Widening volume and persistent outcome disparity in valve operations: New York statewide analysis, 2005-2016

Center case volume is associated with Society of Thoracic Surgeons-defined failure to rescue in cardiac surgery

OBJECTIVE

Our understanding of the impact of a center's case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR.

METHODS

Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year.

RESULTS

A total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2%) developed an FTR complication, and 735 (13.8% of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center-level case volume was associated with significantly greater center-level major complication rates but lower mortality and FTR rates (all P values < .01). Observed-to-expected FTR was significantly associated with case volume (P = .040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P = .001).

CONCLUSIONS

Increasing center case volume is significantly associated with improved FTR rates. Assessment of low-volume centers' FTR performance represents an opportunity for quality improvement.

Early and mid-term outcomes following redo surgical aortic valve replacement in patients with previous transcatheter aortic valve implantation

OBJECTIVES

To analyze the early and mid-term outcomes after redo surgical aortic valve replacement (SAVR) in patients with previous transcatheter aortic valve implantation (TAVI).

METHODS

Retrospective single-center analysis of early and mid-term outcomes following redo SAVR in patients with previous TAVI between 2013 and 2020. Primary outcomes were in-hospital mortality and mid-term survival.

RESULTS

During the study period a total of 5756 patients underwent TAVI. Amongst them, 28 (0.5%) patients required redo SAVR after TAVI. During periods 2013-2016 and 2017-2020, 4/2184 (0.2%) patients and 24/3572 (0.7%) patients required SAVR after TAVI, respectively. Median logistic EuroSCORE was significantly higher at the time of SAVR than at the time of the index TAVI (5.9% vs 11.6%; P < 0.001). Median elapsed time between TAVI and redo SAVR was 7 months (3.5 -14 months). Infective endocarditis (IE) was the most frequent indication for surgery [19 (67.8%) patients]. A total of 11 (39.3%) patients underwent isolated SAVR and 17 (60.7%) SAVR + additional cardiac surgical procedures. The overall in-hospital mortality was 14.3% (4/28). In-hospital mortality was 15.8% (3/19) among IE patients and 11.1% (1/9) among non-IE patients (p = 0.7). Overall estimated survival was 66.5%, 59.9% and 48.0% at 12, 18 and 24 months, respectively. Patients with IE showed a trend towards a lower estimated mid-term survival compared to non-IE patients [41.6% (95% CI; 22.0% - 78.0%) vs 58.3% (95% CI; 30.0% - 100%) survival at 24 months (p = 0.3)].

CONCLUSION

SAVR can be successfully performed in patients with prior TAVI despite the increased surgical risk and technical difficulty. IE is associated with decreased mid-term survival.

The impact of trainees' working hour regulations on outcome in CABG and valve surgery in the State of New York

BACKGROUND AND AIM

In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted the first-year residents' duty-hour to less than 16-hour shifts, decreased the maximum shift duration for senior residents, and increased minimum time off after on-call duties. Whether these changes may have impacted the outcomes in cardiac surgery remains unclear.

METHODS

We performed a difference-in-difference analysis of the New York State Cardiac Surgery Reporting System data in 2004-2006 (before the duty-hour policies change) and 2014-2016 (after the change). We evaluated differences in 30-day risk-adjusted mortality rates (RAMR) in coronary artery bypass grafting (CABG) and valve surgeries, stratifying data by hospital type: teaching hospitals (TH) versus nonteaching hospitals (NTH). NTH served as the control not affected by the duty-hour policies.

RESULTS

(1) The overall surgical volume for CABG surgery has decreased over time (37,645-24,991), while the volume for valve surgery remained similar (20,969-21,532); (2) TH had better short-term outcomes for CABG procedures during 2014-2016 (median RAMR: 1.01% vs. 1.55% in TH vs. NTH, respectively; p = .025) as well as for valve procedures during both 2004-2006 (5.16% vs. 7.49%, p = .020) and 2014-2016 (2.59% vs. 4.09%, p = .033); (3) at difference-in-difference analysis, trainees' duty-hour regulations were not associated with worsening short-term outcomes in both CABG (p = .296) and valve (p = .651) procedures performed in TH.

CONCLUSION

The introduction of the 2011 trainees' duty-hour regulations was not associated with worse short-term outcomes for CABG and valve surgery performed in the State of NY by TH.