Off‐pump coronary artery bypass grafting: department of veteran affairs’ use and outcomes

Background: Coronary artery bypass can be performed off pump (OPCAB) without cardiopulmonary bypass. However, trends over time for OPCAB versus on‐pump (ONCAB) use and long‐term outcome has not been reported, nor has their long‐term outcome been compared. Methods and Results: We queried the national Veterans Affairs database (2005–2019) to identify isolated coronary artery bypass procedures. Procedures were classified as OPCAB on ONCAB using the as‐treated basis. Trend analyses were performed to evaluate longitudinal changes in the preference for OPCAB. The median follow‐up period was 6.6 (3.5–10) years. An inverse probability weighted Cox model was used to compare all‐cause mortality between OPCAB and ONCAB. From 47 685 patients, 6759 (age 64±8 years) received OPCAB (14%). OPCAB usage declined from 16% (2005–2009) to 8% (2015–2019). Patients with triple vessel disease who received OPCAB received a lower mean number of grafts (2.8±0.8 versus 3.2±0.8; P<0.01). The ONCAB 5‐, 10‐, and 15‐year survival rates were 82.9% (82.5–83.3), 60.4% (59.8–61.1), and 37.2% (36.1–38.4); correspondingly, OPCAB rates were 80.7% (79.7–81.7), 57.4% (56–58.7), and 34.1% (31.7–36.6) (P<0.01). OPCAB was associated with increased risk‐adjusted all‐cause mortality (hazard ratio, 1.15 [1.13–1.18]; P<0.01) and myocardial infarction (incident rate ratio, 1.16 [1.05–1.28]; P<0.01). Conclusions: Over 15 years, OPCAB use declined considerably in Veterans Affairs medical centers. In Veterans Affairs hospitals, late all‐cause mortality and myocardial infarction rates were higher in the OPCAB cohort

Building an immune-mediated coagulopathy consensus: early recognition and evaluation to enhance post-surgical patient safety

Topical hemostats, fibrin sealants, and surgical adhesives are regularly used in a variety of surgical procedures involving multiple disciplines. Generally, these adjuncts to surgical hemostasis are valuable means for improving wound visualization, reducing blood loss or adding tissue adherence; however, some of these agents are responsible for under-recognized adverse reactions and outcomes. Bovine thrombin, for example, is a topical hemostat with a long history of clinical application that is widely used alone or in combination with other hemostatic agents. Hematologists and coagulation experts are aware that these agents can lead to development of an immune-mediated coagulopathy (IMC). A paucity of data on the incidence of IMC contributes to under-recognition and leaves many surgeons unaware that this clinical entity, originating from normal immune responses to foreign antigen exposure, requires enhanced post-operative vigilance and judicious clinical judgment to achieve best outcomes

A γ-Lactam Siderophore Antibiotic Effective against Multidrug-Resistant Gram-Negative Bacilli

Treatment of multidrug-resistant Gram-negative bacterial pathogens represents a critical clinical need. Here, we report a novel γ-lactam pyrazolidinone that targets penicillin-binding proteins (PBPs) and incorporates a siderophore moiety to facilitate uptake into the periplasm. The MIC values of γ-lactam YU253434, 1, are reported along with the finding that 1 is resistant to hydrolysis by all four classes of β-lactamases. The druglike characteristics and mouse PK data are described along with the X-ray crystal structure of 1 binding to its target PBP3

Peristaltic Aortomyoplasty

Aortomyoplasty is a new surgical treatment for heart failure in which the latissimus dorsi muscle (LDM) is wrapped around the aorta and electrically activated to provide diastolic counterpulsation. We hypothesized that blood displaced from the wrapped aortic region could be preferentially directed by separately activating regions of the LDM in a peristaltic-like motion. In dogs, the LDM was instrumented with stimulus electrodes and wrapped around the descending thoracic aorta, and a heart pacing lead was positioned in the right ventricle. In a terminal study (following muscle conditioning and induction of heart failure via rapid ventricular pacing), left ventricular and aortic pressures were measured while LDM stimulation was systematically time-shifted between two muscle segments. For each data run, endocardial-viability ratio was calculated. Results suggest that it is possible to preferentially direct blood flow during aortomyoplasty

Optimizing muscle-to-cardiac timing for aortomyoplasty

A new surgical approach to support failing hearts is known as aortomyoplasty-a technique in which the latissimus dorsi muscle is wrapped around the aorta and stimulated during cardiac diastole to provide chronic diastolic counterpulsation. We hypothesized that the timing of muscle contraction within the cardiac cycle effects the amount of diastolic augmentation during counterpulsation. In dogs (n = 9, 20-25 kg), the effect of muscle-to-cardiac timing on hemodynamic outcome of aortomyoplasty was measured. Muscle stimulation was initiated at the dicrotic notch and stimulus durations were systematically increased. Mean diastolic aortic pressure was maximized when stimulation terminated at the ensuing R-wave. Peak left-ventricular pressure was minimized when muscle stimulation terminated before the ensuing R-wave. The endocardial-viability ratio (a ratio of aortic diastolic pressure augmentation to left-ventricular pressure reduction) was maximized when stimulus terminated at the ensuing R-wave. Muscle-to-cardiac timing influences the effectiveness of counterpulsation during aortomyoplasty

Outcomes of coronary artery bypass grafting in patients with heart failure with a midrange ejection fraction

Background: Coronary artery bypass grafting (CABG) improves survival in patients with heart failure and severely reduced left ventricular systolic function (LVEF). Limited data exist regarding adverse cardiovascular event rates after CABG in patients with heart failure with midrange ejection fraction (HFmrEF; LVEF > 40% and < 55%). Methods: We analyzed data on isolated CABG patients from the Veterans Affairs national database (2010-2019). We stratified patients into control (normal LVEF and no heart failure), HFmrEF, and heart failure with reduced LVEF (HFrEF) groups. We compared all-cause mortality and heart failure hospitalization rates between groups with a Cox model and recurrent events analysis, respectively. Results: In 6533 veterans, HFmrEF and HFrEF was present in 1715 (26.3%) and 566 (8.6%) respectively; the control group had 4252 (65.1%) patients. HFrEF patients were more likely to have diabetes mellitus (59%), insulin therapy (36%), and previous myocardial infarction (31%). Anemia was more prevalent in patients with HFrEF (49%) as was a lower serum albumin (mean, 3.6 mg/dL). Compared with the control group, a higher risk of death was observed in the HFmrEF (hazard ratio [HR], 1.3 [1.2-1.5)] and HFrEF (HR, 1.5 [1.2-1.7]) groups. HFmrEF patients had the higher risk of myocardial infarction (subdistribution HR, 1.2 [1-1.6]; P = .04). Risk of heart failure hospitalization was higher in patients with HFmrEF (HR, 4.1 [3.5-4.7]) and patients with HFrEF (HR, 7.2 [6.2-8.5]). Conclusions: Heart failure with midrange ejection fraction negatively affects survival after CABG. These patients also experience higher rates myocardial infarction and heart failure hospitalization

Home health care after discharge is associated with lower readmission rates for patients with acute myocardial infarction

Objective: We studied the utilization of home health care (HHC) among acute myocardial infarction (AMI) patients, impact of HHC on and predictors of 30-day readmission. Methods: We queried the National Readmission Database (NRD) from 2012 to 2014identify patients with AMI discharged home with (HHC+) and without HHC (HHC-). Linkage provided in the data identified patients who had 30-day readmission, our primary end-point. The probability for each patient to receive HHC was calculated by a multivariable logistic regression. Average treatment of treated weights were derived from propensity scores. Weight-adjusted logistic regression was used to determine impact of HHC on readmission. Results: A total of 406 237 patients with AMI were discharged home. Patients in the HHC+ cohort (38 215 patients, 9.4%) were older (mean age 77 vs. 60 years P < 0.001), more likely women (53 vs. 26%, P < 0.001), have heart failure (5 vs. 0.5%, P < 0.001), chronic kidney disease (26 vs. 6%, P < 0.001) and diabetes (35 vs. 26%, P < 0.001). Patients readmitted within 30-days were older with higher rates of diabetes (RR = 1.4, 95% CI: 1.37-1.48) and heart failure (RR = 5.8, 95% CI: 5.5-6.2). Unadjusted 30-day readmission rates were 21 and 8% for HHC+ and HHC- patients, respectively. After adjustment, readmission was lower with HHC (21 vs. 24%, RR = 0.89, 95% CI: 0.82-0.96; P < 0.001). Conclusion: In the United States, AMI patients receiving HHC are older and have more comorbidities; however, HHC was associated with a lower 30-day readmission rate

Home health care after discharge is associated with lower readmission rates for patients with acute myocardial infarction

Objective: We studied the utilization of home health care (HHC) among acute myocardial infarction (AMI) patients, impact of HHC on and predictors of 30-day readmission. Methods: We queried the National Readmission Database (NRD) from 2012 to 2014identify patients with AMI discharged home with (HHC+) and without HHC (HHC-). Linkage provided in the data identified patients who had 30-day readmission, our primary end-point. The probability for each patient to receive HHC was calculated by a multivariable logistic regression. Average treatment of treated weights were derived from propensity scores. Weight-adjusted logistic regression was used to determine impact of HHC on readmission. Results: A total of 406 237 patients with AMI were discharged home. Patients in the HHC+ cohort (38 215 patients, 9.4%) were older (mean age 77 vs. 60 years P < 0.001), more likely women (53 vs. 26%, P < 0.001), have heart failure (5 vs. 0.5%, P < 0.001), chronic kidney disease (26 vs. 6%, P < 0.001) and diabetes (35 vs. 26%, P < 0.001). Patients readmitted within 30-days were older with higher rates of diabetes (RR = 1.4, 95% CI: 1.37-1.48) and heart failure (RR = 5.8, 95% CI: 5.5-6.2). Unadjusted 30-day readmission rates were 21 and 8% for HHC+ and HHC- patients, respectively. After adjustment, readmission was lower with HHC (21 vs. 24%, RR = 0.89, 95% CI: 0.82-0.96; P < 0.001). Conclusion: In the United States, AMI patients receiving HHC are older and have more comorbidities; however, HHC was associated with a lower 30-day readmission rate

Safety-net hospitals versus non-safety centers and clinical outcomes after trans-catheter aortic valve replacement

Objective: To compare post-procedural outcomes of trans-catheter valve replacement (TAVR) among safety-net (SNH) and non-safety net hospitals (non-SNH). Background SNH treat a large population of un-insured and low income patients; prior studies report worse outcome at these centers. Results of TAVR at these centers is limited. Methods: Adults undergoing TAVR at hospitals in the US participating in the National In-patient sample (NIS) database from January 2014 to December 2015 were included. A 1:1 propensity-matched cohort of patients operated at SNH and non-SNH institutions was analyzed, on the basis of 16 demographic and clinical co-variates. Main outcome was all-cause post-procedural mortality. Secondary outcomes included stroke, acute kidney injury and length of post-operative stay. Results: Between 2014 and 2015, 41,410 patients (mean age 80 ± 0.11 years, 46% female) underwent TAVR at 731 centers; 6,996 (16.80%) procedures were performed at SNH comprising 135/731 (18.4%) of all centers performing TAVR. SNH patients were more likely to be female (49% vs. 46%, p < .001); admitted emergently (31% vs. 21%; p < .001; at the lowest quartile for household income (25% % vs. 20%; p < .001) and from minorities (Blacks 5.9% vs. 3.9%; Hispanic 7.2% vs. 3.2%).Adjusted logistic regression was performed on 6,995 propensity-matched patient pairs. Post-procedural mortality [OR 0.99(0.98–1.007); p = .43], stroke [OR 1.009(0.99–1.02); p = .08], acute kidney injury [OR 0.99(0.96–1.01); p = .5] and overall length of stay (6.9 ± 0.1 vs. 7.1 ± 0.2 days; p = .57) were comparable in both cohorts. Conclusion: Post-procedural outcomes after TAVR at SNH are comparable to national outcomes and wider adoption of TAVR at SNH may not adversely influence outcomes