Epidemiology of Coronary Artery Disease

Although the mortality of coronary artery disease (CAD) has declined over recent decades, CAD remains the leading cause of death in the United States (US) and presents a significant economic burden. Epidemiologic studies have identified numerous risk factors for CAD. Some risk factors-including smoking, hypertension, dyslipidemia, and physical inactivity-are decreasing within the US population while Others, including advanced age, diabetes, and obesity are increasing. The most significant historic advances in CAD therapy were the development of coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), and lipid-lowering medications. Contemporary management of CAD includes primary and secondary prevention via medical management and revascularization when appropriate based on best available evidence. Despite the increasing prevalence of CAD nationwide, there has been a steady decline in the number of CABGs and PCIs performed in the US for the past decade. Patients with CABG are becoming older and with more comorbid conditions, although mortality associated with CABG has remained steady

Epidemiology of Valvular Heart Disease

Acquired diseases of the aortic and mitral valves are the most common cause of morbidity and mortality among Valvular heart diseases. Aortic stenosis (AS) is increasing in incidence in the United States (4,43 US), driven largely by an aging demographic. Aortic valve replacement is the only effective treatment of AS and has a dramatic mortality benefit. Mitral valve regurgitation (MR) is the most common form of valvular heart disease (VHD) in the US, whereby MR is most often the result of mitral valve prolapse; rheumatic heart disease (RHD) is a more common etiology of MR in underdeveloped countries. interventions for MR in the US are increasing

The Right Ventricle in the Trans-Catheter Era: A Perspective for Planning Interventions

Dysfunction of the right ventricle (RV) is common in patients with advanced left-sided valve disease and the significant impact of RV dysfunction on both short and long-term outcome is well established. However, considerations of RV function are largely absent in current management guidelines for valve disease and cardiac procedural risk models. As the indications and use of trans-catheter therapies rapidly expand for patients with acquired valvular disease, it is critical for clinicians to understand and consider RV function when making decisions for these patients. This review summarizes contemporary data on the assessment of RV function, the prognostic importance of baseline RV dysfunction on surgical and transcatheter procedures for acquired left-sided valvular disease, and the relative impact of these interventions on RV function. Baseline RV dysfunction is a powerful predictor of poor short- and long-term outcome after any therapeutic intervention for acquired left-sided cardiac valve disease. Surgical intervention for aortic or mitral valve disease is associated with a significant but transient decline in RV function, whereas trans-catheter procedures generally do not appear to have detrimental effects on either longitudinal or global RV function. Guidelines for therapy in patents with acquired left-sided valvular disease should account for RV dysfunction. Whereas surgical intervention in these patients leads to a predictable decline in RV function, trans-catheter therapies largely do not appear to have this effect. Further study is needed to determine the impact of these findings on current practice

Uniportal Video-Assisted Thoracoscopic Lung Resection: A Single-Surgeon Experience and Comparison with Multiportal Technique in the Veteran Population

Uniportal video-assisted thoracoscopic surgery (VATS) has been shown to offer improved postoperative outcomes compared with multiportal technique. Shorter operative time has rarely been described. Our objective was to compare operative time and clinical outcomes between uniportal and multiportal VATS approaches for lung resection. This is a retrospective review of patients that underwent video-assisted thoracoscopic lung resection at United States Veterans Affairs centers between 2008 and 2018 using the Veteran Affairs Surgical Quality Improvement Program. Cases were assigned to uniportal (single surgeon) or multiportal cohorts. Multivariable analysis of clinical outcomes was performed, adjusting for preoperative confounding covariates. Temporal trend in operative time in uniportal cohort was analyzed in the context of cumulative operative volume using Spearman\u27s rank correlation coefficient, rho (). In total, 8,212 cases were selected from 2008 to 2018 at Veterans Affairs centers: 176 (2.1%) uniportal and 8036 (97.9%) multiportal cases. Uniportal cohort was significantly associated with shorter operative time (1.7 hours versus 3.1 hours,  \u3c .001), higher adjusted odds of surgical site infection (adjusted odds ratio = 2.76;  = .005), and longer length of stay (6 days versus 5 days;  = .04). Uniportal cohort operative time decreased over time ( = -0.474), with most significant change corresponding with increased cumulative operative volume from 25 to 44 cases. Uniportal technique offered shorter operative duration in veterans compared with multiportal approach, validating its technical advantages. Operative time decreased as cumulative operative volume increased, demonstrating a learning curve. Future studies should prospectively investigate any association between operative time and clinical outcomes after thoracoscopic lung resection

Hospital Operative Volume and Esophagectomy Outcomes in the Veterans Affairs System

INTRODUCTION: Previous studies reported that increased hospital case volume improves outcomes after esophagectomy. Yet, the standard for high and low-volume hospitals varies in the literature. This study attempts to define the relationship between hospital operative volume and 30-day post-operative outcomes of esophagectomy in the Veterans Affairs (VA) system. METHODS: This is a retrospective review of patients that underwent esophagectomy from 2008 to 2019 utilizing the Veterans Affairs Surgical Quality Improvement Program Database. Receiver operating characteristic (ROC) analysis quantified an inflection point of optimal association between 30-day morbidity and mortality by facility volume. This point was used to separate cohorts for comparison of outcomes using 1:1 propensity score matching (PSM) to account for confounding covariates. RESULTS: Two thousand two hundred and twelve esophagectomies were performed from 2008 to 2019 and ROC analysis identified an inflection point at 43 cases (4 cases/y) where bidirectional operative volume significantly affected outcomes. Subsequent PSM resulted in 1718 cases utilized for analysis (n = 859 per cohort). Facility volume ≥4 cases/y was significantly associated with decreased odds of 30-day mortality (odds ratio(OR) = 0.57; P = 0.03), shorter length of stay (median 13 versus 14 d; P = 0.04) and longer operative times (6.5 versus 6.0 h; P \u3c 0.001). CONCLUSIONS: VA hospitals that averaged ≥4 esophagectomies/y had significantly lower rates of mortality and length of stay. This volume threshold may serve as a benchmark to determine the optimal setting for esophageal resection. However, our findings also may reflect the benefits of cumulative operating room and multidisciplinary team experience at VA centers in conjunction with dedicated surgeons. Future studies should focus on long-term outcomes after esophagectomy in relation to hospital operative volume

Clinical Outcomes and Technical Approach of Thymectomy in the Veterans Health Administration

BACKGROUND: Thymectomy is traditionally performed through a transsternal incision, but less invasive modalities have emerged, including transcervical, thoracoscopic, and robotic approaches. Despite the advantages of video-assisted thoracoscopic surgery (VATS) over thoracotomy, most thymectomies are performed through sternotomy. This study compared the use and 30-day postoperative outcomes of transsternal, transcervical, and VATS thymectomy in the Veterans Health Administration. METHODS: This was a retrospective review of veterans who underwent thymectomy through the Veterans Affairs Surgical Quality Improvement Program. Their 30-day outcomes were compared among techniques, by adjusting for confounding covariates. Temporal trends were analyzed using the Spearman\u27 rank correlation coefficient, rho(ρ). RESULTS: From 2008 to 2019, 594 thymectomies were performed: 376 (63.3%) transsternal, 113 (19.0%) VATS (including robotic approaches), and 105 (17.7%) transcervical cases. VATS use increased from 0% in 2008 to 61% of case volume in 2019. Relative to the transsternal technique, VATS thymectomy was associated with decreased odds of pulmonary complications (adjusted odds ratio, 0.06; P = .028) and shorter hospital stay (2.9 ± 0.4 days shorter; P \u3c .001). No difference in outcomes was detected between VATS and transcervical thymectomy. The postoperative complication rate decreased from 17.7% in 2008 to 5.6% in 2019 (ρ = -0.101; P = .014). Length of stay decreased from median 4 days in 2008 to 3 days in 2019 (ρ = -0.093; P = .026). In thymic cancer, VATS 5-year overall survival was noninferior to the transsternal approach (71.3% vs 74.6%; P = .54). CONCLUSIONS: The transsternal approach comprised most thymectomy cases in veterans, whereas VATS thymectomy use increased over time and was associated with favorable outcomes. The 30-day outcomes after thymectomy improved over time, which may reflect a trend toward wider use of less invasive approaches. Future studies should examine long-term outcomes

Impact of Timing of Smoking Cessation on 30-Day Outcomes in Veterans Undergoing Lobectomy for Cancer

The adverse effects of tobacco use on postoperative outcomes are well documented. While smoking cessation is associated with overall improvement in long-term survival for lung cancer patients, the effects of cessation shortly before lung surgery are unclear. This study compares 30-day outcomes after lobectomy between active smokers, recent quitters, and nonsmokers. Patients who underwent lobectomy for cancer at national Veterans Affairs medical centers from 2012 to 2018 were retrospectively identified in the Veterans Affairs Surgical Quality Improvement Program database. The sample was stratified into 3 groups: smokers within 2 weeks of surgery (“active smokers”), those who quit between 2 weeks and 3 months prior to surgery (“recent quitters”), and “nonsmokers.” Propensity score matching was performed to compare groups. Of 5715 patients who met inclusion criteria, 2696 were nonsmokers, 774 were recent quitters, and 2245 were active smokers. After propensity matching, 572 patients comprised each group. Compared to recent quitters, active smokers had 48% higher odds of suffering a pulmonary complication (95% confidence interval [CI]: 1.03–2.14; P = 0.035) and 72% higher odds of suffering multiple complications (CI: 1.07–2.76; P = 0.026). Relative to nonsmokers, active smokers had 81% higher odds of pulmonary complications (CI: 1.34–2.65; P = 0.003). No differences were detected in outcomes comparing recent quitters to nonsmokers. Veterans undergoing lobectomy for cancer who quit 2 weeks before surgery had less pulmonary complications than active smokers. Recent quitters have similar outcomes to nonsmokers. Surgeons should therefore encourage patients to quit smoking, including just prior to lung surgery

Predictors of 30-Day Pulmonary Complications after Video-Assisted Thoracoscopic Surgery Lobectomy

BACKGROUND: Pulmonary complications are the most common adverse event after lung resection, yet few large-scale studies have examined pertinent risk factors after video-assisted thoracoscopic surgery (VATS) lobectomy. Veterans, older and less healthy compared with nonveterans, represent a cohort that requires further investigation. Our objective is to determine predictors of pulmonary complications after VATS lobectomy in veterans. METHODS: A retrospective review was conducted on patients who underwent VATS lobectomy from 2008 to 2018 using the Veterans Affairs Surgical Quality Improvement Program database. Patients were divided into two cohorts based on development of a pulmonary complication within 30 days. Patient characteristics were compared via multivariable analysis to determine clinical predictors associated with pulmonary complication and reported as adjusted odds ratios (aORs) with 95% confidence intervals. Patients with preoperative pneumonia, ventilator dependence, and emergent cases were excluded. RESULTS: In 4,216 VATS lobectomy cases, 480 (11.3%) cases had ≥1 pulmonary complication. Preoperative factors independently associated with pulmonary complication included chronic obstructive pulmonary disease (COPD) (aOR = 1.37 [1.12-1.69];  = 0.003), hyponatremia (aOR = 1.50 [1.06-2.11];  = 0.021), and dyspnea (aOR = 1.33 [1.06-1.66];  = 0.013). Unhealthy alcohol consumption was associated with pulmonary complication via univariable analysis (17.1 vs. 13.0%;  = 0.016). Cases with pulmonary complication were associated with increased mortality (12.1 vs. 0.8%;  \u3c 0.001) and longer length of stay (12.0 vs. 6.8 days;  \u3c 0.001). CONCLUSION: This analysis revealed several preoperative factors associated with development of pulmonary complications. It is imperative to optimize pulmonary-specific comorbidities such as COPD or dyspnea prior to VATS lobectomy. However, unhealthy alcohol consumption and hyponatremia were linked with development of pulmonary complication in our analysis and should be addressed prior to VATS lobectomy. Future studies should explore long-term consequences of pulmonary complications