Aortoesophageal fistula treated with staged aortic stent graft and subsequent homograft interposition

Aortoesophageal fistula (AEF) is a rare complication of esophageal interventions. We present a 49-year-old woman who underwent Roux-en-Y gastric bypass with a recurrent gastrojejunal anastomotic leak requiring covered esophageal stent placement. She presented 1 month later with abdominal pain, leukocytosis, and hematemesis. A computed tomography scan demonstrated migration of the esophageal stent with aortic erosion concerning for AEF. She underwent emergent endovascular exclusion of an AEF to the descending thoracic aorta with subsequent esophageal resection and diversion and aortic endograft explant, resection, and homograft repair on postoperative day 6 allowing for staged removal of prosthetic material and maintenance of inline flow.

Nationwide comparison of the medical complexity of patients by surgical specialty

OBJECTIVE

Intuitively, the chronic disease burden of surgical patients varies considerably by surgical specialty, although sparse evidence in the literature supports this notion. We sought to characterize the medical complexity of surgical patients by surgical specialty and to quantify the association between medical complexity and outcomes.

METHODS

The National Inpatient Sample, an all-payer inpatient database representative of 97% of all U.S. hospitalizations, was used to identify adults undergoing surgery between 2005 and 2014. The most commonly performed operations that constituted 80% of each surgical specialty's practice were abstracted. The previously validated Elixhauser Comorbidity Index (ECI) was calculated per year by surgical specialty as a measure of medical complexity. Outcomes and resource utilization were assessed by comparing mortality rate, length of stay, and cost.

RESULTS

An estimated 53,232,144 patients underwent operations in one of nine surgical specialty categories. Surgical specialties were ranked by ECI, with cardiac surgery (3.56), vascular surgery (3.49), and thoracic surgery (2.86) having the highest mean ECI (all P values <.0001 compared with vascular surgery). Whereas the high ECI scores in cardiac surgery were driven by arrhythmias and hypertension, vascular patients had a more uniform distribution of comorbidities. The average ECI for all surgical patients increased during the study period from 2.03 in 2005 to 2.65 in 2014 (P < .001), with a similar trend for all specialties considered. Unlike the two specialties with the lowest burden of comorbidities (orthopedic surgery and endocrine surgery), cardiac surgery and vascular surgery exhibited significantly higher inpatient mortality, LOS, and costs.

CONCLUSIONS

Although all surgical patients have exhibited an increase in comorbidities during the past decade, candidates for cardiac and vascular operations appear to carry the largest burden of chronic conditions. Despite caring for patients with the highest burden of comorbidities for emergent operations, vascular surgery did not have the highest mortality, inpatient costs, or length of stay compared with some of the other specialties. The intensity of care and assumed risk in treating medically complex vascular patients should be taken into consideration in deciding health policy, reimbursement, and hospital resource allocation.

Readmission and Resource Use After Robotic-Assisted versus Open Pancreaticoduodenectomy: 2010-2017

BACKGROUND

Unplanned rehospitalization is considered an adverse quality of care indicator. Minimally invasive operations carry the potential to reduce resource use while enhancing recovery. Robotic-assisted pancreaticoduodenectomy (RAPD) has been used to improve outcomes of its morbid open counterpart. We sought to identify factors associated with readmission between RAPD and open pancreaticoduodenectomy (OPD).

MATERIALS AND METHODS

We used the 2010-17 National Readmissions Database to identify adults who underwent RAPD or OPD. The primary outcome was 30-day readmission. Secondary outcomes included readmission diagnosis: index, readmission, and total (index + readmission) length of stay, costs, and mortality.

RESULTS

Of an estimated 84,036 patients undergoing pancreaticoduodenectomy, 96.9% survived index hospitalization. Frequency of both RAPD and OPD increased during the study period with similar mortality (2.5% versus 3.2%, P = 0.46). Compared with OPD, RAPD was not an independent predictor of 30-day readmission (adjusted odds ratio (AOR): 1.0, P = 0.98). Disposition with home health care (AOR: 1.1, P < 0.001) or to a skilled nursing facility (AOR: 1.5, P < 0.001) was significantly associated with increased 30-day readmission.

CONCLUSIONS

Readmission after pancreaticoduodenectomy is common, regardless of surgical approach. Although RAPD saves in-patient days on index admission, readmission rates and length of stay are similar between the two modalities. Neither RAPD nor OPD is a risk factor for readmission, highlighting the complexity of pancreaticoduodenectomy, with complications that may result from factors independent of the operative approach.

National trends in postoperative infections across surgical specialties

BACKGROUND

Despite the introduction of several measures to reduce incidence, postoperative infections have been reported to increase. We aimed to assess trends in the incidence and impact of postoperative infections using a recent national cohort.

METHODS

Patients undergoing the most commonly performed elective inpatient procedures in 9 surgical specialties were identified from the 2006 to 2014 National Inpatient Sample. Diagnostic coding was utilized to identify patients with postoperative infections. To adjust for patient and operative differences in assessing outcomes, an inverse probability of treatment weighing protocol was used.

RESULTS

Of an estimated 23,696,588 patients, 1,213,182 (5.1%) developed postoperative infections. Skin and soft tissue operations had the highest burden (12.9%) and endocrine the lowest (1.3%). During the study period, we found decreasing incidence, case fatality, and incremental cost of postoperative infections. Infection was associated with increased in-hospital mortality (1.4 vs 0.4%, P < .001), duration of stay (7.6 vs 3.7 days, P < .001), and costs ($27,597 vs $17,985, P < .001). Annually, postoperative infections led to an average incremental cost burden exceeding $700 million in the United States alone.

CONCLUSION

During the study period there was a substantial decrease in the burden of postoperative infections. Despite encouraging trends, postoperative infections continue to serve as a suitable quality improvement target, particularly in specialties with a high burden of infections.

National Trends in Readmission and Resource Utilization After Pancreatectomy in the United States

INTRODUCTION

Pancreatectomy is a complex operation that has been associated with excess morbidity and mortality. Although acute index outcomes have been characterized, there are limited data available on nonelective readmission after pancreatic surgery. We sought to identify factors associated with 30-day and 30- to 90-day readmission after pancreatectomy.

MATERIAL AND METHODS

We utilized the National Readmissions Database between 2010 and 2016 to identify adults who underwent a pancreatectomy. The primary outcomes were 30-day (30DR) and 30- to 90-day (90DR) readmission. Secondary outcomes included nonelective readmission trends, diagnosis, length of stay, charges, and mortality.

RESULTS

Of an estimated 130,267 subjects undergoing pancreatectomy, 97% survived index hospitalization. Eighteen percent of patients had nonelective 30DR while 5.6% experienced 90DR. Readmission at the two time points remained stable during the study period. After adjusting for institution, pancreatectomy volume, mortality (2.0% versus 4.9%, P < 0.001), 30DR length of stay (7.3 d versus 7.8 d, P < 0.001), and 90DR rates (6.9% versus 8.1%, P = 0.003) were significantly decreased at high-volume pancreatectomy centers compared to low-volume hospitals. Discharge to a skilled nursing facility (AOR: 1.52) or with home health care (AOR: 1.2) was associated with 30DR (P < 0.001). Patients undergoing total pancreatectomy (AOR: 1.3) or those with a substance use disorder (AOR: 1.4) among others were associated with 90DR (P ≤ 0.01).

CONCLUSIONS

Readmissions are common and costly after pancreatectomy. Approximately 20% of patients experience readmission within 30 d. 30DR and 90DR rates remained stable during the study. Pancreatectomy at a high-volume center was associated with decreased mortality and 90DR. The present analysis confirms associations between pancreatectomy volume, postsurgical complications, comorbidities, and readmission.

Development and Use of a Novel Cardiovascular Simulator: Time for a Paradigm Shift?

Understanding cardiovascular physiology, pharmacology, and treatment of shock is heavily emphasized in current medical school and surgical training. Performance of individuals in treatment of critical illness remains poor despite regular didactic sessions. We have developed a PC computer-based simulator capable of integrating basic hemodynamic parameters to dynamically generate a realistic patient monitor. The methodology includes physiological feedback as found in humans. The trainees are able to learn through a series of scenarios or ad lib manipulation of parameters. Participants including medical students, nurses, and residents were given a pretest before attending either a 30-minute didactic or a 10- or 30-minute simulator session. A posttest was administered to evaluate performance after the intervention. Twenty-four participants were equally randomized with 12 receiving simulator training. Although the two groups had similar pretest scores ( P > 0.5), the simulator group showed a 24 per cent improvement, whereas the lecture group showed a 10 per cent improvement in the posttest score ( P = 0.008). Simulations in surgery and critical care are in early stages of development. Access to such simulators on a personal computer can greatly enhance understanding of the cardiovascular system. These simulators appear to be very effective and may become an integral adjunct to traditional classroom teaching methods.

Acute Care Surgery in Heart Transplant Recipients

Orthotopic heart transplantation (OHT) is the optimal treatment for end-stage heart failure. We reviewed our institutional experience between 2008 and 2012 with acute care surgery (ACS) consultations and procedures within 1 year of OHT in recipients bridged to transplantation with medical therapy (MT, n = 169), including intravenous inotropes, and ventricular assist devices (VADs, n = 74). In total, 28 consultations were required in 21 patients (9%) and 16 procedures were performed in 11 patients (5%). The interval from transplantation to consultation was shorter for the MT group (50 vs 82 days; P = 0.015), whereas the interval from consultation to operation was longer (5 vs 1 day; P = 0.03). Patients undergoing MT were more likely to require consultation for abdominal problems (88 vs 27%; P = 0.004). All but one of the seven ischemic/inflammatory abdominal problems occurred in the MT group. Complications occurred after five ACS procedures (31%) in two patients undergoing MT and three patients undergoing VAD. Mortality was 24 per cent with five deaths occurring within 30 days of ACS consultation and/or operation. In summary, this is one of the largest series of ACS problems in patients undergoing OHT bridged to transplant with MT or VAD. With similar incidence in MT and VAD groups, ACS consultations and operations are infrequent with high mortality and morbidity.

Impact of Hospital Volume on Outcomes of Elective Pneumonectomy in the United States

BACKGROUND

Despite advances in surgical technique and perioperative management, pneumonectomy remains associated with significant morbidity and mortality. The purpose of this study was to examine the impact of annual institutional volume of anatomic lung resections on outcomes after elective pneumonectomy.

METHODS

We evaluated all patients who underwent elective pneumonectomy from 2005 to 2014 in the National Inpatient Sample. Patients less than 18 years of age, or with trauma-related diagnoses, mesothelioma, or a nonelective admission were excluded. Hospitals were divided into volume quartiles based on annual institutional anatomic lung resection caseload. We studied the effect of institutional volume on inhospital mortality, complications, and failure to rescue, as well as costs and length of stay.

RESULTS

During the study period, an estimated 22,739 patients underwent pneumonectomy, with a reduction in national mortality from 7.9% to 5.5% (P trend = .045). Compared with the highest volume centers, operations performed at the lowest volume hospitals were associated with 1.74 increased odds of mortality (95% confidence interval, 1.14 to 2.66). Despite similar odds of postoperative complications, low volume hospital status was associated with increased failure to rescue rates (18.3% vs 12.7%, P = .024) and adjusted odds of mortality (1.70; 95% confidence interval, 1.09 to 2.64) after any complication.

CONCLUSIONS

High volume hospital status is strongly associated with reduced mortality and failure to rescue rates after pneumonectomy. Efforts to centralize care or disseminate best practices may lead to improved national outcomes for this high-risk procedure.

The impact of obesity on outcomes in patients receiving extracorporeal life support

Extracorporeal life support (ECLS) has been increasingly utilized to manage cardiac and pulmonary dysfunction. The impact of obesity on outcomes of ECLS is poorly defined. The purpose of the study was to compare in-hospital mortality, resource use, complications, and readmissions in obese versus non-obese patients receiving ECLS. We performed a retrospective cohort study of all adult ECLS patients with and without an obesity diagnosis using the 2010-2016 Nationwide Readmissions Database (NRD). Mortality, length of stay (LOS), hospital charges, complications, and readmissions were evaluated using multivariable logistic and linear regression. Of 23 876, patients who received ECLS, 1924 (8.1%) were obese. Obese patients received ECLS more frequently for respiratory failure (29.5% vs. 23.7%, P = .001). After adjustment for patient and hospital factors, obesity was not associated with increased odds of mortality (AOR = 1.06, P = .44) and was associated with decreased LOS (13.7 vs. 21.2 days, P < .001), hospital charges ($171 866 vs. $211 445, P < .001), and 30-day readmission (AOR = 0.71, P = .03). Obesity was also associated with reduced odds of hemorrhage (AOR = 0.43, P < .001), neurologic complications (AOR = 0.55, P = .004), and acute kidney injury (AOR=0.83, P = .04). After stratification by ECLS indication, obesity remained predictive of shorter LOS (AOR range: 0.53-0.78, all P < .05 ) and did not impact mortality (all P > .05). Respiratory support remains the most common indication for ECLS among obese patients. Among all patients, as well as by individual ECLS indication, obesity was not associated with increased odds of mortality. These findings suggest that obesity should not be considered a high-risk contraindication to ECLS.

Impact of interhospital transfer on clinical outcomes and costs of extracorporeal life support

BACKGROUND

The impact of interhospital transfers for extracorporeal life support have not been studied in large datasets. The present study sought to determine the impact of such patient transfers on survival, complications, and hospitalization costs.

METHODS

The 2010 to 2016 database of the National Inpatient Sample was used to identify all adults who underwent extracorporeal life support. Patients were categorized based on whether or not they were transferred to another facility. Trend analysis and multivariable models were used to characterize the impact of inter hospital transfer on in-hospital mortality, complications, duration of stay, and costs.

RESULTS

Of an estimated 29,298 extracorporeal life support hospitalizations during the study period, 36.8% were transferred from an outside facility. Extracorporeal life support hospitalizations experienced a 7-fold increase with no difference in mortality between transferred and not transferred cohorts in 2016 (4.79% vs 4.79%, P = .97). Mortality rates were less for patients transferred to high volume centers compared to low volume hospitals (48.7% vs 51.6%, P < .001). Transfer to a low volume hospital for cardiogenic shock was associated with greater odds of mortality (adjusted odds Rratio: 2.25, confidence interval 1.01-5.03).

CONCLUSION

Utilization of extracorporeal life support in both transferred and not transferred patients has statistically significantly increased with a decrement in mortality for those transferred. Survival in the transferred cohort is strongly associated with extracorporeal life support procedure volume of the center and this must be taken into account when considering extracorporeal life support transfer.

National Analysis of Coronary Artery Bypass Grafting in Autoimmune Connective Tissue Disease

BACKGROUND

Autoimmune connective tissue diseases (CTDs) are associated with accelerated atherosclerosis and inflammation, while often requiring immunosuppression. Large-scale outcomes of coronary artery bypass graft (CABG) surgery in this population have not been reported thus far. This study characterized trends in use of CABG in patients with CTDs and the impact of the disease on mortality, in-hospital complications, length of stay, and costs.

METHODS

The 2005 to 2015 National Inpatient Sample was used to identify all adult patients undergoing isolated CABG. The CTDs cohort included rheumatoid arthritis, lupus erythematosus, and antiphospholipid syndrome (APLS), among others. Hierarchical multivariable logistic models were used to calculate the independent impact of CTDs on clinical outcomes and costs.

RESULTS

Of an estimated 2,101,591 patients, 41,567 (1.8%) were diagnosed with CTDs (rheumatoid arthritis, 58%; systemic lupus erythematosus, 12%; APLS, 11%) Although the overall annual use of CABG decreased, the proportion of patients with CTDs receiving the operation significantly increased. After adjusting for patient and hospital characteristics, CTDs were not associated with increased mortality (adjusted odds ratio [AOR], 0.91; P = .34) but were protective against cardiovascular (AOR, 0.92; P < .003), neurologic (AOR, 0.81; P = .01), and infectious (AOR, 0.80; P = .01) complications. The diagnosis of CTDs was also predictive of reduced length of hospital stay (β-coefficient = -0.40; P < .001) and costs (β-coefficient, -$1200; P = .01). On subgroup analysis patients with APLS had significantly increased odds of mortality (AOR, 1.5) and increased renal (AOR, 1.3), infectious (AOR, 1.7), and thromboembolic (AOR, 4.3) complications (all P < .05).

CONCLUSIONS

CABG in patients with CTDs provides acceptable outcomes and paradoxically improved resource use. However CABG in patients with APLS warrants careful consideration given inferior outcomes.

Incidence, Predictors, and Impact of Clostridium difficile Infection on Cardiac Surgery Outcomes

BACKGROUND

Clostridium difficile infection (CDI) has been associated with morbidity and mortality after cardiac operations. The present study examined incidence, predictors, and impact of CDI on inpatient mortality and resource utilization.

METHODS

An analysis of adult patients undergoing elective coronary artery bypass grafting or valvular operations from 2005 to 2016 was performed using the National Inpatient Sample. Trends in CDI were assessed using a modified Cochran-Armitage analysis. Multivariable multilevel regressions were used to identify predictors of CDI, and propensity-matched pairs were generated using Mahalanobis 1-to-1 matching to compare mortality, length of stay, and costs of CDI patients with the non-CDI cohort.

RESULTS

The overall rate of CDI for an estimated 2,026,267 patients who underwent elective major cardiac surgery was 0.5% with no change in incidence (P for trend = .99). Predictors of CDI included advanced age (≥65 y; adjusted odds ratio [AOR], 1.88; 95% confidence interval [CI], 1.58-2.24), female gender (AOR, 1.29; 95% CI, 1.15-1.44), heart failure (AOR, 1.57; 95% CI, 1.40-1.76), and combined coronary artery bypass grafting/valve operations (AOR, 1.60; 95% CI, 1.24-2.08). Neither region nor bed size was associated with CDI. In contrast CDI mortality was lower at teaching hospitals compared with rural hospitals. Among matched pairs CDI was independently associated with higher mortality, length of stay, and Gross Domestic Product-adjusted costs.

CONCLUSIONS

CDI occurs in less than 1% of all elective, major cardiac operations. Patient predictors included advanced age, female gender, and several chronic comorbidities. Teaching institutions had the highest odds of CDI but lowest odds of case fatality. Further investigation of factors contributing to CDI is warranted to disseminate institutional best practices.

Impact of Malnutrition on Outcomes Following Transcatheter Aortic Valve Implantation (from a National Cohort)

Malnutrition is associated with increased mortality in open cardiac surgery, but its impact on transcatheter aortic valve implantation (TAVI) is unknown. This study utilized the National Readmissions Database to evaluate the impact of malnutrition on mortality, complications, length of stay (LOS), 30-day readmission, and total charges following TAVI. Adult patients undergoing isolated TAVI for severe aortic stenosis were identified using the 2011 to 2016 National Readmissions Database, which accounts for 56.6% of all US hospitalizations. The malnourished cohort included patients with nutritional neglect, cachexia, protein calorie malnutrition, postsurgical nonabsorption, weight loss, and underweight status. Multivariable models were utilized to evaluate the impact of malnutrition on selected outcomes. Of 105,603 patients, 5,280 (5%) were malnourished. Malnourished patients experienced greater mortality (10.4% vs 2.2%, p <0.001), postoperative complications (49.2% vs 22.6%, p <0.001), 30-day readmission rates (21.4 vs 14.9%, p <0.001), index hospitalization charges ($331,637 vs $208,082, p <0.001), and LOS (16.4 vs 6.2 days, p <0.001) relative to their nourished counterparts. On multivariable analysis, malnutrition remained a significant, independent predictor of increased index mortality (Adjusted odds ratio (AOR) = 2.68, p <0.001), complications (AOR = 2.09, p <0.001), and 30-day readmission rates (AOR = 1.34, p <0.001). Malnutrition was most significantly associated with infectious complications at index hospitalization (AOR = 3.88, p <0.001) and at 30-day readmission (AOR = 1.43, p <0.027). In conclusion, malnutrition is independently associated with increased mortality, complications, readmission, and resource utilization in patients undergoing TAVI. Preoperative risk stratification and malnutrition modification may improve outcomes in this vulnerable population.

Trends in utilization, mortality, and resource use after implantation of left ventricular assist devices in the United States

OBJECTIVES

Adoption of implantable left ventricular assist devices has dramatically improved survival and quality of life in suitable patients with end-stage heart failure. In the era of value-based healthcare delivery, assessment of clinical outcomes and resource use associated with left ventricular assist devices is warranted.

METHODS

Adult patients undergoing left ventricular assist device implantation from 2008 to 2016 were identified using the National Inpatient Sample. Hospitals were designated as low-volume, medium-volume, or high-volume institutions based on annual institutional left ventricular assist device case volume. Multivariable logistic regression was used to evaluate adjusted odds of mortality across left ventricular assist device volume tertiles.

RESULTS

Over the study period, an estimated 23,972 patients underwent left ventricular assist device implantation with an approximately 3-fold increase in the number of annual left ventricular assist device implantations performed (P for trend <.001). In-hospital mortality in patients with left ventricular assist devices decreased from 19.6% in 2008 to 8.1% in 2016 (P for trend <.001) and was higher at low-volume institutions compared with high-volume institutions (12.0% vs 9.2%, P < .001). Although the overall adjusted mortality was higher at low-volume compared with high-volume institutions (adjusted odds ratio, 1.66; 95% confidence interval, 1.28-2.15), this discrepancy was only significant for 2008 and 2009 (low-volume 2008 adjusted odds ratio, 5.5; 95% confidence interval, 1.9-15.8; low-volume 2009 adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.8).

CONCLUSIONS

Left ventricular assist device use has rapidly increased in the United States with a concomitant reduction in mortality and morbidity. With maturation of left ventricular assist device technology and increasing experience, volume-related variation in mortality and resource use has diminished. Whether the apparent uniformity in outcomes is related to patient selection or hospital quality deserves further investigation.

Clinical Outcomes of Infective Endocarditis in Injection Drug Users

BACKGROUND

Rising rates of hospitalization for infective endocarditis (IE) have been increasingly tied to rising injection drug use (IDU) associated with the opioid epidemic.

OBJECTIVES

This study analyzed recent trends in IDU-IE hospitalization and characterized outcomes and readmissions for IDU-IE patients.

METHODS

The authors evaluated the National Readmissions Database (NRD) for IE cases between January 2010 and September 2015. Patients were stratified by IDU status and surgical versus medical management. Primary outcome was 30-day readmission and cause, with secondary outcomes including mortality, length of stay (LOS), adjusted costs, and 180-day readmission. The Kruskal-Wallis and chi-square tests were used to analyze baseline differences by IDU status. Multivariable regressions were used to analyze mortality, readmissions, LOS, and adjusted costs.

RESULTS

The survey-weighted sample contained 96,344 (77.8%) non-IDU-IE and 27,432 (22.2%) IDU-IE cases. IDU-IE increased from 15.3% to 29.1% of IE cases between 2010 and 2015 (p < 0.001). At index hospitalization, IDU-IE was associated with reduced mortality (6.8% vs. 9.6%; p < 0.001) but not 30-day readmission (23.8% vs. 22.9%; p = 0.077) relative to non-IDU-IE. Medically managed IDU-IE patients had higher LOS (β = 1.36 days; 95% confidence interval [CI]: 0.71 to 2.01), reduced costs (β = -$4,427; 95% CI: -$7,093 to -$1,761), and increased readmission for endocarditis (18.1% vs. 5.6%; p < 0.001), septicemia (14.0% vs. 7.3%; p < 0.001), and drug abuse (4.3% vs. 0.7%; p < 0.001) compared with medically managed non-IDU-IE. Surgically managed IDU-IE patients had increased LOS (β = 4.26 days; 95% CI: 2.73 to 5.80) and readmission for septicemia (15.6% vs. 5.2%; p < 0.001) and drug abuse (7.3% vs. 0.9%; p < 0.001) compared with non-IDU-IE.

CONCLUSIONS

The incidence of IDU-IE continues to rise nationally. Given the increased readmission for endocarditis, septicemia, and drug abuse, IDU-IE presents a serious challenge to current management of IE.

Donor history of malignancy: A limited risk for heart transplant recipients

Organ donor contraindications are frequently reassessed for impact on recipient outcomes in attempt to meet demand for transplantation. This study retrospectively analyzed the United Network for Organ Sharing (UNOS) registry for adult heart transplants from 1987 to September 2016 to characterize the impact of donor malignancy history in heart transplantation. Kaplan-Meier estimates illustrated 10-year survival. Propensity score matching was utilized for 1:1 matching of donors with and without history of malignancy, and Cox proportional hazards and logistic regressions were used to analyze the matched population. Of 38 781 heart transplants, 622 (1.6%) had a donor history of malignancy. Cox regressions demonstrated that donor malignancy predicted increased 10-year mortality (HR = 1.16 [1.01-1.33]), but this difference did not persist when conditioned upon 1 year post-transplant survival (log-rank = 0.643). Cox regressions of the propensity score-matched population (455 pairs) found no association between donor malignancy and 10-year mortality (HR = 1.02 [0.84-1.24]). Older age and higher rates of hypertension were observed in donors with a history of malignancy whose recipients died within the first year post-transplant. Therefore, increased recipient mortality is likely due to donor characteristics beyond malignancy, creating the potential for expanded donor selection.