Socioeconomic Position, Not Race, Is Linked to Death After Cardiac Surgery

Background—Health disparities have been associated with the prevalence of cardiovascular disease. In cardiac surgery, association has been found between race, sex, and poorer prognosis after surgery. However, there is a complex interplay between race, sex, and socioeconomic position (SEP). In our investigation we sought to identify which of these was the driver of risk-adjusted survival. Methods and Results—From January 1, 1995, and December 30, 2005, 23 330 patients (15 156 white men, 6932 white women, 678 black men, and 564 black women) underwent isolated coronary artery bypass grafting, valve, or combined coronary artery bypass grafting and valve procedures. Median follow-up was 5.8 years (25th and 75th percentiles: 3 and 8.6 years). Effect of race, sex, and SEP on all-cause mortality was examined with 2-phase Cox model and generalized propensity score technique. As expected, blacks and women had lower SEP as compared with whites and men for all 6 SEP indicators. Patients with lower SEP had more atherosclerotic disease burden, more comorbidity, and were more symptomatic. Lower SEP was associated with a risk-adjusted dose-dependent reduction in survival after surgery (men, P 0.0001; women, P 0.0079), but black race, once adjusted for SEP, was not. Conclusions—Our large investigation demonstrates that disparities in SEP are present and significantly affect health outcomes. Although race per se was not the driver for reduced survival, patients of low SEP were predominantly represented by blacks and women. Socioeconomically disadvantaged patients had significantly higher risk-adjusted mortality after surgery. Further investigation and targeted intervention should focus specifically on patients of low SEP, their health behaviors, and secondary prevention efforts.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/79037/1/Koch_et_al.pd

Short term outcomes of total arterial coronary revascularization in patients above 65 years: a propensity score analysis

<p>Abstract</p> <p>Background</p> <p>Despite the advantages of bilateral mammary coronary revascularization, many surgeons are still restricting this technique to the young patients. The objective of this study is to demonstrate the safety and potential advantages of bilateral mammary coronary revascularization in patients older than 65 years.</p> <p>Methods</p> <p>Group I included 415 patients older than 65 years with exclusively bilateral mammary revascularization. Using a propensity score we selected 389 patients (group II) in whom coronary bypass operations were performed using the left internal mammary artery and the great saphenous vein.</p> <p>Results</p> <p>The incidence of postoperative stroke was higher in group II (1.5% vs. 0%, P = 0.0111). The amount of postoperative blood loss was higher in group I (908 ± 757 ml vs. 800 ± 713 ml, P = 0.0405). There were no other postoperative differences between both groups.</p> <p>Conclusion</p> <p>Bilateral internal mammary artery revascularization can be safely performed in patients older than 65 years. T-graft configuration without aortic anastomosis is particularly beneficial in this age group since it avoids aortic manipulation, which is an important risk factor for postoperative stroke.</p

The cost of transcatheter aortic valve implantation according to different access routes

Abstract OBJECTIVE Identifying the average direct cost of TAVI (Transcatheter Aortic Valve Implantation) for the different access routes. METHOD This is a research with a quantitative, exploratory and descriptive approach carried out in a government teaching hospital in the state of São Paulo. RESULTS The average direct cost of TAVI procedures by the access routes resulted in R$82,826.38 (transfemoral route), R$79,440.91 (transaortic route) and R$78,173.41 (transapical route). The transcatheter valve cost represented a percentage variation between 78.47% and 83.14% of the total cost of the procedure. The Kruskal-Wallis test was used and presented a statistically significant difference between the three access routes: p=0.008. The Bonferroni test showed a difference in the association between transfemoral and transapical routes, while no statistically significant difference was observed in association with the transaortic route. CONCLUSION The results are important for formulating adequate funding policies for the hospital network and understanding the costs according to the route facilitates rationalizing resources in order for them to be guaranteed for patients who present surgical contraindication to the valve implant

Worldwide Esophageal Cancer Collaboration : clinical staging data

Peer reviewe

Thromboembolism and mechanical heart valves: A randomized study revisited

Background. This study was designed to revise and substantiate previous inferences, based on short-term follow-up, about differences in the incidence of anticoagulant-related events after heart valve replacement among patients who had been randomly assigned to receive either a Bjork-Shiley, Edwards-Duromedics. or Medtronic-Hall mechanical heart valve prosthesis. Methods. Intermediate-term follow-up to January 1995 was completed in 418 of 419 patients randomized to receive one of three types of heart valve prostheses between January 1982 and January 1987. Median follow-up was 98.5 months. Multivariable analysis in the hazard function domain was performed to identify factors that influenced the incidence of time-related thromboembolism and bleeding. These findings were compared with those made previously after a median follow-up of 37.5 months. Results. No differences were found among the three prostheses in rates of anticoagulant-related hemorrhage. However, the incidence of thromboembolism was higher after mitral valve replacement among patients who had received the Medtronic-Hall prosthesis (linearized rate, 5.4% per patient year: 70% confidence interval, 4.0% to 7.1%), compared with Edwards-Duromedics (1.3%; 70% confidence interval, 0.4% to 3.0%) and Bjork-Shiley prostheses (1.2%; 70% confidence interval, 0.6% to 2.2%). Conclusions. At long-term follow-cap, in contrast to the findings at short-term follow-up, patients with either Bjork-Shiley or Edwards-Duromedics prostheses had low rates of thromboembolism, whereas higher rates occurred in patients with a Medtronic-Hall prosthesis in the mitral position. (Ann Thorac Surg 1998;66:101-7) (C) 1998 by The Society of Thoracic Surgeons