The Performance of the EuroSCORE and the Society of Thoracic Surgeons Mortality Risk Score: The Gender Factor.

The purpose of this study was to explore potential differences in the performance of the EuroSCORE and the STS mortality risk score in the prediction of operative mortality following cardiac surgery with special focus on the impact of gender. We retrospectively reviewed 3125 consecutive cases of coronary artery bypass surgery performed at our institution between 2001 and 2004. STS and EuroSCORE (logistic [E-log] and additive [E-add]) operative mortality risk scores were calculated for each patient and stratified by gender (female: n=692; male: n=2433). Mortality risk scores were compared between the STS and EuroSCORE using C-statistics and likelihood ratios (LR). Stratified by gender, the E-log and E-add correlated well with the STS (female: r=0.77, 0.78,

Percutaneous In Situ Oxygenated Pump Perfusion of a Transplanted Kidney During Abdominal Aortic Aneurysm Repair.

The surgical management of aortic aneurysms in kidney transplant patients is a difficult clinical scenario where preservation of the kidney allograft during aortic cross-clamping is paramount. We describe a novel technique for renal protection during abdominal aortic aneurysm repair with in situ oxygenated pump perfusion of the transplanted kidney. A percutaneous approach is used for common femoral artery and vein cannulation and a cardiopulmonary bypass circuit to provide retrograde oxygenated pump perfusion to the transplanted kidney. This technique allows adequate kidney perfusion during warm ischemia and minimizes morbidity by using a percutaneous access technique

Regional Collaboration as a Model for Fostering Accountability and Transforming Health Care.

An era of increasing budgetary constraints, misaligned payers and providers, and a competitive system where United States health outcomes are outpaced by less well-funded nations is motivating policy-makers to seek more effective means for promoting cost-effective delivery and accountability. This article illustrates an effective working model of regional collaboration focused on improving health outcomes, containing costs, and making efficient use of resources in cardiovascular surgical care. The Virginia Cardiac Surgery Quality Initiative is a decade-old collaboration of cardiac surgeons and hospital providers in Virginia working to improve outcomes and contain costs by analyzing comparative data, identifying top performers, and replicating best clinical practices on a statewide basis. The group\u27s goals and objectives, along with 2 generations of performance improvement initiatives, are examined. These involve attempts to improve postoperative outcomes and use of tools for decision support and modeling. This work has led the group to espouse a more integrated approach to performance improvement and to formulate principles of a quality-focused payment system. This is one in which collaboration promotes regional accountability to deliver quality care on a cost-effective basis. The Virginia Cardiac Surgery Quality Initiative has attempted to test a global pricing model and has implemented a pay-for-performance program where physicians and hospitals are aligned with common objectives. Although this collaborative approach is a work in progress, authors point out preconditions applicable to other regions and medical specialties. A road map of short-term next steps is needed to create an adaptive payment system tied to the national agenda for reforming the delivery system

Endovascular Stent-Graft Repair of Penetrating Descending Thoracic Aortic Ulcer

This article presents a case in which covered stent-graft cuffs were used to treat a penetrating ulcer of the descending thoracic aorta. An 80-year-old woman presented with penetrating ulcer in the descending thoracic aorta. Two endovascular stent graft cuffs were used for total exclusion of the penetrating ulcer, because the patient had a high operative risk. Her postoperative course was uneventful, and follow-up computed tomographic angiography showed complete coverage of the ulcer without evidence of leak. This case demonstrates that endoluminal stent-graft repair of penetrating descending thoracic aortic ulcers is a safe, less-invasive treatment, especially for elderly, high-risk patients

Endovascular Stent-Graft Repair of Penetrating Descending Aortic Ulcer.

This article presents a case in which covered stent-graft cuffs were used to treat a penetrating ulcer of the descending thoracic aorta. An 80-year-old woman presented with penetrating ulcer in the descending thoracic aorta. Two endovascular stent graft cuffs were used for total exclusion of the penetrating ulcer, because the patient had a high operative risk. Her postoperative course was uneventful, and follow-up computed tomographic angiography showed complete coverage of the ulcer without evidence of leak. This case demonstrates that endoluminal stent-graft repair of penetrating descending thoracic aortic ulcers is a safe, less-invasive treatment, especially for elderly, high-risk patients

Percutaneous in Situ Oxygenated Pump Perfusion of a Transplanted Kidney during Abdominal Aortic Aneurysm Repair

The surgical management of aortic aneurysms in kidney transplant patients is a difficult clinical scenario where preservation of the kidney allograft during aortic cross-clamping is paramount. We describe a novel technique for renal protection during abdominal aortic aneurysm repair with in situ oxygenated pump perfusion of the transplanted kidney. A percutaneous approach is used for common femoral artery and vein cannulation and a cardiopulmonary bypass circuit to provide retrograde oxygenated pump perfusion to the transplanted kidney. This technique allows adequate kidney perfusion during warm ischemia and minimizes morbidity by using a percutaneous access technique

Institutional and National Trends in Isolated Mitral Valve Surgery Over the Past Decade.

PURPOSE OF REVIEW: To review trends in practice for mitral valve surgery in the US over the past decade. RECENT FINDINGS: Advances in the understanding of mitral valve pathophysiology and the technology involved with mitral valve surgery have led to significant changes of the current practice for mitral valve surgery, with mitral valve repair being the technique of choice. Mitral valve repair is currently applied to close to 60% of patients having surgery for mitral valve disease in the US. This trend in the change of practice also contributed to a sharp decrease in the use of mechanical mitral valve prosthesis even in the younger population. SUMMARY: Current practice for mitral valve surgery in the US reflects a steady increase in performed procedures over the last decade. The increased use of mitral valve repair techniques to address mitral valve disease can be related to increased surgical experience and greater understanding of the pathophysiology of mitral valve disease as well as the improved outcome related to mitral valve repair

Additive Costs of Postoperative Complications for Isolated Coronary Artery Bypass.

Complications after open-heart surgery result in an increased length of stay and greater financial burdens for all. The purpose of this study was to measure the additive costs of postoperative complications for selected subgroups of patients after coronary artery bypass grafts in the Commonwealth of Virginia. A multiyear statewide data repository with clinical and billing data was used to measure outcomes for the period 2004 to 2007. The Society of Thoracic Surgeons records matched with Universal Billing (UB-04) charge data for all payers were used to estimate the additive costs of cardiac surgical outcomes using cost-to-charge ratios. Additive cost was defined as the difference between the baseline cost of an average case with no complications and one with a postoperative morbidity or mortality. Multivariate analysis was used to account for important covariates and apportion incremental costs. The baseline cost of isolated coronary artery bypass grafting (CABG) cases with no complications during the study period was $26,056. Isolated atrial fibrillation was the most frequently cited complication and had the lowest additive cost ($2,574). Additive costs for isolated CABG patients were greatest for those cases involving prolonged ventilation ($40,704), renal failure ($49,128), mediastinitis ($62,773), and operative mortality ($49,242). Additive costs can serve as an indicator for pursuing quality improvement initiatives. Our results suggest additive costs vary according to type of postoperative complication and comorbidities. Regional collaborations of multidisciplinary groups in cardiac surgery are an effective means to implement quality guidelines and drive down additive costs

Survival Following Combined Intrapericardial Inferior Vena Cava and Thoracic Aortic Injury Caused by Blunt Trauma.

Inferior vena cava (IVC) rupture from blunt trauma is rare. It occurs most commonly in the retrohepatic location in association with liver trauma involving the hepatic veins.1,2 Rupture of the IVC has a reported mortality of up to 50% before arrival to the hospital and nearly 57% in patients who reach the hospital with signs of life.2 Traumatic transection of the thoracic aorta occurs more commonly. It remains a highly lethal injury with 85% of patients dying at the injury scene. If left untreated, approximately 50% of survivors die within the first 24 hours and 90% within the first 4 months.3–5 The most common location of thoracic aortic injury is immediately distal to the origin of the left subclavian artery at the attachment of the ligamentum arteriosum. We report an unusual case of a 19-year-old patient who survived combined intrapericardial rupture of the IVC with transection of the mid-thoracic aorta, and a grade-III splenic injury after a motor vehicle crash