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Patail H, Kompella R, Hoover NE, Reis W, Masih R, Mather JF, Sutton TS, McKay RG. In-Hospital and One-Year Outcomes of Transcatheter Aortic Valve Replacement in Patients Requiring Supplemental Home Oxygen Use. Cardiol Res 2023; 14:228-236. [PMID: 37304920 PMCID: PMC10257506 DOI: 10.14740/cr1497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 04/28/2023] [Indexed: 06/13/2023] Open
Abstract
Background There have been limited reports with inconsistent results on the impact of long-term use of oxygen therapry (LTOT) in patients treated with transcatheter aortic valve replacement (TAVR). Methods We compared in-hospital and intermediate TAVR outcomes in 150 patients requiring LTOT (home O2 cohort) with 2,313 non-home O2 patients. Results Home O2 patients were younger, and had more comorbidities including chronic obstructive pulmonary disease (COPD), diabetes, carotid artery disease, lower forced expiratory volume (FEV1) (50.3±21.1% vs. 75.0±24.7%, P < 0.001), and lower diffusion capacity (DLCO, 48.6±19.2% vs. 74.6±22.4%, P < 0.001). These differences represented higher baseline Society of Thoracic Surgeons (STS) risk score (15.5±10.2% vs. 9.3±7.0%, P < 0.001) and lower pre-procedure Kansas City Cardiomyopathy Questionnaire (KCCQ-12) scores (32.5 ± 22.2 vs. 49.1 ± 25.4, P < 0.001). The home O2 cohort required higher use of alternative TAVR vascular access (24.0% vs. 12.8%, P = 0.002) and general anesthesia (51.3% vs. 36.0%, P < 0.001). Compared to non-home O2 patients, home O2 patients showed increased in-hospital mortality (5.3% vs. 1.6%, P = 0.001), procedural cardiac arrest (4.7% vs. 1.0%, P < 0.001), and postoperative atrial fibrillation (4.0% vs. 1.5%, P = 0.013). At 1-year follow-up, the home O2 cohort had a higher all-cause mortality (17.3% vs. 7.5%, P < 0.001) and lower KCCQ-12 scores (69.5 ± 23.8 vs. 82.1 ± 19.4, P < 0.001). Kaplan-Meir analysis revealed a lower survival rate in the home O2 cohort with an overall mean (95% confidence interval (CI)) survival time of 6.2 (5.9 - 6.5) years (P < 0.001). Conclusion Home O2 patients represent a high-risk TAVR cohort with increased in-hospital morbidity and mortality, less improvement in 1-year KCCQ-12, and increased mortality at intermediate follow-up.
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Affiliation(s)
- Haris Patail
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Ritika Kompella
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | | | - Wyona Reis
- Department of Cardiology, Hartford Hospital, Hartford, CT, USA
| | - Rohit Masih
- Department of Internal Medicine, Hartford Hospital, Hartford, CT, USA
| | - Jeff F. Mather
- Department of Research Administration, Hartford Hospital, Hartford, CT, USA
| | - Trevor S. Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
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Sutton TS, Bailey DL, Rizvi A, Al-Araji R, Kasliwala Q, Nero T, Scalzo M, Panza G, Mather JF, Orlando R, Hashim S, McKay RG. Racial and Ethnic Disparities in the Treatment and Outcomes for Witnessed Out-of-Hospital Cardiac Arrest in Connecticut. Resuscitation 2023:109850. [PMID: 37230326 DOI: 10.1016/j.resuscitation.2023.109850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/14/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Racial and ethnic disparities in the treatment and outcomes for witnessed out-of-hospital cardiac arrest (OHCA) in the United States have been previously described. We sought to characterize disparities in pre-hospital care, overall survival, and survival with favorable neurological outcomes following witnessed OHCA in the state of Connecticut. METHODS We performed a cross-sectional study to compare pre-hospital treatment and outcomes for White versus Black and Hispanic (Minority) OHCA patients submitted from Connecticut to the Cardiac Arrest Registry to Enhance Survival (CARES) between 2013 and 2021. Primary outcomes included bystander CPR use, bystander automated external defibrillator (AED) use with attempted defibrillation, overall survival, and survival with favorable cerebral function. RESULTS 2,809 patients with witnessed OHCA were analyzed (924 Black or Hispanic; 1885 White). Minorities had lower rates of bystander CPR (31.4% vs 39.1%, P=0.002) and bystander AED placement with attempted defibrillation (10.5% vs 14.4%, P=0.004), with lower rates of survival to hospital discharge (10.3% vs 14.8%, P=0.001) and survival with favorable cerebral function (65.3% vs 80.2%, P=0.003). Minorities were less likely to receive bystander CPR in communities with median annual household income >$80, 000 (OR, 0.56; 95% CI, 0.33 - 0.95; P=0.030) and in integrated neighborhoods (OR, 0.70; 95% CI, 0.52 - 0.95; P=0.020). CONCLUSIONS Black and Hispanic Connecticut patients with witnessed OHCA have lower rates of bystander CPR, attempted AED defibrillation, overall survival, and survival with favorable neurological outcomes compared to White patients. Minorities were less likely to receive bystander CPR in affluent and integrated communities.
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Affiliation(s)
| | | | - Asad Rizvi
- Department of Cardiology, Hartford Hospital
| | | | | | - Thomas Nero
- Department of Cardiology, St Vincent's Medical Center
| | | | - Gregory Panza
- Department of Research Administration, Hartford Hospital
| | - Jeff F Mather
- Department of Research Administration, Hartford Hospital
| | | | - Sabet Hashim
- Department of Cardiac Surgery, Hartford Hospital
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Takata ET, Eschert J, Mather J, McLaughlin T, Hammond J, Hashim SW, McKay RG, Sutton TS. Enhanced Recovery After Surgery Is Associated With Reduced Hospital Length of Stay after Urgent or Emergency Isolated Coronary Artery Bypass Surgery at an Urban, Tertiary Care Teaching Hospital: An Interrupted Time Series Analysis With Propensity Score Matching. J Cardiothorac Vasc Anesth 2023; 37:31-41. [PMID: 36379833 DOI: 10.1053/j.jvca.2022.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate whether enhanced recovery after surgery (ERAS) was associated with reduced length of stay (LOS) after urgent or emergency coronary artery bypass graft surgery (CABG). DESIGN A retrospective analysis of an institutional database for urgent or emergency isolated CABG before versus after ERAS. Propensity matching identified comparable subpopulations pre- versus post-ERAS. Interrupted time series analysis was used to evaluate LOS. SETTING At a tertiary care teaching hospital. PARTICIPANTS A total of 1,012 patients undergoing urgent or emergent CABG-346 from 2016 to 2017 (pre-ERAS), and 666 from 2018 to 2020 (post-ERAS). Emergent CABG was performed within 24 hours, and urgent CABG was performed during the same hospitalization to reduce clinical risk. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Propensity-matched post-ERAS (n = 565) versus pre-ERAS patients (n = 330) demonstrated reduced LOS (9 [8-13] v (10 [8-14] days p = 0.015), increased likelihood of extubation within 6 hours (46.0% v 35.8%, p = 0.003), shorter ventilation time (6.3 [5.1-10.2] v (7.2 [5.4-12.2] hours, p = 0.003), reduced morphine milligram equivalent use on postoperative days 1 and 2 (69.6 ± 62.2 v 99.0 ± 61.6, p < 0.001), and increased intraoperative ketamine use (58.8% v 35.2%, p < 0.001). There were no differences regarding reintubation, intensive care unit readmission, or 30-day morbidity. Adjusted segmental regression (n = 1,012) for LOS demonstrated reduced mean LOS of approximately 2 days after ERAS (β2 coefficient -1.943 [-3.766 to -0.121], p = 0.037), with stable trends for mean LOS and no change in slope throughout the pre-ERAS and post-ERAS time periods. CONCLUSIONS Enhanced recovery after surgery was associated with reduced LOS after urgent or emergency CABG without adverse effects on prolonged ventilation, reintubation, intensive care unit readmission, or 30-day outcomes.
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Affiliation(s)
- Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT
| | - John Eschert
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT
| | - Jeff Mather
- Research Administration, Hartford Hospital, Hartford, CT
| | | | - Jonathan Hammond
- Department of Cardiac Surgery and Heart and Vascular Institute, Hartford Hospital, Hartford, CT
| | - Sabet W Hashim
- Department of Cardiac Surgery and Heart and Vascular Institute, Hartford Hospital, Hartford, CT
| | - Raymond G McKay
- Heart and Vascular Research Institute, Hartford Hospital, Hartford, CT
| | - Trevor S Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT.
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Ingrassia JJ, Mosleh W, Conner CM, Mather JF, Loya DS, Yaffee DW, Sutton TS, Takata ET, McMahon SR, Hashim SW, McKay RG. Impact of Ticagrelor Versus Clopidogrel on Bleeding Outcomes of Isolated Coronary Artery Bypass Grafting. Cardiovasc Revasc Med 2023; 46:44-51. [PMID: 35961855 DOI: 10.1016/j.carrev.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/02/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Increased bleeding risks have been documented in patients exposed to P2Y12 inhibitors within 5 days of coronary artery bypass surgery (CABG). This study aimed to determine the relative CABG bleeding risks of clopidogrel versus ticagrelor exposure and the proper time course of ticagrelor discontinuation prior to surgery. METHODS Clinical outcomes were assessed in 2075 isolated CABG patients, including 375 who had received P2Y12 inhibitors within 5 days of surgery (155 clopidogrel, 213 ticagrelor, 7 prasugrel). BARC-4 CABG bleeding complications and perioperative blood product usage were assessed in propensity-matched P2Y12-inhibited and non-P2Y12-inhibited cohorts. RESULTS P2Y12-inhibited patients (n = 375) in comparison to matched non-P2Y12-inhibited patients (n = 1138) had higher rates of re-operation for bleeding (3.8 % vs 1.3 %, p = 0.003), postoperative red blood cell transfusion ≥5 units (5.7 % vs 2.7 %, p = 0.007), and intraoperative and postoperative blood product utilization (42.3 % vs 27.1 %, p < 0.001; 41.8 % vs 32.2 %, p < 0.001, respectively). Univariate predictors of BARC-4 bleeding included clopidogrel (OR: 2.145, 95 % CI: 1.131-4.067, p = 0.019) and ticagrelor discontinued within 3 days of surgery (OR: 2.153, 95 % CI: 1.003-4.169, p = 0.049). Multivariate logistic regression demonstrated that only clopidogrel exposure was an independent BARC-4 bleeding predictor (OR: 1.850, 95 % CI: 1.007-3.398, p = 0.048). Unadjusted ticagrelor patients with drug discontinuation 4-5 days prior to CABG only demonstrated higher rates of perioperative platelet transfusion, without additional signs of excessive bleeding. CONCLUSIONS Clopidogrel exposure within 5 days of CABG is an independent predictor of BARC-4 bleeding, whereas major ticagrelor bleeding effects are confined to drug exposure within 3 days of surgery.
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Affiliation(s)
- Joseph J Ingrassia
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Chad M Conner
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | | | - Deborah S Loya
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - David W Yaffee
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Trevor S Sutton
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
| | - Edmund T Takata
- Integrated Anesthesia Associates, Hartford Hospital, Hartford, CT, USA
| | - Sean R McMahon
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Sabet W Hashim
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Raymond G McKay
- Hartford HealthCare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA.
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Sutton TS, McKay RG, Mather J, Takata E, Eschert J, Cox M, Douglas A, McLaughlin T, Loya D, Mennett R, Cech MG, Hinchey J, Walker A, Hammond J, Hashim S. Enhanced Recovery After Surgery is Associated with Improved Outcomes and Reduced Racial and Ethnic Disparities Following Isolated Coronary Artery Bypass Surgery: A Retrospective Analysis with Propensity Score Matching. J Cardiothorac Vasc Anesth 2022; 36:2418-2431. [DOI: 10.1053/j.jvca.2022.02.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 11/11/2022]
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Sutton TS, Koblin DD, Gruenke LD, Weiskopf RB, Rampil IJ, Waskell L, Eger EI. Fluoride metabolites after prolonged exposure of volunteers and patients to desflurane. Anesth Analg 1991; 73:180-5. [PMID: 1854033 DOI: 10.1213/00000539-199108000-00011] [Citation(s) in RCA: 85] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We examined the metabolism of desflurane in 13 healthy volunteers given 7.35 +/- 0.81 MAC-hours (mean +/- SD) of desflurane and 26 surgical patients given 3.08 +/- 1.84 MAC-hours (mean +/- SD). Markers of desflurane metabolism included fluoride ion measured via an ion-specific electrode, nonvolatile organic fluoride measured after sodium fusion of urine samples, and trifluoroacetic acid determined by a gas chromatographic-mass spectrometric method. In both volunteer and patient groups, postanesthesia serum fluoride ion concentrations did not differ from background fluoride ion concentrations. Similarly, postanesthesia urinary excretion of fluoride ion and organic fluoride in volunteers was comparable to preanesthesia excretion rates. However, small but significant levels of trifluoroacetic acid were found in both serum and urine from volunteers after exposure to desflurane. A peak serum concentration of 0.38 +/- 0.17 mumol/L of trifluoroacetic acid and a peak urinary excretion rate of 0.169 +/- 0.107 mumol/h were detected in volunteers at 24 h after desflurane exposure. Although these increases in trifluoroacetic acid after exposure to desflurane were statistically significant, they are approximately 10-fold less than levels seen after exposure to isoflurane. Thus, desflurane strongly resists biodegradation, but a small amount is metabolized in humans.
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Affiliation(s)
- T S Sutton
- Department of Anesthesia, Veterans Administration Medical Center, San Francisco, CA 94121
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Sutton TS, Koblin DD, Weiskopf RB, Gruenke LD, Waskell L, Eger EI. FLUORIDE METABOLITES FOLLOWING PROLONGED EXPOSURE OF VOLUNTEERS TO DESFLURANE. Anesth Analg 1990. [DOI: 10.1213/00000539-199002001-00398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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