Abstract 14264: National Comparison of Hospital Market Share for Out-of-Hospital Cardiac Arrest and Elective Cardiac Surgery

Introduction: Competition in the healthcare market is a theoretical driver of innovation, cost-savings, and improved quality. When patients are treated for certain emergent conditions, such as out-of-hospital cardiac arrest (OHCA), individuals have less choice in their treating hospital. For patients undergoing elective cardiac valve replacement surgery (EVRS), hospital choice may reflect distinct referral patterns and preferences. Our objective was to compare hospital market share for different cardiac services, thus allowing for better understanding of the care landscape and target interventions to improve outcomes. Methods: Using age-eligible Medicare fee-for-service institutional claims, an emergency department (ED) treated OHCA cohort was identified via ICD-9/10 diagnosis codes and ED charges. EVRS, an inpatient referral procedure, were identified from in-patient summary claims using procedure codes. Market shares were built for each hospital by sequential addition of ZIP-code areas and calculating the hospital’s cumulative market share. Geographic market share areas were defined for each hospital at 90%, 25% and 10% cut-offs if present. Correlation between corresponding market shares and patient counts were assessed using Pearson’s r. Results: Between 1/2013 and 12/2015, we identified 206,162 EVRS claims and 222,018 OHCA claims. Median age was similar (77 vs 78 yrs), as was percent of female patient (43% vs 44%). Very few beneficiaries (0.38%) appeared in both cohorts. Many more hospitals cared for OHCA than EVRS (4482 vs 1170). More OHCA treating hospitals achieved a 25% market share (68% vs 57%) however, EVRS hospital with a 25% market share covered more population (420,294 vs 66,394) and had a greater client radius (21 vs 15 miles). Among the hospitals providing care to both cohorts, the cumulative market share and patient counts were positively correlated (r = 0.49 and 0.46 respectively, p<0.001 for both). Conclusion: Despite many more hospitals providing care for OHCA, the market share for EVRS and OHCA trend together. This market trend, combined with the association of better outcomes with higher OHCA volume suggests that OHCA should be regionalized within markets to facilities that provide elective cardiac surgical procedures.

Graded epidural anesthesia for open cholecystectomy in elderly patient with ischemic heart disease

Geriatric patients with a limited physiological reserve and associated comorbidities present a challenge to anesthesiologists. Patients with cardiac disease coming for non-cardiac surgical procedures are at increased risk of perioperative cardiovascular events such as myocardial ischemia, myocardial infarction (MI) and are associated with greater morbidity and mortality. In this case report, the patient had a previous history of MI and was a known case of diabetes mellitus with acute cholecystitis with cholelithiasis with anterolateral ischemic heart disease with an ejection fraction of 35%. This patient was posted for open cholecystectomy with CBD exploration and successfully managed under graded epidural anesthesia and had an uneventful recovery.

Consensus Defined Diastolic Dysfunction and Cardiac Postoperative Morbidity Score: A Prospective Observational Study

Diastolic dysfunction is associated with major adverse outcomes following cardiac surgery. We hypothesized that multisystem endpoints of morbidity would be higher in patients with diastolic dysfunction. A total of 142 patients undergoing cardiac surgical procedures with cardiopulmonary bypass were included in the study. Intraoperative assessments of diastolic function according to the 2016 American Society of Echocardiography and European Association of Cardiovascular Imaging guidelines using transesophageal echocardiography were performed. Cardiac Postoperative Morbidity Score (CPOMS) on days 3, 5, 8, and 15; length of stay in ICU and hospital; duration of intubation; incidence of new atrial fibrillation; 30-day major adverse cardiac and cerebrovascular events were recorded. Diastolic function was determinable in 96.7% of the dataset pre and poststernotomy assessment (n = 240). Diastolic dysfunction was present in 70.9% (n = 88) of measurements before sternotomy and 75% (n = 93) after sternal closure. Diastolic dysfunction at either stage was associated with greater CPOMS on D5 (p = 0.009) and D8 (p = 0.009), with CPOMS scores 1.24 (p = 0.01) higher than in patients with normal function. Diastolic dysfunction was also associated with longer durations of intubation (p = 0.001), ICU length of stay (p = 0.019), and new postoperative atrial fibrillation (p = 0.016, OR (95% CI) = 4.50 (1.22–25.17)). We were able to apply the updated ASE/EACVI guidelines and grade diastolic dysfunction in the majority of patients. Any grade of diastolic dysfunction was associated with greater all-cause morbidity, compared with patients with normal diastolic function.

Balloon Aortic Valvuloplasty for Severe Aortic Stenosis as Rescue or Bridge Therapy

The study aimed to assess procedural complications, patient flow and clinical outcomes after balloon aortic valvuloplasty (BAV) as rescue or bridge therapy, based on data from our registry. A total of 382 BAVs in 374 patients was performed. The main primary indication for BAV was a bridge for TAVI (n = 185, 49.4%). Other indications included a bridge for AVR (n = 26, 6.9%) and rescue procedure in hemodynamically unstable patients (n = 139, 37.2%). The mortality rate at 30 days, 6 and 12 months was 10.4%, 21.6%, 28.3%, respectively. In rescue patients, the death rate raised to 66.9% at 12 months. A significant improvement in symptoms was confirmed after BAV, after 30 days, 6 months, and in survivors after 1 year (p < 0.05 for all). Independent predictors of 12-month mortality were baseline STS score [HR (95% CI) 1.42 (1.34 to 2.88), p < 0.0001], baseline LVEF <20% [HR (95% CI) 1.89 (1.55–2.83), p < 0.0001] and LVEF <30% at 1 month [HR (95% CI) 1.97 (1.62–3.67), p < 0.0001] adjusted for age/gender. In everyday clinical practice in the TAVI era, there are still clinical indications to BAV a standalone procedure as a bridge to surgery, TAVI or for urgent high risk non-cardiac surgical procedures. Patients may improve clinically after BAV with LV function recovery, allowing to perform final therapy, within limited time window, for severe AS which ameliorates long-term outcomes. On the other hand, in patients for whom an isolated BAV becomes a destination therapy, prognosis is extremely poor.

The occurrence and risk factors of bradycardia after the Maze procedure in patients with atrial fibrillation and tricuspid regurgitation

Objective To evaluate the occurrence and risk factors of bradycardia after the Maze procedure in patients with atrial fibrillation and tricuspid regurgitation. Methods All patients underwent mitral valve (MV) replacement and concomitant bi-atrial cut-and-sew Maze procedure along with other cardiac surgical procedures were recruited from the Department of Cardiovascular Surgery at the First Affiliated Hospital of Medical College of Xi'an Jiaotong University. According to the severity of tricuspid regurgitation, all patients were divided into mild tricuspid regurgitation group and moderate-to-severe tricuspid regurgitation group. The general clinical data, biochemical indexes, intraoperative and postoperative data were collected. The relationship between tricuspid regurgitation and sinus bradycardia after the Maze procedure was analyzed by multivariate logistic regression model. Results We enrolled 82 patients, including 24 males and 58 females. The patients had an average age of 56 ± 10 years old. There were 50 cases in mild tricuspid regurgitation group and 32 cases in moderate-to-severe tricuspid regurgitation group. Compared with the mild tricuspid regurgitation group, postoperative bradyarrhythmia (41% vs. 14%), pre-discharge bradyarrhythmia (63% vs. 14%), postoperative sinus bradycardia (34% vs. 10%) and pre-discharge sinus bradycardia (63% vs. 10%) in moderate-to-severe tricuspid regurgitation group were significantly increased (P < 0.01). In moderate-to-severe tricuspid regurgitation, the risk of sinus bradycardia increased after the Maze procedure (OR = 1.453, 95% CI 1.127–1.874), area under ROC curve was 0.81, the Jordan index was 0.665. Conclusion The severity of tricuspid regurgitation may be an important factor affecting sinus bradycardia after the Maze procedure. It can be considered as a factor to predict sinus bradycardia after the Maze procedure.

Future of cardiac surgery, introducing the interventional surgeon

The swift advances in interventional cardiology combined with the increasing risk of cardiac surgical procedures resulted in diminishing volume of coronary and valvular surgery and affected the future of cardiac surgery service and training. Application to cardiac surgery training programs have steadily declined. This cross-sectional study aimed at identifying main weakness facing cardiac surgery and advocating some recommendations to improve the status of current and future of cardiac surgery.

Surgical Experience with Normothermic Cardiopulmonary Bypass- 3 Years of History: Retrospective Case Series of 50 Patients

Introduction: Numerous beneficial mechanisms have been linked to normothermic open cardiac surgical procedures. The objective of our research is the evaluation of the experience in the Hospital General de la Plaza de la Salud, after 50 cases, as a propitious moment to assume it as an option Pursues to nurture the debate with the evaluation of patients who underwent different open cardiac surgical procedures using normothermia. Materials and Methods: This is a prospective, case series study, which includes a sample of 50 patients who underwent normothermic open cardiac surgery requiring cardiopulmonary bypass from 2017 to 2021. Results: Of the sample, 30% (n=15) accounted for procedures involving aortic valve replacement on cardiopulmonary bypass, 42% (n=21) accounted for mitral valve replacement, and 28% (n=14) of case represented open coronary vessels interventions on cardiopulmonary bypass. The average age for such procedure was 49.6 years. An average of 83.5 minutes were spent on cardiopulmonary bypass. On average, patients underwent 64.8 minutes with clamped vessels. Average blood loss was quantified in milliliters for the three procedures and was reported for the 1st hour, 4th hour, and the 12th hour after procedure initiation as well as total quantified blood loss. The combined set of procedures represented a cumulative average of 272.3 mL of blood loss. Haemoglobin percent change for the cases included in the study were represented by an average change of -.002% for all procedures. On average, patients undergoing all procedures required 1.3 whole blood packets and 1.2 packets of fresh frozen plasma. Hospital stays, counted from the day of admission to the day of discharge, was another factor evaluated for the study. 8.2, 8.0 and 8.8 days represented the average hospital stay for patients undergoing aortic valve replacement, mitral valve replacement and coronary interventions respectively. Conclusion: Normothermia during cardiothoracic surgery that employed cardiopulmonary bypass is a safe and effective strategy.