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ObjectiveWe hypothesized that infants with fetal growth restrictions have increased mortality and morbidity after congenital heart disease surgery.MethodsThe study included patients in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010-2016) who underwent cardiac surgery at a corrected gestational age of ≤44 weeks. Patients were classified as severely (birth weight Z-score -4 to -2), moderately (Z-score -2 to -1), and mildly growth restricted (Z-score -1.0 to -0.5) and compared with a reference population (Z-score 0-0.5). Multivariable logistic regression clustering on center was used to evaluate the association of birth weight Z-score with operative mortality and postoperative complications and its interaction with gestational age was assessed.ResultsIn 25,244 patients, operative mortality was 8.6% and major complications occurred in 19.4%. Compared with the reference group, the adjusted odds ratio (AOR) of mortality was increased in infants with severe (AOR, 2.4; 95% confidence interval [CI], 2.0-3.0), moderate (AOR, 1.7; 95% CI, 1.4-2.0), and mild growth restriction (AOR, 1.4; 95% CI, 1.2-1.6). The AOR for major postoperative complications was increased for severe (AOR, 1.4; 95% CI, 1.2-1.7) and moderate growth restriction (AOR, 1.2; 95% CI, 1.1-1.4). There was significant interaction between birth weight Z-score and gestational age (P = .007).ConclusionsEven birth weight Z-scores slightly below average are independent risk factors for mortality and morbidity in infants who undergo cardiac surgery. The strongest association between poor fetal growth and operative mortality exists in early-term infants. These novel findings might account for some of the previously unexplained variation in cardiac surgical outcomes.

Objective: To evaluate the interaction between smoking status and operative approach following esophagectomy on perioperative outcomes., Methods: Patients undergoing esophagectomy for esophageal cancer between January 1, 2009, and December 31, 2022, were identified from the STS-GTSD database and divided into 6 groups based on smoking status-never (NS), former (FS), or current (CS)-and surgical approach-minimally invasive (MIE) or open (OpenE). Primary outcomes were respiratory complications, operative mortality, major morbidity, and composite major morbidity and mortality., Results: The final study population comprised 27,373 patients (28.3% NS, 68.0% FS, and 13.7% CS) from 295 hospitals. Most cases were OpenE (58.1%), but the proportion of MIE increased from 19.2% in 2009 to 56.3% in 2022. Multivariable analysis showed that (1) risk-adjusted operative mortality was decreased only in never-smokers who underwent MIE (MIE-NS: adjusted odds ratio [aOR], 0.61; 95% confidence interval [CI], 0.45-0.82), and; (2) there were no significant differences in mortality among the groups compared to the reference OpenE-NS group. Respiratory complications, major morbidity, and composite mortality and morbidity outcomes showed similar smoking and surgical approach effects. All outcomes were worse in smokers irrespective of approach, and within the same smoking status group, AORs for respiratory complications and morbidity were slightly lower in MIE versus OpenE, but these differences were nonsignificant., Conclusions: Respiratory complications and other major morbidity outcomes following esophagectomy are substantially worsened by smoking history, particularly in current smokers. Among NS, MIE is associated with reduced operative mortality., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study sought to identify the optimal temperature for moderate hypothermic circulatory arrest in patients undergoing elective hemiarch replacement with antegrade brain perfusion., Methods: The Society of Thoracic Surgeons adult cardiac surgery database was queried for elective hemiarch replacements using antegrade brain perfusion for aneurysmal disease (2014-2019). Generalized estimating equations and restricted cubic splines were used to determine the risk-adjusted relationships between temperature as a continuous variable and outcomes., Results: Elective hemiarch replacement with antegrade brain perfusion occurred in 3898 patients at 374 centers with a median nadir temperature of 24.9°C (first quartile, third quartile = 22.0°C, 27.5°C) and median circulatory arrest time of 19 minutes (first quartile, third quartile = 14.0 minutes, 27.0 minutes). After adjustment for comorbidities, circulatory arrest time, and individual surgeon, patients cooled between 25 and 28°C had an early survival advantage compared with 24°C, whereas those cooled between 21 and 23°C had higher risks of mortality compared with 24°C. A nadir temperature of 27°C was associated with the lowest risk-adjusted odds of mortality (odds ratio, 0.62; 95% confidence interval, 0.42-0.91). A nadir temperature of 21°C had the highest risk of mortality (odds ratio, 1.4; 95% confidence interval, 1.13-1.73). Risk of experiencing a major morbidity was elevated in patients cooled between 21 and 23°C, with the highest risk occurring in patients cooled to 21°C (odds ratio, 1.12; 95% confidence interval, 1.01-1.24)., Conclusions: For patients with aneurysmal disease undergoing elective hemiarch with antegrade brain perfusion, circulatory arrest with a nadir temperature of 27°C confers the greatest early survival benefit and smallest risk of postoperative morbidity., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Beginning in 2002, all 14 Massachusetts nonfederal cardiac surgery programs submitted Society of Thoracic Surgeons (STS) National Database data to the Massachusetts Data Analysis Center for mandatory state-based analysis and reporting, and to STS for nationally benchmarked analyses. We sought to determine whether longitudinal prevalences and trends in risk factors and observed and expected mortality differed between Massachusetts and the nation., Methods: We analyzed 2003 to 2014 expected (STS predicted risk of operative [in-hospital + 30-day] mortality), observed, and risk-standardized isolated coronary artery bypass graft mortality using Massachusetts STS data (N = 39,400 cases) and national STS data (N = 1,815,234 cases). Analyses included percentage shares of total Massachusetts coronary artery bypass graft volume and expected mortality rates of 2 hospitals before and after outlier designation., Results: Massachusetts patients had significantly higher odds of diabetes, peripheral vascular disease, low ejection fraction, and age ≥75 years relative to national data and lower odds of shock (odds ratio, 0.66; 99% confidence interval, 0.53-0.83), emergency (odds ratio, 0.57, 99% confidence interval, 0.52-0.61), reoperation, chronic lung disease, dialysis, obesity, and female sex. STS predicted risk of operative [in-hospital + 30-day] mortality for Massachusetts patients was higher than national rates during 2003 to 2007 (P < .001) and no different during 2008 to 2014 (P = .135). Adjusting for STS predicted risk of operative [in-hospital + 30-day] mortality, Massachusetts patients had significantly lower odds (odds ratio, 0.79; 99% confidence interval, 0.66-0.96) of 30-day mortality relative to national data. Outlier programs experienced inconsistent, transient influences on expected mortality and their percentage shares of Massachusetts coronary artery bypass graft cases., Conclusions: During 12 years of mandatory public reporting, Massachusetts risk-standardized coronary artery bypass graft mortality was consistently and significantly lower than national rates, expected rates were comparable or higher, and evidence for risk aversion was conflicting and inconclusive., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Outcomes for lung cancer surgery are currently measured according to perioperative morbidity and mortality. However, the oncologic efficacy of the surgery is reflected by long-term survival. We examined correlation between measures of short-term and long-term performance for lung cancer surgery., Methods: The Society of Thoracic Surgeons General Thoracic Surgery Database linked to Medicare survival data was queried for pathologic stage I lung cancer resected between 2009 and 2013. Two separate multivariable models were created: (1) short-term: avoidance of perioperative major morbidity and mortality; and (2) long-term: 3-year survival. Standardized incidence ratios were calculated for the Society of Thoracic Surgeons programs (participants) to determine risk-adjusted participant performance measures for the short- and long-term time points. Correlation of participant standardized incidence ratios for short- and long-term performance was assessed using the Pearson correlation coefficient., Results: The study population included 12,596 patients from 229 participating programs. One hundred fifty-one participants met minimum volume and follow-up requirements for analysis. Overall, performance for the short-term measure was uniform with only 2 (1.3%) participants performing better than expected and 2 (1.3%) worse than expected. For the long-term measure, 9 (6%) participants achieved better than expected and 5 (3.3%) worse than expected survival. No participant was an above or below average performer for the short- and long-term measures. Further, no correlation was observed between participant short- and long-term performance (Pearson correlation coefficient, 0.12; 95% confidence interval, -0.04 to 0.28; P = .14)., Conclusions: Avoidance of perioperative morbidity and mortality is an incomplete measure of performance in lung cancer surgery. Lung cancer surgery performance metrics should assess the safety of surgery and long-term survival., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The multiarterial grafting survival advantage noted in the overall population undergoing coronary artery bypass grafting is not well defined in the obese. We investigated the early to late survival effects of the radial artery in left internal thoracic artery-based multiarterial bypass grafting (radial artery-multiarterial bypass grafting) versus single arterial bypass grafting (left internal thoracic artery-single arterial bypass grafting) in obese patients., Methods: We analyzed 15-year Kaplan-Meier survival in 6102 patients receiving primary, left internal thoracic artery-based coronary artery bypass grafting with 2 or more grafts divided into body mass index groups: nonobese (<30 kg/m 2 ) and all-obese, comprised of mildly obese (30-35 kg/m 2 ) and morbidly obese (>35 kg/m 2 ). Risk-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of radial artery-multiarterial bypass grafting versus left internal thoracic artery-single arterial bypass grafting were derived via Cox regression and applied separately for early (<0.5 years), intermediate (0.5-5 years), and late (5-15 years) follow-up in each body mass index cohort. Propensity score matching between radial artery-multiarterial bypass grafting and left internal thoracic artery-single arterial bypass grafting cohorts within the body mass index groups was performed as a corroborating analysis., Results: Radial artery-multiarterial bypass grafting was more frequently used in obese patients who were younger (62 ± 10 years; mild/morbid: 45.4%/54.4% radial artery-multiarterial bypass grafting) compared with nonobese patients (66 ± 10 years; 37.4% radial artery-multiarterial bypass grafting). Unadjusted 15-year survival was significantly better for radial artery-multiarterial bypass grafting in all body mass index groups. Multivariate analysis showed a survival benefit of radial artery-multiarterial bypass grafting over the entire 0- to 15-year study period in the all-obese cohort (HR, 0.85; 95% CI, 0.74-0.98) and was more pronounced in the mildly obese (HR, 0.79; 95% CI, 0.66-0.96) versus morbidly obese (HR, 0.88; 95% CI, 0.69-1.13). The radial artery-multiarterial bypass grafting survival benefit was realized between 0.5 and 5 years postoperatively and was comparable for all-obese (HR, 0.69; 95% CI, 0.51-0.94) and nonobese (HR, 0.68; 95% CI, 0.52-0.88) groups. Propensity score matching was confirmatory., Conclusions: Radial artery-multiarterial bypass grafting confers a long-term survival advantage in both obese and nonobese patients., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Complications adversely affect survival after lung cancer surgery. We tested the hypothesis that effects of complications after lung cancer surgery on survival vary substantially across the spectrum of postoperative complications., Methods: The Society of Thoracic Surgeons General Thoracic Surgery Database was linked to Medicare data for lung cancer resections from 2002 through 2013. Linkage was achieved for 29,899 patients. A survival model was created that included operative complications as explanatory variables and adjusted for relevant baseline covariates. Because of violation of the proportional hazard assumption, we used time-varying coefficient Cox modeling for the complication variables., Results: Median patient age was 73 years, and 48% were male. Procedures performed were lobectomy in 69%, wedge in 17%, segmentectomy in 7%, bilobectomy in 3%, pneumonectomy in 3%, and sleeve lobectomy in 1%. Most frequent complications were atrial arrhythmia (14%), pneumonia (4.3%), reintubation (3.8%), delirium (2%), and acute kidney injury (1.4%). In the early period (0-90 days), 12 complications are associated with worse survival. From 3 to 18 months after surgery, only 4 complications are associated with survival: delirium, blood transfusion, reintubation, and pneumonia. After 18 months, only sepsis and blood transfusion are associated with a significant late hazard., Conclusions: Our analysis confirmed the presence of differential magnitude and time-varying effects on survival of individual complications after lung cancer surgery. We conclude that the derived time-dependent hazard ratios can serve as objective weights in future models that enhance performance measurement and focus attention on prevention and management of complications with greatest effects., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Recent studies have indicated that coronary artery bypass grafting (CABG) outcomes in patients with prior stents are suboptimal. We aimed to study the impact of prior percutaneous coronary intervention (PCI) with stenting (PCI-S) on late CABG mortality in diabetic patients with triple-vessel disease., Methods: We reviewed the primary nonemergency CABG experience from a single U.S. institution (n = 7005; 1996-2007, Toledo, Ohio). Diabetics with triple-vessel disease (n = 1583) were identified and divided into 2 groups: (1) prior PCI-S (n = 202); and (2) no prior PCI (No-PCI [n = 1381]). Hierarchic Cox proportional hazards models were used to assess the effect of prior PCI-S on 5-year mortality after CABG. A propensity score for PCI-S and No-PCI patients was derived using a nonparsimonious logistic regression and used to generate a 1:1 (PCI-S to No-PCI) matched cohort., Results: In model 1, after adjusting for preoperative clinical characteristics, medications, off-pump surgery, and isolated CABG surgery status, prior PCI-S was associated with a 39% increased risk of mortality (hazard ratio [HR] = 1.39, with 95% confidence interval [CI; 1.02, 1.90]; P = .04). Further adjustment for date of surgery (model 2) (HR = 1.39, with 95% CI [1.02, 1.91]; P = .04) or operative parameters (model 3) (HR = 1.38, with 95% CI [1.01, 1.88]; P = .046) did not alter the association. The 1:1 matched-cohort analysis confirmed the increased risk associated with PCI-S (HR = 1.61, with 95% CI [1.03, 2.51]; P = .037)., Conclusions: Patients who have both diabetes and triple-vessel disease, and have undergone prior PCI-S, have poorer long-term outcomes after CABG compared with those who have had no prior PCI-S., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The association of new-onset postoperative atrial fibrillation (POAF) and late death after coronary artery bypass grafting (CABG) has been confounded by the frequent concomitant serious complications that co-occur with POAF. We aimed to define the magnitude and time dependence of the effect of isolated POAF on late survival after uncomplicated CABG to comprehensively account for comorbidity and perioperative confounding factors., Methods: Nonsalvage CABG patients with no history of AF, no concomitant aortic or valvular surgery, and no perioperative complications other than POAF were studied (n=6305). Patients were divided into AF (n=1211, 68 years old, 72% male) and no-AF (n=5094, 63 years old, 70% male) groups. Propensity matching was done using 55 patient variables, including coronary grafts, completeness of revascularization, and transfusion data. The AF effect was quantified using time-segmented hazard ratios by Cox regression analysis., Results: Single (1-to-1), double (1-to-2), and triple (1-to-3) propensity matching of the AF and no-AF was achieved for 1196, 993, and 719 cases, respectively. The AF group showed significantly worse, yet time-varying, 0- to 18-year survival: 0 to 1 year, HR, 1.18 (95% confidence interval, 0.77-1.81); 1 to 6 years, HR, 1.37 (95% confidence interval, 1.12 to 1.67); and 6 to 17 years, HR, 1.25 (95% confidence interval, 1.05 to 1.49)., Conclusions: Isolated POAF was associated with a time-varying increase in mortality after CABG. Given these findings and the high incidence of POAF, efforts to reduce POAF should be pursued to potentially improve resource usage, morbidity, and mortality., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We investigated whether use of radial artery versus saphenous vein grafts during coronary artery bypass grafting reoperations is associated with a significant long-term survival benefit., Methods: We reviewed a series of 347 consecutive coronary artery bypass grafting reoperations (1996-2007; 270 [78%] male patients; age, 65.3 +/- 9.2 years). Internal thoracic artery grafts were used in 248 (71%) patients at the time of the first coronary artery bypass grafting operation and in 154 (44%) patients at reoperation. Patients were grouped based on whether a functional radial artery graft was present after coronary artery bypass grafting reoperation (radial artery cohort, n = 203 [59%]) or not (saphenous vein cohort, n = 144 [41%]). Median time to reoperation was similar for the radial artery (10.3 years) and saphenous vein (10.1 years) cohorts (P = .55). Angiographic data were used to ascertain the number and type of grafts that remained functional from initial coronary artery bypass grafting. Survival data (< or = 12 years) were time segmented based on multiphase hazard modeling at 90 days, and late survival was then analyzed by using proportional hazard Cox regression, with risk adjustment based on a radial artery-use propensity score computed from 48 covariates, including time to reoperation, month of surgical intervention, and total arterial and vein grafts after reoperation. Propensity-matched and propensity quintile comparisons were also done., Results: Follow-up was similar for the radial artery versus saphenous vein cohorts (5.7 +/- 3.4 vs 5.8 +/- 4.0 years, P = .86), and 112 (50 in the radial artery and 62 in the saphenous vein cohorts) deaths were documented. Early mortality (< or = 90 days) did not differ for the radial artery (7.4%) and saphenous vein (12.5%) cohorts (P = .14). Unadjusted late outcomes were superior for the radial artery versus saphenous vein cohorts, with survival of 97.3% versus 92.9%, 84.9% versus 77.2%, and 74.1% versus 60.3% at 1, 5, and 10 years, respectively. Propensity-adjusted radial artery survival was superior, with a hazard ratio of 0.58 (P = .04), and this result was confirmed in a propensity-matched comparison., Conclusions: We conclude that the use of radial artery as opposed to saphenous vein grafting for reoperative coronary artery bypass grafting, either with or without concomitant internal thoracic artery grafts, is associated with a substantial improvement in late survival. This benefit is likely derived from the increased overall number of arterial grafts., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Hemodilutional anemia during cardiopulmonary bypass can lead to inadequate oxygen delivery and, consequently, to ischemic organ injury. In adult bypass, the nadir hematocrit can vary widely with body size and prebypass hematocrit variations, yet its effects on perioperative organ dysfunction and patient outcomes remain largely unknown., Methods: To elucidate these effects, we retrospectively analyzed operative results and resource utilization data from 5000 consecutive cardiac operations with cardiopulmonary bypass performed on adults (1994 to 2000). Rolling decile groups (500 patients each; 75% overlapping) of increasing lowest hematocrit values were used to characterize hemodilution-outcome relationships. Intermediate-term (0 to 6 years) survival was assessed for coronary artery bypass patients (n = 3800) via Kaplan-Meier analysis in quintile subgroups based on lowest hematocrit. Multivariate logistic regression (operative mortality and morbidity) and Cox proportional hazard model (0- to 6-year mortality) analyses were used to determine independent predictors of poor outcomes., Results: Stroke, myocardial infarction, low cardiac output, cardiac arrest, renal failure, prolonged ventilation, pulmonary edema, reoperation due to bleeding, sepsis, and multiorgan failure were all significantly and systematically increased as lowest hematocrit value decreased below 22%. Consequently, intensive care requirements, hospital stays, operative costs, and operative deaths were also significantly greater as a function of hemodilution severity. Longer-term survival was improved systematically for increasing lowest hematocrit coronary artery bypass grafting quintiles; for example, 6-year survival was 80.5% and 92.3% for quintiles I (lowest hematocrit = 16.1%) and V (lowest hematocrit = 27.5%). The continuous variable lowest hematocrit was an independent predictor of (1) operative mortality, (2) prolonged cardiovascular intensive case (>2 days) and postoperative hospital (>8 days) stays, and (3) worse 0- to 6-year survival., Conclusions: Increased hemodilution severity during cardiopulmonary bypass was associated with worse perioperative vital organ dysfunction/morbidity and increased resource use, as well as greater short- and intermediate-term mortality. We speculate that these results derive from inadequate oxygen delivery causing ischemic and/or inflammatory vital organ injury, as recently demonstrated intravitally in cerebral tissues. Although this analysis of a large observational study offers evidence linking low on-pump hematocrit values to these adverse outcomes, prospective randomized trials are needed (1) to establish whether a causal effect of hemodilution on poor outcomes actually exists and (2) to test the potential efficacy of maintaining on-pump hematocrit above 22% for improving outcomes of cardiopulmonary bypass.