Surgery News - September 2008 - (Page 13) SEPTEMBER 2008 • SURGERY NEWS THORACIC Heart Transplant Waiting-List Risks Quantified New results may help physicians decide when to use a bridge-to-transplant device. “To bridge or not to bridge is one of the most challenging decisions for medically managed, B O S T O N — Patients with three high-urgency, status 1A patients” or more risk factors who were list- who are awaiting a heart transed with the highest urgency for a plant, said Dr. Lietz, a transplant heart transplant—status 1A—on cardiologist at Columbia Univerthe U.S. waiting list had at least a sity in New York. Three key factors enter into this de30% risk of dying becision: the patient’s fore a donor heart was risk of dying while available, based on acawaiting a donor tual experience during heart, the chances of 2000-2006. successfully receiving Records from the a transplanted heart, United Network for and the risk of comOrgan Sharing plications from im(UNOS) for this periplantation with a meod showed that when chanical support high-risk patients (deWhen high-risk fined as those with patients received a device. To better document more than three risk circulatory support the first two factors, factors for death) redevice, 90-day ceived a mechanical survival rates rose Dr. Lietz and her ascirculatory support from 50% to 89%. sociates analyzed data collected on 1,755 padevice, their 90-day DR. LIETZ tients who were listed survival rate jumped from 50% to 89%, said Dr. Kather- with UNOS as status 1A candiine Lietz, who presented an analy- dates for a heart transplant during sis of UNOS data at the annual January 2000–December 2006. meeting of the International So- During their first 30 days on the ciety for Heart and Lung Trans- UNOS list, 14% of the patients plantation. A ventricular assist im- died, 49% received a transplanted plant used this way is often called heart, 33% remained active on the list, and the remaining 4% a “bridge-to-transplant” device. BY MITCHEL L. ZOLER Else vier Global Medical Ne ws were removed from the list because their status had improved. The investigators identified the following six features that were significantly associated with an elevated risk for death during the first 30 days on the list: Blood type O. Age older than 60 years. Ventilator support. Intra-aortic balloon pump. Serum creatinine greater than 1.5 mg/dL. Serum albumin less than 3.0 g/dL. Analysis showed that the risk of death increased in patients who had more of these risk factors. Patients with none of the risk factors had an 11% risk of dying while they were maintained on medical treatment during their first 30 days on the list. Mortality risk increased as the number of risk factors rose (15% for patients with any single risk factor, 20% for two factors, 30% for three factors, and 50% for four or more factors). A second analysis identified a non–O blood type and a body weight of 89 kg or less as the most important determinants of receiving a heart transplant during the first 30 days on the list. Patients who met both of these criteria had a 66% chance of receiving a heart during this period, those with either one of these 30-Day Mortality Risk Rates of Heart Transplant Patients Increase With Number of Risk Factors 50% 30% 20% 11% 0 15% 1 2 3 4 ELSEVIER GLOBAL MEDICAL NEWS Number of risk factors* *Risk factors are blood type O, age >60 years, ventilator support, intra-aortic balloon pump, serum creatinine >1.5 mg/dL, and serum albumin <3.0 g/dL. Note: Based on data for 1,755 patients listed as status 1A candidates. Source: Dr. Lietz two factors had about a 50% chance, and patients without either factor had about a 23% chance, Dr. Lietz said. Physicians need to determine how these findings can be used to help guide individual decisions about whether to rely on medical treatment alone or opt for implantation of a mechanical support device while a patient is awaiting a heart. A reasonable cutoff might be a risk for dying of 30% or greater while listed, which corresponds to a patient’s having three or more mortality risk factors, Dr. Lietz suggested. Dr. Fred A. Crawford, Jr., an ACS Fellow who was asked to comment on the study, said that it does not really clarify the indication for implanting mechanical support, but contributes to it. Greater use of support devices in stable status 1A patients with multiple risk factors would hopefully prolong their overall survival, he said. “At the same time, careful follow-up of this group would be necessary to confirm the hypothesis,” said Dr. Crawford, surgery department chairman at the Medical University of South Carolina, Charleston. ■ Esophagectomy Database Patients Showed Lower Mortality BY DOUG BRUNK Else vier Global Medical Ne ws S A N D I E G O — Thoracic surgeons who participated in the Society of Thoracic Surgery’s general thoracic surgery database over a 5-year period performed esophagectomy for esophageal cancer with a mortality rate of 2.5%, which is significantly lower than published mortality rates ranging from 8% to 23%. In addition, induction therapy was not associated with increased major morbidity. Those are two key findings from an evaluation of 1,986 esophagectomies performed for esophageal cancer from January 2002 to June 2007 by 68 centers that participated in the STS’s general thoracic surgery database. “While there are many single-institution reports on morbidity and mortality after esophagectomy, there is a paucity of multi-institutional reports,” Dr. Cameron D. Wright said at the annual meeting of the American Association for Thoracic Surgery. “The [Veterans Affairs] National Surgery Quality Improvement Program reported on 1,777 patients, but the VA patient population is not representative of the entire U.S. population, and the mortality was on the high side at 9.8%.” He also pointed out that many parties—including government, insurance companies, and industry—“have decided that volume alone is an adequate proxy to measure the quality of care in our than 35 kg/m2; 24% had diabetes; and 44% esophagectomy patients due to the cost, had induction therapy. difficulty of data collection, and lack of Major morbidity occurred in 23% of parisk adjustment models,” said Dr. Wright, tients. Only 7% of patients with no major a thoracic surgeon at Massachusetts Gen- morbidity returned to the operating room eral Hospital, Boston, who also chairs the for another procedure during the same STS General Thoracic Surgery Database hospitalization, but 55% of patients who Task Force. “Clearly we need had major morbidity returned risk-adjusted models to assess to the OR. and compare results after Overall mortality was 2.5%, esophagectomy.” but the incidence was signifiHe and his associates evalucantly higher (11%) in those ated the standard risk factors, with major morbidity. outcome measures, and adThe mean hospital length of verse events from the 1,986 stay for patients without major cases in the database, and conmorbidity was 11 days comstructed a multivariate risk pared with 25 days for patients model for mortality and major ‘The STS database with major morbidity, a signifmorbidity, which was defined icant difference. participants are as reoperation for bleeding, Univariate risk factors for very select. . . . anastomotic leak, pneumonia, major morbidity were age oldI think that’s why reintubation, initial ventilation er than 75 years, African Amerthe results are so beyond 48 hours, or death. ican race, a Zubrod perforgood.’ Forced expiratory volume in mance status score greater than DR. WRIGHT 1 second as a percentage of 3, an ASA score greater than 3, forced vital capacity and other pulmonary a BMI greater than 35, heart failure, corofunction data were excluded from the fi- nary artery disease, peripheral vascular nal multivariate model because of missing disease, diabetes, hypertension, smoking, data in more than half of cases. chronic obstructive pulmonary disease, The mean age of patients was 63 years, and excessive intraoperative blood loss and most (82%) were male. More than half that required transfusion. (57%) had an American Society of AnesPostoperative events were more comthesiologists (ASA) score greater than 3, mon in patients with major morbidity indicating multiple serious comorbidities; compared with those who did not have 10% had a body mass index (BMI) greater major morbidity, including deep vein thrombosis (3.4% vs. 1.4%); a need for tracheostomy (15% vs. 3%); atrial fibrillation (26% vs. 15%); sepsis (12% vs. 7%); a need for blood transfusions (7.4% vs. 4.6%); recurrent laryngeal nerve injury (4.6% vs. 1.4%); and renal failure (8.5% vs. 1%). Multivariate analysis revealed the following risk factors for major morbidity after esophagectomy: age older than 75 years (odds ratio, 1.50); African American race (OR, 1.84), heart failure (OR, 2.68), peripheral vascular disease (OR, 1.70), diabetes (OR, 1.99), cigarette smoking (OR, 1.31), ASA score greater than 3 (OR, 1.45), and a BMI greater than 35 (OR, 1.67). Important factors not associated with increased risk for major morbidity on multivariate analysis included induction therapy, gender, and a Zubrod score greater than 3. “We also looked at the major morbidity by volume after esophagectomy, and there was not a striking relationship,” Dr. Wright said. “In fact, when we examined volume performance relationship in our model by adding volume as a linear covariate, there was no significant association.” He cautioned that this volume performance relationship may not be true of all surgery centers in America. “The STS database participants are very select: They belong to the STS, they’re board certified, and they’re very interested in quality improvement,” Dr. Wright said. “I think that’s why the results are so good.” ■
Table of Contents Feed for the Digital Edition of Surgery News - September 2008 Surgery News - September 2008 Contents Appreciation Low Scores News From the College: New Leader Practice Trends: High Price to Pay Surgery News - September 2008 Surgery News - September 2008 - Contents (Page 1) Surgery News - September 2008 - Contents (Page 2) Surgery News - September 2008 - Contents (Page 3) Surgery News - September 2008 - Appreciation (Page 4) Surgery News - September 2008 - Low Scores (Page 5) Surgery News - September 2008 - Low Scores (Page 6) Surgery News - September 2008 - Low Scores (Page 7) Surgery News - September 2008 - News From the College: New Leader (Page 8) Surgery News - September 2008 - News From the College: New Leader (Page 9) Surgery News - September 2008 - News From the College: New Leader (Page 10) Surgery News - September 2008 - Practice Trends: High Price to Pay (Page 11) Surgery News - September 2008 - Practice Trends: High Price to Pay (Page 12) Surgery News - September 2008 - Practice Trends: High Price to Pay (Page 13) Surgery News - September 2008 - Practice Trends: High Price to Pay (Page 14) Surgery News - September 2008 - Practice Trends: High Price to Pay (Page 15) Surgery News - September 2008 - Practice Trends: High Price to Pay (Page 16)
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