Impact of the Anesthesiologist and Surgeon on Cardiac Surgical Outcomes

ObjectiveTo determine the impact of anesthesiologists, surgeons, and their monthly caseload volume on mortality after cardiac surgery.DesignTen-year audit of prospectively collected cardiac surgical data.SettingLarge adult cardiothoracic hospital.ParticipantsA total of 18,569 cardiac surgical patients in the decade from April 2002 through March 2012, plus 21 consultant surgeons and 29 consultant anesthesiologists.InterventionsMajor risk-stratified cardiac surgical operations.MethodsThe primary outcome was in-hospital death. Random intercept models for the surgeon and anesthesiologist cluster, respectively, were fitted, achieving risk-adjustment through the logistic EuroSCORE. The intraclass correlation coefficient (ICC) subsequently was used to measure the amount of outcome variation due to clustering.Measurements and Main ResultsAfter exclusions (duplicates, very-short-term appointments, and cases performed by more than one consultant), there were 18,426 patients with 581 (3.15%) in-hospital deaths. The overwhelming factor associated with outcome variation was the patient risk profile, accounting for 97.14% of the variation. The impact of the surgeon was small (ICC = 2.78%), and the impact of the anesthesiologist was negligible (ICC = 0.08%). Low monthly surgeon volume of surgery, adjusted for average case mix, was associated with higher risk-adjusted mortality (odds ratio = 0.93, 95% CI 0.87-0.98).ConclusionsOutcome was determined primarily by the patient. There were small but significant differences in outcome between surgeons. The attending anesthesiologist did not affect patient outcome in this institution. Low average monthly surgeon volume was a significant risk factor. In contrast, low average monthly anesthesiologist volume had no effect

The impact of altitude on early outcome following the Fontan operation

BACKGROUND: The success of a Fontan circulation depends on several factors including low pulmonary vascular resistance. Pulmonary vascular resistance rises in response to hypoxia. Hypoxia is associated with altitude. Therefore, we wondered whether altitude is a risk factor for early failure after the Fontan operation. The aim was to test this hypothesis. METHODS: Data were obtained from all published series of 'total cavopulmonary' Fontan operations since 1990. The early failure rate from each series and the altitude of the respective cities were recorded. Early failure was defined as death, takedown of Fontan, or transplantation during the same hospital admission. The association between altitude and failure rate was investigated by rank correlation and logistic regression. RESULTS: 24 series were identified from centres situated at altitudes ranging from sea level to 520 metres. The plot of failure rate versus altitude suggests that failure rate increases with altitude. Logistic regression did not fit the data adequately. This was possibly due to the influence of unmeasured and unknown factors affecting the results, as well as the fact that centres were not randomly chosen but were self-selected by virtue of publishing their results. However, Spearman's rank correlation was 0.74 (p = 0.001). CONCLUSION: The early outcome of the Fontan circulation appears to be adversely affected by altitude

An alternative surgical approach to subclavian and innominate stenosis: a case series

We report three cases of symptomatic stenosis of the great vessels or supra-aortic trunks successfully treated surgically with aorto-subclavian and aorto-innominate bypass. Two were performed via manubriotomy and a third case via standard median sternotomy because of concomitant coronary revascularisation. There was complete symptomatic relief on follow-up, and radiological imaging confirmed good flow in the grafts and post-stenotic arteries

Does the "Weekend Effect" for Postoperative Mortality Stand Up to Scrutiny? Association for Cardiothoracic Anesthesia and Critical Care Cohort Study of 110,728 Cardiac Surgical Patients.

OBJECTIVE: Ongoing debate focuses on whether patients admitted to the hospital on weekends have higher mortality than those admitted on weekdays. Whether this apparent "weekend effect" reflects differing patient risk, care quality differences, or inadequate adjustment for risk during analysis remains unclear. This study aimed to examine the existence of a "weekend effect" for risk-adjusted in-hospital mortality after cardiac surgery. DESIGN: Retrospective analysis of prospectively collected cardiac registry data. SETTING: Ten UK specialist cardiac centers. PARTICIPANTS: A total of 110,728 cases, undertaken by 127 consultant surgeons and 190 consultant anesthetists between April 2002 and March 2012. INTERVENTIONS: Major risk-stratified cardiac surgical operations. MEASUREMENTS AND MAIN RESULTS: Crude in-hospital mortality rate was 3.1%. Multilevel multivariable models were employed to estimate the effect of operative day on in-hospital mortality, adjusting for center, surgeon, anesthetist, patient risk, and procedure priority. Weekend elective cases had significantly lower mortality risk compared to Monday elective cases (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.42, 0.96) following risk adjustment by the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and procedure priority; differences between weekend and Monday for urgent and emergency/salvage cases were not significant (OR 1.12, 95% CI 0.73, 1.72, and 1.07, 95% CI 0.79, 1.45 respectively). Considering only the logistic EuroSCORE but not procedure priority yielded 29% higher odds of death for weekend cases compared to Monday operations (OR 1.29, 95% CI 1.08, 1.54). CONCLUSIONS: This study suggests that undergoing cardiac surgery during the weekend does not affect negatively patient survival, and highlights the importance of comprehensive risk adjustment to avoid detecting spurious "weekend effects.

Formal consensus study on surgery to replace the aortic valve in adults aged 18-60 years

Objective: There is uncertainty about surgical procedures for adult patients aged 18-60 years undergoing aortic valve replacement (AVR). Options include conventional AVR (mechanical, mAVR; tissue, tAVR), the pulmonary autograft (Ross) and aortic valve neocuspidisation (Ozaki). Transcatheter treatment may be an option for selected patients. We used formal consensus methodology to make recommendations about the suitability of each procedure. Methods: A working group, supported by a patient advisory group, developed a list of clinical scenarios across seven domains (anatomy, presentation, cardiac/non-cardiac comorbidities, concurrent treatments, lifestyle, preferences). A consensus group of 12 clinicians rated the appropriateness of each surgical procedure for each scenario on a 9-point Likert scale on two separate occasions (before and after a 1-day meeting). Results: There was a consensus that each procedure was appropriate (A) or inappropriate (I) for all clinical scenarios as follows: mAVR: total 76% (57% A, 19% I); tAVR: total 68% (68% A, 0% I); Ross: total 66% (39% A, 27% I); Ozaki: total 31% (3% A, 28% I). The remainder of percentages to 100% reflects the degree of uncertainty. There was a consensus that transcatheter aortic valve implantation is appropriate for 5 of 68 (7%) of all clinical scenarios (including frailty, prohibitive surgical risk and very limited life span). Conclusions: Evidence-based expert opinion emerging from a formal consensus process indicates that besides conventional AVR options, there is a high degree of certainty about the suitability of the Ross procedure in patients aged 18-60 years. Future clinical guidelines should include the option of the Ross procedure in aortic prosthetic valve selection

Amaze: a randomized controlled trial of adjunct surgery for atrial fibrillation

OBJECTIVES: Atrial fibrillation (AF) reduces survival and quality of life (QoL). It can be treated at the time of major cardiac surgery using ablation procedures ranging from simple pulmonary vein isolation to a full maze procedure. The aim of this study is to evaluate the impact of adjunct AF surgery as currently performed on sinus rhythm (SR) restoration, survival, QoL and costeffectiveness. METHODS: In a multicentre, Phase III, pragmatic, double-blinded, parallel-armed randomized controlled trial, 352 cardiac surgery patients with >3 months of documented AF were randomized to surgery with or without adjunct maze or similar AF ablation between 2009 and 2014. Primary outcomes were SR restoration at 1 year and quality-adjusted life years at 2 years. Secondary outcomes included SR at 2 years, overall and stroke-free survival, medication, QoL, cost-effectiveness and safety. RESULTS: More ablation patients were in SR at 1 year [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.20–3.54; P = 0.009]. At 2 years, the OR increased to 3.24 (95% CI 1.76–5.96). Quality-adjusted life years were similar at 2 years (ablation - control -0.025, P = 0.6319). Significantly fewer ablation patients were anticoagulated from 6 months postoperatively. Stroke rates were 5.7% (ablation) and 9.1% (control) (P = 0.3083). There was no significant difference in stroke-free survival [hazard ratio (HR) = 0.99, 95% CI 0.64–1.53; P = 0.949] nor in serious adverse events, operative or overall survival, cardioversion, pacemaker implantation, New York Heart Association, EQ-5D-3L and SF-36. The mean additional ablation cost per patient was £3533 (95% CI £1321–£5746). Cost-effectiveness was not demonstrated at 2 years. CONCLUSIONS: Adjunct AF surgery is safe and increases SR restoration and costs but not survival or QoL up to 2 years. A continued follow-up will provide information on these outcomes in the longer term

Assessing quality in cardiac surgery

There is a the strong temporal, if not causal, link between the intervention and the outcome in cardiac surgery and therefore a link becomes established between operative mortality and the measurement of surgical performance. In Britain the law stipulates that data collected by any public body or using public funds must be made freely available. Tools and mechanisms we devise and develop are likely to form the models on which the quality of care is assessed in other surgical and perhaps medical specialties. Measuring professional performance should be done by the profession. To measure risk there are a number of scores as crude mortality is not enough. A very important benefit of assessing the risk of death is to use this knowledge in the determination of the indication to operate. The second benefit is in the assessment of the quality of care as risk prediction gives a standard against performance of hospitals and surgeons. Peer review and “naming and shaming” are two mechanisms to monitor quality. There are two potentially damaging outcomes from the publication of results in a league-table form: the first is the damage to the hospital; the second is to refuse to operate on high-risk patients. There is a real need for quality monitoring in medicine in general and in cardiac surgery in particular. Good quality surgical work requires robust knowledge of three crucial variables: activity, risk prediction and performance. In Europe, the three major specialist societies have agreed to establish the European Cardiovascular and Thoracic Surgery Institute of Accreditation (ECTSIA). Performance monitoring is soon to become imperative. If we surgeons are not on board, we shall have no control on its final destination, and the consequences may be equally damaging to us and to our patients