016/j.athoracsur.2017.05.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 04/09/2017] [Accepted: 05/15/2017] [Indexed: 11/17/2022]
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20
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Idrees JJ. Surgeon Volume or Hospital Volume? Does It Matter When the Risk Is Already Low? Semin Thorac Cardiovasc Surg 2017; 29:231-232. [PMID: 28823335 DOI: 10.1053/j.semtcvs.2017.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Jay J Idrees
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
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Roselli EE, Hasan SM, Idrees JJ, Aftab M, Eagleton MJ, Menon V, Svensson LG. Inoperable patients with acute type A dissection: are they candidates for endovascular repair?†. Interact Cardiovasc Thorac Surg 2017; 25:582-588. [DOI: 10.1093/icvts/ivx193] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Accepted: 04/26/2017] [Indexed: 01/16/2023] Open
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22
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Javadikasgari H, Gillinov AM, Idrees JJ, Mihaljevic T, Suri RM, Raza S, Houghtaling PL, Svensson LG, Navia JL, Mick SL, Desai MY, Sabik JF, Blackstone EH. Valve Repair Is Superior to Replacement in Most Patients With Coexisting Degenerative Mitral Valve and Coronary Artery Diseases. Ann Thorac Surg 2017; 103:1833-1841. [DOI: 10.1016/j.athoracsur.2016.08.076] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 08/03/2016] [Accepted: 08/22/2016] [Indexed: 10/20/2022]
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23
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Javadikasgari H, Roselli EE, Aftab M, Suri RM, Desai MY, Khosravi M, Cikach F, Isabella M, Idrees JJ, Raza S, Tappuni B, Griffin BP, Svensson LG, Gillinov AM. Combined aortic root replacement and mitral valve surgery: The quest to preserve both valves. J Thorac Cardiovasc Surg 2017; 153:1023-1030.e1. [DOI: 10.1016/j.jtcvs.2017.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 12/28/2016] [Accepted: 01/18/2017] [Indexed: 11/26/2022]
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24
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Abstract
Over the last several decades, significant advances and improvements in care of transplant patients have resulted in markedly improved outcomes. A number of options are available for patients with advanced cardiopulmonary dysfunction requiring transplantation. There is a debate about when isolated heart or isolated lung transplantation is no longer possible or advisable and combined heart-lung transplantation is justified. Organ availability and allocation severely limit the latter option to very few well-selected patients. We review practice patterns, trends, and outcomes after triple-organ heart-lung transplant (HLTx) worldwide, as well as our own experience with heart-lung transplant in the modern era.
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Affiliation(s)
- Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue/Mail Stop J4-1, Cleveland, OH, 44195, USA.,Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue/Mail Stop J4-1, Cleveland, OH, 44195, USA. .,Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, OH, USA.
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25
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Arafat A, Roselli EE, Idrees JJ, Feng K, Banaszak L, Eagleton M, Menon V, Svensson LG. Stent Grafting Acute Aortic Dissection: Comparison of DeBakey Extent IIIA Versus IIIB. Ann Thorac Surg 2016; 102:1473-1481. [DOI: 10.1016/j.athoracsur.2016.04.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 03/11/2016] [Accepted: 04/25/2016] [Indexed: 10/21/2022]
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26
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Zhu Y, Roselli EE, Idrees JJ, Kapadia S, Svensson LG. Combined Transapical Transcatheter Aortic Valve Replacement and Thoracic Endovascular Aortic Repair for Severe Aortic Stenosis and Arch Aneurysm. Aorta (Stamford) 2016; 4:175-177. [PMID: 28516094 DOI: 10.12945/j.aorta.2016.16.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 10/23/2016] [Indexed: 11/18/2022]
Abstract
An 83-year-old male with multiple comorbidities presented with critical aortic stenosis and a saccular aortic arch aneurysm. Through a mini thoracotomy, a balloon expandable transcatheter aortic valve was delivered transapically. A thoracic stent graft was then delivered through the prosthetic valve and deployed in the arch, while a covered stent was deployed in the left common carotid artery. Three-year postoperative computed tomography showed a thrombosed arch aneurysm with decreased size. This case demonstrates the feasibility of using combined transapical transcatheter technologies to treat multicomponent disease in a high-risk patient during a single operation.
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Affiliation(s)
- Yuanjia Zhu
- Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric E Roselli
- Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jay J Idrees
- Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G Svensson
- Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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27
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Idrees JJ, Yazdchi F, Soltesz EG, Vekstein AM, Rodriguez C, Roselli EE. Outcomes after aortic graft-to-graft anastomosis with an automated circular stapler: A novel approach. J Thorac Cardiovasc Surg 2016; 152:1052-7. [PMID: 27449353 DOI: 10.1016/j.jtcvs.2016.06.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/01/2016] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Patients with complex aortic disease often require multistaged repairs with numerous anastomoses. Manual suturing can be time consuming. To reduce ischemic time, a circular stapling device has been used to facilitate prosthetic graft-to-graft anastomoses. Objectives are to describe this technique and assess outcomes. METHODS From February 2009 to May 2014, 44 patients underwent complex aortic repair with a circular end-to-end anastomosis (EEA) stapler at Cleveland Clinic. All patients had extensive aneurysms: 17 after ascending dissection repair, 10 chronic type B dissections, and 17 degenerative aneurysms. Stapler was used during total arch repair as an end-to-side anastomosis (n = 36; including first stage elephant trunk [ET] in 32, frozen ET in 3) and an end-to-end anastomosis during redo thoracoabdominal repair (n = 11). Three patients had the stapler used during both stages of repair. Patients underwent early and annual follow-ups with computed tomography analysis. RESULTS There were no bleeds, ruptures, or leaks at the stapled site, but 2 patients died. Complications included 7 reoperations not related to the site of stapled anastomosis and 6 tracheostomies, but there was no paralysis or renal failure. Mean circulatory arrest time was 16 ± 5 minutes. Mean follow-up was 26 ± 17 months and consisted of imaging before discharge, at 3 to 6 months, and at 1 year. Planned reinterventions included 21 second-stage ET completion: Endovascular (n = 18) and open (n = 3). There were 4 late deaths. CONCLUSIONS Use of an end-to-end anastomotic automated circular stapler is safe, effective, and durable in performing graft-to-graft anastomoses during complex thoracic aortic surgery. Further evaluation and refinement of this technique are warranted.
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Affiliation(s)
- Jay J Idrees
- Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Farhang Yazdchi
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Andrew M Vekstein
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christopher Rodriguez
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Aorta Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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Raza S, Sabik JF, Rajeswaran J, Idrees JJ, Trezzi M, Riaz H, Javadikasgari H, Nowicki ER, Svensson LG, Blackstone EH. Enhancing the Value of Population-Based Risk Scores for Institutional-Level Use. Ann Thorac Surg 2016; 102:70-7. [PMID: 26952298 DOI: 10.1016/j.athoracsur.2015.12.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 12/14/2015] [Accepted: 12/22/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND We hypothesized that factors associated with an institution's residual risk unaccounted for by population-based models may be identifiable and used to enhance the value of population-based risk scores for quality improvement. METHODS From January 2000 to January 2010, 4,971 patients underwent aortic valve replacement (AVR), either isolated (n = 2,660) or with concomitant coronary artery bypass grafting (AVR+CABG; n = 2,311). Operative mortality and major morbidity and mortality predicted by The Society of Thoracic Surgeons (STS) risk models were compared with observed values. After adjusting for patients' STS score, additional and refined risk factors were sought to explain residual risk. Differences between STS model coefficients (risk-factor strength) and those specific to our institution were calculated. RESULTS Observed operative mortality was less than predicted for AVR (1.6% [42 of 2,660] vs 2.8%, p < 0.0001) and AVR+CABG (2.6% [59 of 2,311] vs 4.9%, p < 0.0001). Observed major morbidity and mortality was also lower than predicted for isolated AVR (14.6% [389 of 2,660] vs 17.5%, p < 0.0001) and AVR+CABG (20.0% [462 of 2,311] vs 25.8%, p < 0.0001). Shorter height, higher bilirubin, and lower albumin were identified as additional institution-specific risk factors, and body surface area, creatinine, glomerular filtration rate, blood urea nitrogen, and heart failure across all levels of functional class were identified as refined risk-factor variables associated with residual risk. In many instances, risk-factor strength differed substantially from that of STS models. CONCLUSIONS Scores derived from population-based models can be enhanced for institutional level use by adjusting for institution-specific additional and refined risk factors. Identifying these and measuring differences in institution-specific versus population-based risk-factor strength can identify areas to target for quality improvement initiatives.
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Affiliation(s)
- Sajjad Raza
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Matteo Trezzi
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haris Riaz
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hoda Javadikasgari
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward R Nowicki
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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29
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Zhu Y, Roselli EE, Idrees JJ, Wojnarski CM, Griffin B, Kalahasti V, Pettersson G, Svensson LG. Outcomes After Operations for Unicuspid Aortic Valve With or Without Ascending Repair in Adults. Ann Thorac Surg 2015; 101:613-9. [PMID: 26453423 DOI: 10.1016/j.athoracsur.2015.07.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 07/19/2015] [Accepted: 07/22/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Unicuspid aortic valve is an important subset of bicuspid aortic valve, and knowledge regarding its aortopathy pattern and surgical outcomes is limited. Our objectives were to characterize unicuspid aortic valve patients, associated aortopathy, and surgical outcomes. METHODS From January 1990 to May 2013, 149 adult unicuspid aortic valve patients underwent aortic valve replacement or repair for aortic stenosis (n = 13), regurgitation (n = 13), or both (n = 123), and in 91 (61%) the aortic valve operation was combined with aortic repair. Data were obtained from the Cardiovascular Information Registry and medical record review. Three-dimensional imaging analysis was performed from preoperative computed tomography and magnetic resonance imaging scans. The Kaplan-Meier method was used for survival analysis. RESULTS Patients had a mean maximum aortic diameter of 44 ± 8 mm and variably involved the aortic root, ascending, or arch, or both. Patients with valve operations alone were more likely to be hypertensive (p = 0.01) and to have severe aortic stenosis (p = 0.07) than those who underwent concurrent aortic operations. There were no operative deaths, strokes, or myocardial infarctions. Patients undergoing aortic repair had better long-term survival. Estimated survival at 1, 5, and 10 years was 100%, 100%, and 100% after combined operations and was 100%, 88%, and 88% after valve operations alone (p = 0.01). CONCLUSIONS Patients with a dysfunctional unicuspid aortic valve frequently present with an ascending aneurysm that requires repair. Combined aortic valve operations and aortic repair was associated with significantly better long-term survival than a valve operation alone. Further study of this association may direct decisions about timing of surgical intervention.
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Affiliation(s)
- Yuanjia Zhu
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio.
| | - Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Charles M Wojnarski
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
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Masabni K, Sabik JF, Raza S, Carnes T, Koduri H, Idrees JJ, Beach J, Riaz H, Shishehbor MH, Gornik HL, Blackstone EH. Nonselective carotid artery ultrasound screening in patients undergoing coronary artery bypass grafting: Is it necessary? J Thorac Cardiovasc Surg 2015; 151:402-8. [PMID: 26586360 DOI: 10.1016/j.jtcvs.2015.09.108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/14/2015] [Accepted: 09/26/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine whether nonselective preoperative carotid artery ultrasound screening alters management of patients scheduled for coronary artery bypass grafting (CABG), and whether such screening affects neurologic outcomes. METHODS From March 2011 to September 2013, preoperative carotid artery ultrasound screening was performed on 1236 of 1382 patients (89%) scheduled to undergo CABG. Carotid artery stenosis (CAS) was classified as none or mild (any type 0%-59% stenosis), moderate (unilateral 60%-79% stenosis), or severe (bilateral 60%-79% stenosis or unilateral 80%-100% stenosis). RESULTS A total of 1069 (86%) had <moderate; 90 (7.3%) had moderate; and 77 (6.2%) had severe CAS. Of those with moderate CAS, 4 (4.4%) had preoperative confirmatory testing, and 1 (1.1%) underwent combined CABG + carotid endarterectomy (CEA); 11 (12%) had off-pump surgery. Of those with severe CAS, 18 (23%) had confirmatory testing, and 18 (23%) underwent combined CABG + CEA; 6 (7.8%) had off-pump surgery. Stroke occurred in 14 of 1069 (1.3%) patients with <moderate CAS; 2 of 90 (2.2%) of those with moderate CAS; and 2 of 77 (2.6%) of those with severe CAS (P = .3). In patients with ≥moderate CAS, 1 of 19 (5.3%) undergoing CABG + CEA and 3 of 148 (2.0%) undergoing CABG alone experienced stroke (P = .4). In patients with moderate CAS, stroke occurred in 1 of 11 (9.1%) off-pump and 1 of 79 (1.3%) on-pump patients (P = .2). In patients with severe CAS, stroke occurred in 1 of 6 (17%) off-pump and 1 of 71 (1.4%) on-pump patients (P = .15). CONCLUSIONS Routine preoperative carotid artery evaluation altered the management of a minority of patients undergoing CABG; this did not translate into perioperative stroke risk. Hence, a more targeted approach for preoperative carotid artery evaluation should be adopted.
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Affiliation(s)
- Khalil Masabni
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio.
| | - Sajjad Raza
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
| | - Theresa Carnes
- Department of Quantitative Health Sciences, Research Institute, Cleveland, Ohio
| | - Hemantha Koduri
- Department of Vascular Medicine, Heart and Vascular Institute, Cleveland, Ohio
| | - Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
| | - Jocelyn Beach
- Department of Vascular Surgery, Heart and Vascular Institute, Cleveland, Ohio
| | - Haris Riaz
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mehdi H Shishehbor
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland, Ohio
| | - Heather L Gornik
- Department of Vascular Medicine, Heart and Vascular Institute, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland, Ohio
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Vivacqua A, Idrees JJ, Johnston DR, Soltesz EG, Svensson LG, Roselli EE. Thoracic endovascular repair first for extensive aortic disease: the staged hybrid approach. Eur J Cardiothorac Surg 2015; 49:764-9. [DOI: 10.1093/ejcts/ezv274] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 05/27/2015] [Indexed: 11/14/2022] Open
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Idrees JJ, Roselli EE, Wojnarski CM, Feng K, Aftab M, Johnston DR, Soltesz EG, Sabik JF, Svensson LG. Prophylactic stage 1 elephant trunk for moderately dilated descending aorta in patients with predominantly proximal disease. J Thorac Cardiovasc Surg 2015; 150:1150-5. [PMID: 26433635 DOI: 10.1016/j.jtcvs.2015.07.077] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/14/2015] [Accepted: 07/22/2015] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Staged elephant trunk (ET) repair is a commonly performed procedure for extensive aortic disease. A significant proportion of patients with predominantly proximal aortic pathology often have in addition a moderately dilated descending aorta (<5 cm) that can progress over time. Objectives were to characterize patients, determine completion rate after prophylactic stage 1 ET, and assess outcomes. METHODS From 1992 to 2012, a total of 572 patients underwent stage 1 ET for degenerative aneurysm and dissection at Cleveland Clinic. Prophylactic stage 1 ET was performed in 117 (20.5%) who had predominantly proximal disease (5.5 ± 1 cm) with moderate dilation of the descending aorta (4 ± 0.6 cm). Aortic pathology included: aneurysm (n = 56 [48%]); chronic dissection (n = 41 [35%]); pseudoaneurysm (n = 9 [7.7%]); penetrating ulcer (n = 9 [7.7%]); and intramural hematoma (n = 2 [1.7%]). Other diagnoses included connective tissue disorder (12 [10%]); aortitis (20 [17%]); bicuspid aortic valve (9 [7.6%]); and previous type A dissection repair (27 [23%]). RESULTS Operative mortality was 0.8% (1 of 117). This patient suffered postoperative myocardial infarction and mesenteric ischemia, resulting in sepsis and death. Other complications included: stroke (n = 7 [6%]); tracheostomy (n = 6 [5%]); renal dialysis (n = 4 [3.3%]); and reoperation for bleeding (n = 7 [6%]). The mean follow-up time was 4 ± 3 years. Fifty-three (45%) patients completed the stage 2 ET (open: 20 [38%]; endovascular: 33 [62%]) at a median interval of 6 months (9 days-10 years). The mean descending diameter increased from 4.1 ± 0.6 cm to 5 ± 1 cm at the time of stage 2 completion. In 11 patients, stage 2 was performed for acute aortic events. Estimated survival at 1, 5, and 8 years was 94%, 88%, and 74%, respectively. CONCLUSIONS Prophylactic ET for moderately dilated descending aorta is an effective strategy for staged repair, especially in patients with chronic dissection, connective tissue disorder, and aortitis. In addition, this approach can be beneficial for emergency treatment of late distal aortic complications.
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Affiliation(s)
- Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Charles M Wojnarski
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ke Feng
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Muhammad Aftab
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery and Aortic Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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Wojnarski CM, Svensson LG, Roselli EE, Idrees JJ, Lowry AM, Ehrlinger J, Pettersson GB, Gillinov AM, Johnston DR, Soltesz EG, Navia JL, Hammer DF, Griffin B, Thamilarasan M, Kalahasti V, Sabik JF, Blackstone EH, Lytle BW. Aortic Dissection in Patients With Bicuspid Aortic Valve-Associated Aneurysms. Ann Thorac Surg 2015. [PMID: 26209494 DOI: 10.1016/j.athoracsur.2015.04.126] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Data regarding the risk of aortic dissection in patients with bicuspid aortic valve and large ascending aortic diameter are limited, and appropriate timing of prophylactic ascending aortic replacement lacks consensus. Thus our objectives were to determine the risk of aortic dissection based on initial cross-sectional imaging data and clinical variables and to isolate predictors of aortic intervention in those initially prescribed serial surveillance imaging. METHODS From January 1995 to January 2014, 1,181 patients with bicuspid aortic valve underwent cross-sectional computed tomography (CT) or magnetic resonance imaging (MRI) to ascertain sinus or tubular ascending aortic diameter greater than or equal to 4.7 cm. Random Forest classification was used to identify risk factors for aortic dissection, and among patients undergoing surveillance, time-related analysis was used to identify risk factors for aortic intervention. RESULTS Prevalence of type A dissection that was detected by imaging or was found at operation or on follow-up was 5.3% (n = 63). Probability of type A dissection increased gradually at a sinus diameter of 5.0 cm--from 4.1% to 13% at 7.2 cm--and then increased steeply at an ascending aortic diameter of 5.3 cm--from 3.8% to 35% at 8.4 cm--corresponding to a cross-sectional area to height ratio of 10 cm(2)/m for sinuses of Valsalva and 13 cm(2)/m for the tubular ascending aorta. Cross-sectional area to height ratio was the best predictor of type A dissection (area under the curve [AUC] = 0.73). CONCLUSIONS Early prophylactic ascending aortic replacement in patients with bicuspid aortic valve should be considered at high-volume aortic centers to reduce the high risk of preventable type A dissection in those with aortas larger than approximately 5.0 cm or with a cross-sectional area to height ratio greater than approximately 10 cm(2)/m.
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Affiliation(s)
- Charles M Wojnarski
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Ehrlinger
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jose L Navia
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Donald F Hammer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Maran Thamilarasan
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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