Postoperative Mortality in Patients With Cirrhosis: Reconsidering Expectations

BACKGROUND

A diagnosis of cirrhosis increases a patient's risk of postoperative mortality. Surgeons are reticent to operate when cirrhosis is known unless no option is available. This study aimed to identify the modern perioperative risk in cirrhotic patients undergoing intervention under general anesthesia for non-transplant operations.

METHODS

A retrospective chart review was conducted utilizing the Rush Medical Center electronic medical record. All patients over 18 years of age with a diagnosis of cirrhosis undergoing intervention between 2009 and 2019 were reviewed. 90-day mortality rates in patients grouped by Child's score, Model for End-Stage Liver Disease (MELD), and Model for End-Stage Liver Disease with sodium incorporated (MELDNa) were compared to previously accepted rates.

RESULTS

93 patients (46% women) aged 22-72 years of all Child-Turcot-Pugh (CTP) (40% A, 36% B, and 25% C) classifications and MELD/MELDNa ranging 6-40 were analyzed. 90-day mortality of the entire population was 16%, significantly lower than expected based on CTP score (16% vs. 32%; P = .0005), MELD (16% vs. 41%; P < .0001), and MELDNa (16% vs. 46.8%; P < .0001). This was also true for CTP-B patients (12% vs. 30%; P = .025), CTP-C patients (35% vs. 70%; P = .0002), patients with MELD >14 (27% vs. 70%; P < .001), and patients with MELDNa >14 (23% vs. 70%; P < .0001).

CONCLUSION

Data indicate that perioperative mortality is lower than widely accepted. This suggests the need for a national database study using a representative population to determine the risk of mortality for patients with cirrhosis having surgery in recent times. Accurate estimation of this risk allows for meaningful discussion between physicians and patients when deciding to proceed with elective, necessary operations.

Pregnancy-related mortality in the United States, 2003-2016: age, race, and place of death

BACKGROUND

Pregnancy-related deaths in the United States are increasing. Medical, social, economic, and cultural issues have all been implicated in this trend, but few data exist to differentiate the relative contributions of these various factors.

OBJECTIVE

The objective of the study was to examine trends in US pregnancy-related mortality by place of death and maternal race and age. We hypothesized that such an analysis may allow some distinction between deaths related to medical performance and those more closely related to social, cultural, or environmental issues.

STUDY DESIGN

We conducted a retrospective, cross-sectional study for the years 2003-2016 using multiple cause-of-death mortality data provided by the Centers for Disease Control and Natality Data provided by National Vital Statistics System of the National Center for Health Statistics. Temporal trends analyses for the place of death, race/ethnicity, and age at the time of death were performed using joinpoint regression over the study period.

RESULTS

Approximately one third of pregnancy-related deaths occurred outside a medical facility. The fraction of maternal deaths occurring in inpatient facilities fell by 20% over the study period, from 53% to 44% of all maternal deaths (P < .0001). Maternal deaths in an outpatient facility or emergency room demonstrated a similar decline (24%) in relative frequency (P < .0001). In contrast, there was a significant increase in the relative frequency of maternal mortality in other settings, particularly within the descendant's home, with a doubling over this time period. However, overall pregnancy-related deaths continued to increase in all settings. These increases were particularly striking in non-Hispanic black and white women and among women in the youngest and oldest age groups.

CONCLUSION

Against a background of rising US pregnancy-related mortality, stratification of such deaths by place of death and maternal age and race highlights both the need for ongoing improvements in the quality of medical care and the potential contribution of events occurring outside a medical facility to the overall morality ratio. Current trends in pregnancy-related mortality in the United States are, in part, driven by social, cultural, and financial issues beyond the direct control of the medical community.

Primary Aortic Root Replacement Outcomes and Risk Factors in Pediatric Patients

BACKGROUND

The study sought to identify the optimal aortic root replacement (ARR) strategy for pediatric patients, and a single-center experience was analyzed.

METHODS

Retrospective review of patients undergoing ARR from 1995 to 2018 was performed. Patients were stratified by surgical strategy (pulmonary autograft [Ross procedure], aortic homograft, mechanical valve conduit [Bentall procedure], or porcine xenograft [Freestyle bioprosthesis]) and aortic annulus size.

RESULTS

ARR was performed in 206 patients with a median follow-up of 5.0 (interquartile range, 1.4-11.4) years. Root replacements included Ross procedure (n = 98), homograft (n = 83), Bentall procedure (n = 18), and Freestyle bioprosthesis (n = 7). Overall survival was 92%, and freedom from reoperation or death was 81%. Reoperation-free survival was superior in the Ross group when compared with other groups. Because surgical options differ based on the size of the aortic annulus, the analysis was arbitrarily stratified. When the aortic annulus diameter was greater than 19 mm (n = 74), procedures included Ross procedure (n = 23), homograft (n = 29), Bentall procedure (n = 17), and Freestyle bioprosthesis (n = 5). Reoperation-free survival at median follow-up (5 years) was 86%, 58%, 100%, and 100%, respectively. The Bentall procedure offered the longest freedom from reoperation. In the subset with aortic annulus diameter less than 19 mm and a pulmonary valve suitable for a Ross procedure, patients underwent the Ross procedure (n = 75) or homograft ARR (n = 36). At median follow-up (3.8 years), reoperation-free survival was longer after the Ross procedure than after homograft ARR (88% vs 46%; P < .001).

CONCLUSIONS

In patients with a large aortic annulus, a Bentall ARR offers the longest reoperation-free survival. For patients with small aortic roots, a Ross procedure provides better a reoperation-free survival than does homograft ARR.

Congenitally Corrected Transposition of the Great Arteries: Anatomic, Physiologic Repair, and Palliation

Congenitally corrected transposition of the great arteries (ccTGA) is a lesion that rarely occurs in isolation. The presenting physiology of ccTGA is predominantly secondary to the concurrent cardiac lesions; however, as the child ages, unrepaired ccTGA results in progressive failure of the morphologic right ventricle under the strain of maintaining a systemic pressure. Repair of ccTGA was initially focused on rectification of the underlying physiologic aberrations, but in recent years, the focus of repair has shifted toward anatomic correction to avoid failure of the morphologic right ventricle. This anatomic repair is commonly associated with improved long-term mortality at the cost of increased short-term mortality. Key preoperative considerations such as morphologic left ventricular pressure, tricuspid valve competency, and out flow tract obstructions can assist in determining the optimal repair for individual patients. An alternative, single ventricle, pathway has been proposed for any patient without optimal preoperative anatomy to improve long-term survival. Adjunctive repair options including pulmonary artery banding and one-and-a-half ventricle repairs have also been proposed to augment the survival curves.