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Background: Global disparities in valvular surgery services exist. Cost-effectiveness analysis (CEA) and cost-utility analysis can be used to guide national investment decisions. This scoping review aims to synthesize economic evaluations for valvular surgery by income settings and provide recommendations., Methods: A systematic literature review identified primary CEAs or CUAs in English comparing surgical management strategies for valvular heart disease. MEDLINE, Embase, CINAHL, Web of Science, and Business Source Complete were searched using keywords "valvular surgery," "valve disease," "cost-effectiveness," and "cost-benefit analysis". Articles comparing outcomes or costs only were excluded. Search results were uploaded and screened on COVIDENCE. Variables from eligible articles were charted in a spreadsheet., Results: Twenty articles were eligible, six from low- and middle-income countries (LMICs) and 14 from high-income countries (HICs). In HICs, the top conditions were degenerative aortic valve disease (7/14) and mitral valve disease (4/14) compared to congenital (2/6) and rheumatic heart diseases (2/6) in LMICs. HICs evaluated new technologies and techniques, whereas LMICs compared different valve types or surgery versus no intervention. Most articles used published studies (12/20) or databases (7/20) to conduct their CEA and quality-adjusted life years was the most common effectiveness measure (12/20). Comparator interventions were cost-effective in all LMIC articles and in 8/14 for HICs., Conclusion: Economic evaluations are mostly conducted in HICs and for adult conditions. More analyses in LMICs are needed. This can be facilitated by maintaining databases, documenting costs, and implementing quality of life assessments., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Objectives: An increased risk of mortality and postoperative side effects led to aprotinin (Trasylol®) withdrawal from the market in 2008, but since 2018 aprotinin has again been used in France. The French retrospective multicentre APACHE study (AProtinin versus tranexamic Acid in Cardiac surgery patients with High-risk for Excessive bleeding) compared the efficacy of tranexamic acid versus half-dose aprotinin. The aim of this study, ancillary to the APACHE study, is to carry out a medico-economic analysis of the use of these two antifibrinolytics on an APACHE subpopulation., Methods: Economic data on reimbursement by the French health insurance system were extracted from the program for the data processing of medical information, and quantitative data on the cost of healthcare products were obtained from the hospital pharmacy software., Results: The main analysis of costs for the population shows that the global valuation was not significantly different between the two treatment groups (P=0.60), but the costs of blood products included in the related hospital stay group (Groupe Homogène de séjour [GHS]) (whole blood, platelets and plasma) were higher for the tranexamic acid group (P=0.007). In a sub-analysis of patients alive at discharge, the costs of blood products in addition to GHS (blood-derived medicines) and the costs of blood products in the GHS were higher for the tranexamic acid group (P=0.04 and 0.001, respectively)., Conclusions: The additional cost of aprotinin at the time of purchase is offset by the additional costs of blood products in the tranexamic acid group., (Copyright © 2024 Académie Nationale de Pharmacie. Published by Elsevier Masson SAS. All rights reserved.)

Background: Until local healthcare infrastructure is strengthened, cardiac surgical care in low- and middle-income countries is often provided by non-governmental organizations by way of visiting healthcare teams. This is generally considered to be a cost-effective alternative to transporting patients to high income countries for surgical care, but the costs of cardiac surgery consumables under this model are poorly understood. Our objective was to identify the per-patient cost of cardiac surgery consumables used in single and double valve replacements performed by a non-governmental organization in Rwanda., Methods: Financial data from 2020 were collected from Team Heart, a non-governmental organization that supports cardiac surgical care in Rwanda. A comprehensive list of consumables was generated, including surgical, perfusion, anesthesia, and inpatient supplies and medications. Acknowledging the variability in perioperative needs, the quantities of consumables were calculated from an average of six patients who underwent single or double-valve replacement in 2020. Total costs were calculated by multiplying purchasing price by average quantity per patient. Costs absorbed by the local hospital were excluded from the calculations., Results: The total cost per patient was estimated at $9,450. Surgical supplies comprised the majority of costs ($6,140 per patient), with the most substantial cost being that of replacement valves ($3,500 per valve), followed by surgical supplies ($1,590 per patient)., Conclusions: This preliminary analysis identifies a cost of just over $9,000 per patient for consumables used in cardiac valve surgery in Rwanda, which is lower than the estimated costs of transporting patients to centers in high income countries. This work highlights the relative cost effectiveness of cardiac surgical care in low- and middle- income countries under this model and will be instrumental in guiding the allocation of local and international resources in the future., (© 2024. The Author(s).)

Background: Minimally invasive surgery has emerged as a favorable alternative to conventional surgery for various cardiac conditions. This study aimed to compare the perioperative outcomes and follow-up results of the robotic approach versus the sternotomy approach for left atrial myxoma (LAM) resection., Method: We retrospectively analyzed the perioperative outcomes and follow-up results of 94 patients who underwent left atrial myxoma resection using either the sternotomy approach (n = 64) or the robotic approach (n = 30) at our center between January 2017 and April 2023. Multiple linear regressions were employed to examine the actual impact of the surgical approach on perioperative outcomes while controlling for potential confounding factors., Results: There were no in-hospital deaths or follow-up deaths in the robotic group. Univariate analyses revealed that robotic LAM resection had a longer cardiopulmonary bypass (CPB) time (99.93 ± 22.30 vs. 76.28 ± 24.92, P < 0.001), longer aortic clamping time (57.80 ± 20.27 vs. 47.89 ± 18.10, P = 0.019), reduced postoperative drainage (P < 0.001), shorter mechanical ventilation time (P = 0.005), shorter postoperative bed-stay time (P < 0.001), shorter postoperative hospitalization time (P = 0.040), and higher hospital costs (P = 0.001) compared to the sternotomy group. After adjusting for baseline characteristics in a multiple regression model, a longer CPB time (B = 28.328; CI, 18.609-38.047; P < 0.001), longer aortic clamping time (B = 11.856; CI, 4.069-19.644; P = 0.003), reduced postoperative drainage (B = -200.224; CI, -254.962- -145.486; P < 0.001), shorter mechanical ventilation time (B = -3.429; CI, -6.562- -0.295; P = 0.032), shorter postoperative bed-stay time (B = -2.230; CI, -3.267- -1.193; P < 0.001), shorter postoperative hospitalization time (B = -1.998; CI, -3.747- -0.250; P = 0.026), and higher hospital costs (B = 2096.866, P = 0.002) were found in the robotic group. Furthermore, the robotic group exhibited a faster return to exercise compared to the sternotomy group (Log-Rank χ 2  = 34.527, P < 0.001)., Conclusion: Both the robotic and sternotomy approaches are viable and safe options for LAM resection. However, despite the higher costs, longer CPB time, and longer aortic clamping time associated with robotic LAM resection, this technique was correlated with reduced postoperative drainage and faster postoperative recovery compared to the sternotomy technique., Competing Interests: Declaration of competing interest The authors declare that they have no competing interests., (Copyright © 2024 Asian Surgical Association and Taiwan Society of Coloproctology. Published by Elsevier B.V. All rights reserved.)

Background: Treatment of congenital heart disease (CHD), being the most common congenital anomaly, puts immense financial burden in low- and middle-income countries (LMICs) and contributes significantly to infant mortality. We report experiences of treatment of CHD in the Indian state of West Bengal by a public-private partnership (PPP) model. Methods: Under the Rashtriya Bal Swasthya Karyakram, the government of the state of West Bengal in India launched a program called the "Sishu Sathi Scheme" to provide free treatment to children who need heart surgeries, irrespective of economic status. Treatment was provided in selected private hospitals and some public hospitals in a reimbursement model where government compensated the hospitals. Data were collected on such procedures from 2013 to 2022 and analyzed. Results: A total of 27,844 patients with CHD received treatment under the Sishu Sathi Scheme from August 2013 to December 2022. The average number of patients per year was 3,093. Detailed data of procedures from January 2016 to December 2022 showed a total of 22,572 procedures (6,249 device interventions, 4,840 cardiac catheterizations, and 11,483 surgical interventions). The in-hospital mortality of surgical procedures and catheterization lab procedures were 5.2% and 0.9%, respectively. Conclusions: A large number of patients with CHD were successfully treated under a PPP in the state of West Bengal in India. In spite of its inherent challenges, this model is of special relevance in LMICs where access and affordability for treatment of CHD always remain a challenge., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Time-directed extubation (fast-track) protocols may decrease length of stay and cost but data on operating room (OR) extubation is limited. The objective of this study was to compare the outcomes of extubation in the OR versus fast-track extubation within 6 hours of leaving the operating room. Patients undergoing nonemergent STS index cases (2011-2021) who were extubated within 6 hours were identified from a regional STS quality collaborative. Patients were stratified by extubation in the OR versus fast track. Propensity score matching (1:n) was performed to balance baseline differences. Of the 24,962 patients, 498 were extubated in the OR. After matching, 487 OR extubation cases and 899 fast track cases were well balanced. The rate of reintubation was higher for patients extubated in the OR [21/487 (4.3%) vs 16/899 (1.8%), P = 0.008] as was the incidence of reoperation for bleeding [12/487 (2.5%) vs 8/899 (0.9%), P = 0.03]. There was no significant difference in the rate of any reoperation [16/487 (3.3%) vs 15/899 (1.6%), P = 0.06] or operative mortality [4/487 (0.8%) vs 6/899 (0.6%), P = 0.7]. OR extubation was associated with shorter hospital length of stay (5.6 vs 6.2 days, P < 0.001) and lower total cost of admission ($29,602 vs $31,565 P < 0.001). OR extubation is associated with a higher postoperative risk of reintubation and reoperation due to bleeding, but lower resource utilization.Future research exploring predictors of extubation readiness may be required prior to widespread adoption of this practice., Competing Interests: Disclosures Dr. Ailawadi is a consultant and advisor for Medtronic, Inc; Edwards Lifescience; Abbott Laboratories; AtriCure and Cephea Valve Technologies. Dr. Joseph is a speaker for Angiodynamics. Dr. Yarboro has received honoraria for consulting and proctoring for Medtronic and has proctored for Abbott Laboratories., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: Left atrial appendage occlusion during cardiac surgery is a therapeutic option for stroke prevention in patients with atrial fibrillation. The effectiveness and safety of left atrial appendage occlusion have been evaluated in several studies, including the LAAOS-III trial. While these studies have demonstrated efficacy and safety, the long-term economic impact of this surgical technique has not yet been assessed. Here, we aimed to evaluate the cost-effectiveness and cost-utility of left atrial appendage occlusion during cardiac surgery over a long-term time horizon., Methods: Our study was based on a model representing an hypothetical cohort with the same characteristics as LAAOS-III trial patients. We modelled the incidence of ischemic strokes and systemic embolisms in each intervention arm: "occlusion" and "no-occlusion," using a one-month cycle length with a 20-year time horizon. Regarding occlusion devices, sutures, staples, or an approved surgical occlusion device (AtriClip™-AtriCure, Ohio, USA) could be used., Results: Our model generated an average cost savings of 607 euros per patient and an incremental gain of 0.062 quality-adjusted life years (QALYs), resulting an incremental cost-utility ratio (ICUR) of €-9,775/QALY. The scenario analysis in which occlusion was systematically performed using the AtriClip™ device generated an ICUR of €3,952/QALY gained., Conclusions: In the base-case analysis, the strategy proved to be more effective and less costly, confirming left atrial appendage occlusion during cardiac surgery as an economically dominant strategy. The scenario analysis also appeared cost-effective, although it did not result in cost savings. This study provides a new perspective on the assessment of the cost-effectiveness of these techniques., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Benmalek et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, costing the lives of 18 million people annually, with up to one-third being attributable to cardiac surgical conditions. Approximately 6 billion people do not have access to safe, timely, and affordable cardiac surgery, predominantly affecting populations living in low-middle income countries. Cardiac surgical care is costly, resulting in few centers in variable-resource contexts operating continuously or with the resources observed in higher-resource environments. As a result, innovations may be formally developed or informally adopted to bypass resource constraints and ensure care delivery. Innovations have been observed across the cardiac surgical care continuum and across settings, potentially benefiting both high-income countries, where growing health care costs are becoming unsustainable, and low- and middle-income countries, where competing health agendas may limit investments into cardiac surgery. This narrative review attempts to address the costs associated with cardiac surgery, placing an emphasis on frugal innovations in the perioperative and postoperative care spectrum., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Lack of consensus remains about factors that may be associated with high resource use (HRU) in adult cardiac surgical patients. This study aimed to identify patient-related, hospital, and perioperative characteristics associated with HRU admissions involving elective cardiac operations., Methods: Data from the National Inpatient Sample was used to identify patients who underwent coronary artery bypass graft, valve replacement, and valve repair operations between 2005 and 2016. Admissions with HRU were defined as those in the highest decile for total hospital costs. Multivariable regressions were used to identify factors associated with HRU., Results: An estimated 1,750,253 hospitalizations coded for elective cardiac operations. The median hospitalization cost was $34,700 (interquartile range, $26,800- to $47,100), with the HRU (N = 175,025) cutoff at $66,029. Although HRU patients comprised 10% of admissions, they accounted for 25% of cumulative costs. On multivariable regression, patient-related characteristics predictive of HRU included female sex, older age, higher comorbidity burden, non-White race, and highest income quartile. Hospital factors associated with HRU were low-volume hospitals for both coronary artery bypass graft and valvular operations. Among postoperative outcomes, mortality, infectious complications, extracorporeal membrane oxygenation use, and hospitalization for more than 8 days were associated with greater odds of HRU., Conclusions: In this nationwide study of elective cardiac surgical patients, several important patient-related and hospital factors, including patients' race, comorbidities, postoperative infectious complications, and low hospital operative volume were identified as predictors of HRU. These highly predictive factors may be used for benchmarking purposes and improvement in surgical planning., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: This manuscript aims to explore the impact of race/ethnicity and socioeconomic status on in-hospital complication rates after left atrial appendage closure (LAAC)., Methods: The US National Inpatient Sample was used to identify hospitalisations for LAAC between 1 October 2015 to 31 December 2018. These patients were stratified by race/ethnicity and quartiles of median neighbourhood income. The primary outcome was the occurrence of in-hospital major adverse events, defined as a composite of postprocedural bleeding, cardiac and vascular complications, acute kidney injury and ischaemic stroke., Results: Of 6478 unweighted hospitalisations for LAAC, 58% were male and patients of black, Hispanic and 'other' race/ethnicity each comprised approximately 5% of the cohort. Adjusted by the older Americans population, the estimated number of LAAC procedures was 69.2/100 000 for white individuals, as compared with 29.5/100 000 for blacks, 47.2/100 000 for Hispanics and 40.7/100 000 for individuals of 'other' race/ethnicity. Black patients were ~5 years younger but had a higher comorbidity burden. The primary outcome occurred in 5% of patients and differed significantly between racial/ethnic groups (p<0.001) but not across neighbourhood income quartiles (p=0.88). After multilevel modelling, the overall rate of in-hospital major adverse events was higher in black patients as compared with whites (OR: 1.60, 95% CI 1.22 to 2.10, p<0.001); however, the incidence of acute kidney injury was higher in Hispanics (OR: 2.19, 95% CI 1.52 to 3.17, p<0.001). No significant differences were found in adjusted overall in-hospital complication rates between income quartiles., Conclusion: In this study assessing racial/ethnic disparities in patients undergoing LAAC, minorities are under-represented, specifically patients of black race/ethnicity. Compared with whites, black patients had higher comorbidity burden and higher rates of in-hospital complications. Lower socioeconomic status was not associated with complication rates., Competing Interests: Competing interests: DH is on the Advisory Board for Boston Scientific, unpaid., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: This study documents trends in risk-adjusted quality and cost for a variety of inpatient surgical procedures among Medicare beneficiaries from 2002 through 2015, which can provide valuable insight on future strategies to improve public health and health care., Methods: We focused on 11 classes of inpatient surgery, defined by the Agency for Health Research and Quality's (AHRQ's) Clinical Classification System. The surgical classes studied included a wide range of surgeries, including tracheostomy, heart valve procedures, colorectal resection, and wound debridement, among others. For each surgical class, we assessed trends in treatment costs and quality outcomes, as defined by 30-day survival without unplanned readmissions, among Medicare beneficiaries receiving these procedures during hospital stays. Quality and costs were adjusted for patient severity based on demographics, comorbidities, and community context. We also explored surgical innovations of these 11 classes of inpatient surgery from 2002-2015., Results: We found significant improvements in quality for 7 surgical classes, ranging from 0.08% (percutaneous transluminal coronary angioplasty) to 0.74% (heart valve procedures) per year. Changes in cost varied by surgery, the significant decrease in cost ranged from -2.59% (tracheostomy) to -0.34% (colorectal resection) per year. Treatment innovation occurred with respect to surgical procedures utilized for heart valve procedures and colorectal resection, which may be associated with the decrease in surgical cost., Conclusions: Our results suggest that there was significant quality improvement for 7 surgery categories over the 14-year study period. Costs decreased significantly for 6 surgery categories, and increased significantly for 3 other categories., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Acute kidney injury (AKI) is common after cardiac surgery. We quantified the mortality and costs of varying degrees of AKI using a population-based cohort in Alberta, Canada., Methods: A cohort of patients undergoing cardiac surgery from 2004 to 2009 was assembled from linked Alberta administrative databases. AKI was classified by Kidney Disease Improving Global Outcomes stages of severity. Our outcomes were in-hospital mortality, length of stay, and costs; among survivors, we also examined mortality and costs at 365 days. Estimates were adjusted for demographic characteristics, comorbidities, and other covariates., Results: Ten thousand one hundred seventy participants were included, of whom 9771 patients were discharged to community. Overall in-hospital mortality, costs, and length of stay were 4%, 7 days, and Can $34,000, respectively. Postcardiac surgery, AKI occurred in 25%. Compared with those without AKI, AKI was independently associated with increased in-hospital mortality across severity categories, with the highest risk (adjusted odds ratio, 37.1; 95% confidence interval, 26.3-52.1; P < .001) in patients who required acute dialysis. AKI severity was associated with increased hospital days and costs, with costs ranging from 1.21 for stage 1 AKI (95% confidence interval, 1.17-1.23) to 2.74 for acute dialysis (95% confidence interval, 2.49-3.00) (P < .001) times higher than in patients without AKI, after covariate adjustment. Postdischarge to 365 days, patients with AKI continued to experience increased costs up to 1.35-fold, and patients who required dialysis acutely continued to experience a 2.86-fold increased mortality., Conclusions: AKI remains an important indicator of mortality and health care costs postcardiac surgery., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Institutional experience has been associated with reduced mortality after coronary artery bypass grafting and valve operations. Using a contemporary, national cohort, we examined the impact of hospital volume on hospitalization costs and postdischarge resource utilization after these operations., Methods: Adults undergoing elective coronary artery bypass grafting or valve operations were identified in the 2016 to 2017 Nationwide Readmissions Database. Institutions were grouped into volume quartiles based on annual elective cardiac surgery caseload, and comparisons were made between the lowest and highest quartiles, using generalized linear models., Results: Of an estimated 296,510 patients, 24.8% were treated at low-volume hospitals and 25.2% at high-volume hospitals. Compared with patients treated at low-volume hospitals, patients managed at high-volume hospitals were younger, had more comorbidities, and more frequently underwent combined coronary artery bypass grafting valve (13.0% vs 12.3%, P < .001) and multivalve operations (6.2% vs 3.1%, P < .001). After adjustment, operations at high-volume hospitals were associated with a $7,600 reduction (95% confidence interval $4,700-$10,500) in costs. High-volume hospitals were also associated with reduced odds of mortality, non-home discharge, and 30-day non-elective readmission compared to low-volume hospitals., Conclusion: Despite increased complexity at high-volume centers, greater operative volume was independently associated with reduced hospitalization costs and mortality after elective cardiac operations. Reduction in non-home discharge and readmissions suggests this effect to extend beyond acute hospitalization, which may guide value-based care paradigms., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To compare the safety and resource-efficacy of the fast-track (FT) concept (extubation ≤8 hours after surgery) versus the conventional approach (non-FT, >8 hours postoperatively) in infants undergoing open-heart surgery., Methods: Infants <7 kg operated on cardiopulmonary bypass between 2014 and 2018 were analyzed. Propensity score matching (1:1) was performed for group comparison (FT vs non-FT). Intensive care unit (ICU) personnel use and unit performance were evaluated. Postoperative outcome and reimbursement based on German diagnosis-related groups were compared., Results: Of 717 infants (median age: 4 months, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery mortality score: 0.1-4), FT extubation was achieved in 182 infants (25%). After matching, 123 pairs (FT vs non-FT) were formed without significant differences in baseline characteristics. FT versus non-FT showed a significantly shorter ICU stay (in days): 1.8 (0.9-2.8) versus 4.2 (1.9-6.4), P < .01, and postoperative length of stay (in days): 7 (6-10) versus 10 (7-15.5), P < .01; significantly lower postoperative transfusion rates: 61.3% versus 77%, P < .01; and tendency toward lower early mortality: 0% versus 2.8%, P = .08. Reintubation rate did not differ between the groups (P = .7). Despite a decrease in personnel capacity (2014 vs 2018), the unit performance was maintained. The mean case-mix-index of FT versus non-FT was 8.56 ± 6.08 versus 11.77 ± 12.10 (P < .01), resulting in 27% less reimbursement in the FT group., Conclusions: FT concept can be performed safely and resource-effectively in infants undergoing open-heart surgery. Since German diagnosis-related group systems reimburse costs, not performance, there is little incentive to avoid prolonged mechanical ventilation. Greater ICU turnover rates and excellent postoperative outcomes are not rewarded adequately., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Prolonged cardiopulmonary bypass time (prolonged CPBT; PCPBT) during operations for adult congenital heart disease (ACHD) may lead to worse postoperative outcomes, which could add a significant burden to hospitals in developing countries. This study aimed to identify risk factors and outcomes of PCPBT in patients undergoing operations for ACHD., Methods: This retrospective study included all adult patients (≥18 years) who underwent cardiac surgery with cardiopulmonary bypass for their congenital heart defect from 2011-2016 at a tertiary-care private hospital in Pakistan. Prolonged CPBT was defined as CPBT>120 minutes (65 th percentile)., Results: This study included 166 patients (53.6% males) with a mean age of 32.05±12.11 years. Comorbid disease was present in 59.0% of patients. Most patients underwent atrial septal defect repair (42.2%). A total of 58 (34.9%) of patients had a PCPBT. Postoperative complications occurred in 38.6% of patients. Multivariable analysis adjusted for age, gender and RACHS-1 Categories showed that mild preoperative left ventricular (LV) dysfunction was associated with PCPBT (OR=3.137 [95% CI: 1.003-9.818]), while obesity was found to be protective (0.346 [0.130-0.923]). PCPBT was also associated with a longer duration of ventilation (1.298 [1.005-1.676]), longer cardiac ICU stay (1.204 [1.061-1.367]) and longer hospital stay (1.120 [1.005-1.247])., Conclusions: While mild preoperative LV dysfunction was associated with PCPBT, obesity was found to be protective. Postoperatively, PCPBT was associated with longer duration of ventilation, cardiac ICU stay, and hospital stay. Operations with shorter CPBT may help minimize the occurrence and impact of these postoperative adverse outcomes especially in resource-constrained developing countries.

Background: In the UK National Health Service, finite resources make the adoption of minimally invasive (MI) mitral valve surgery challenging unless greater operative costs (vs sternotomy [ST]) are balanced by postoperative savings. This study examined whether the cost analysis now became unfavorable., Methods: All patients (n = 380) undergoing isolated mitral valve surgery with or without a maze procedure over a 3-year period by either MI or ST approaches were included. Propensity matching (2 cohorts, 1:1 matched;, n = 75 per group) and multivariable regression were used to assess for the effect on cost. Cost data were prospectively collected from Service Line Reporting and reported in Sterling (£) as median (interquartile range [IQR])., Results: Matched data revealed that total hospital costs were equivalent (MI vs ST, £16,672 [IQR, £15,044, £20,611] vs £15,875 [IQR, £12,281, £20,687]; P .33). Three of 15 costing pools were significantly different: operative costs were higher for the MI group (MI vs ST, £7458 [IQR, £6738, £8286] vs £5596 iIQR, £4204, £6992]; P < .001), whereas ward costs (boarding, nursing) (MI vs ST, £1464 [IQR, £1146, £1864] vs £1733 [IQR, £1403, £2445] P = .006) and pharmacy services (MI vs ST, £187 [IQR, £140, £239] vs £244 [IQR, £179, £375] P < .001) were lower for the MI group. Hospital stay was shorter in the MI group (MI vs ST, 6 days [IQR, 5, 8 days] vs 8 days [IQR, 6, 11 days]; P < .001). Multivariable regression produced similar findings., Conclusions: There was no difference in overall hospital cost between MI and ST mitral valve surgery: higher operative costs of MI surgery were offset by lower postoperative costs, with a 2-day shorter hospital stay., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Adoption of implantable left ventricular assist devices has dramatically improved survival and quality of life in suitable patients with end-stage heart failure. In the era of value-based healthcare delivery, assessment of clinical outcomes and resource use associated with left ventricular assist devices is warranted., Methods: Adult patients undergoing left ventricular assist device implantation from 2008 to 2016 were identified using the National Inpatient Sample. Hospitals were designated as low-volume, medium-volume, or high-volume institutions based on annual institutional left ventricular assist device case volume. Multivariable logistic regression was used to evaluate adjusted odds of mortality across left ventricular assist device volume tertiles., Results: Over the study period, an estimated 23,972 patients underwent left ventricular assist device implantation with an approximately 3-fold increase in the number of annual left ventricular assist device implantations performed (P for trend <.001). In-hospital mortality in patients with left ventricular assist devices decreased from 19.6% in 2008 to 8.1% in 2016 (P for trend <.001) and was higher at low-volume institutions compared with high-volume institutions (12.0% vs 9.2%, P < .001). Although the overall adjusted mortality was higher at low-volume compared with high-volume institutions (adjusted odds ratio, 1.66; 95% confidence interval, 1.28-2.15), this discrepancy was only significant for 2008 and 2009 (low-volume 2008 adjusted odds ratio, 5.5; 95% confidence interval, 1.9-15.8; low-volume 2009 adjusted odds ratio, 2.3; 95% confidence interval, 1.4-3.8)., Conclusions: Left ventricular assist device use has rapidly increased in the United States with a concomitant reduction in mortality and morbidity. With maturation of left ventricular assist device technology and increasing experience, volume-related variation in mortality and resource use has diminished. Whether the apparent uniformity in outcomes is related to patient selection or hospital quality deserves further investigation., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

The influx of Syrian refugees to Lebanon that began in 2012 created new health-care and financial stressors on the country with an increase in communicable and non-communicable diseases. This study aims to describe the presentations, diagnoses, management, financial burden, and outcomes among Syrian refugees with congenital heart disease (CHD) in Lebanon. This is a retrospective study that was conducted through reviewing the charts of all Syrian pediatric patients referred to the Children's Heart Center at the American University of Beirut Medical Center for evaluation between the years 2012 and 2017. We reviewed the charts of 439 patients. The mean age at presentation was 3.97 years, and 205 patients (46.7%) were females. 99 Patients (22.6%) were found to have no heart disease, 69 (15.7%) had simple, 146 (33.3%) had moderate, and 125 (28.5%) had complex heart diseases. 176 (40.1%) Patients underwent interventional procedures, with a surgical mortality rate of 10.1%, compared to a rate of 2.9% among non-Syrian children. The average cost per surgical procedure was $15,160. CHD poses a significant health and financial burden on the Syrian refugee population in Lebanon, a small country with very limited resources. The Syrian cohort had a higher frequency of complex cardiac lesions, presented late with additional comorbidities, and had a strikingly elevated surgical mortality rate. Securing appropriate funds can improve the lives of this population, ease the financial burden on the hosting country, provide adequate health-care services, and improve morbidity and mortality.

Objectives: Infants undergoing congenital heart surgery require central venous lines which can be achieved by various combinations of transthoracic lines, percutaneous-indwelling central catheters and tunneled Broviac catheters. Transthoracic lines are removed by protocol prior to cardiac intensive care unit discharge (risk of bleeding), at which time percutaneous-indwelling central catheters are placed. Transdiaphragmatic tunneled Broviac catheters placed at the time of sternotomy, remain in place until hospital discharge, when they are safely removed at bedside. We characterized actual cost profiles associated with strategies that do versus do not include tunneled Broviac catheters., Methods: From January 2014 to December 2016, we identified a study population of 220 consecutive patients under 1 year of age undergoing congenital heart surgery. Cost data were acquired from our electronic patient system interface database and office of finance. Our cohort was divided into 2 groups, tunneled Broviac catheter and nontunneled Broviac catheter. We calculated the total cost associated with each groups' central venous lines, propensity matched, and used the Mann-Whitney U test to analyze the results., Results: Eighty-three (37.7%) of the 220 patients had tunneled Broviac catheters. The tunneled Broviac catheter group had 4 percutaneous-indwelling central catheter insertions and 6 radiological interventions while the nontunneled Broviac catheter group had 90 percutaneous-indwelling central catheters and 203 radiologic interventions. After propensity score matching, both groups were reduced to 82 patients and sum, median and interquartile range cost for tunneled Broviac catheters and nontunneled Broviac catheters was $17,351.84, $159.76 (128-159.76) versus $72,809.32, $1277.26 (31.76-1277.26), P < .02 respectively., Conclusions: Tunneled Broviac catheters, placed routinely at cardiac surgery, incur lower costs than the conventional combination of transthoracic lines and percutaneous-indwelling central catheters. The cost-effectiveness is achieved by reducing the number of percutaneous-indwelling central catheters and associated radiologic interventions., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Early mortality rates for paediatric cardiac surgery have fallen due to advancements in care. Alternative indicators of care quality are needed. Postoperative morbidities are of particular interest. However, while health impacts have been reported, associated costs are unknown. Our objective was to calculate the costs of postoperative morbidities following paediatric cardiac surgery., Design: Two methods of data collection were integrated into the main study: (1) case-matched cohort study of children with and without predetermined morbidities; (2) incidence rates of morbidity, measured prospectively., Setting: Five specialist paediatric cardiac surgery centres, accounting for half of UK patients., Patients: Cohort study included 666 children (340 with morbidities). Incidence rates were measured in 3090 consecutive procedures., Methods: Risk-adjusted regression modelling to determine marginal effects of morbidities on per-patient costs. Calculation of costs for hospital providers according to incidence rates. Extrapolation using mandatory audit data to report annual financial burden for the health service., Outcome Measures: Impact of postoperative morbidities on per-patient costs, hospital costs and UK health service costs., Results: Seven of the 10 morbidity categories resulted in significant costs, with mean (95% CI) additional costs ranging from £7483 (£3-£17 289) to £66 784 (£40 609-£103 539) per patient. On average all morbidities combined increased hospital costs by 22.3%. Total burden to the UK health service exceeded £21 million each year., Conclusion: Postoperative morbidities are associated with a significant financial burden. Our findings could aid clinical teams and hospital providers to account for costs and contextualise quality improvement initiatives., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Children and adolescents with congenital heart disease (CHD) are at an increased risk of neuropsychiatric disorders (NPDs). The purpose of this study is to determine how a comorbid NPD affects hospital outcomes and costs for CHD patients undergoing cardiac surgery., Methods: Retrospective review of the 2000-2012 Healthcare Cost and Utilization Project Kids' Inpatient Databases for admissions 10 to 21 years old with an ICD-9 code for moderate or severe CHD and a procedure code for cardiopulmonary bypass as a marker for cardiac surgery; admissions with syndromes that could be associated with NPD were excluded. Demographics, hospital outcomes, and charges were compared between admissions with and without NPD ICD-9 codes using analysis of variance, independent samples Kruskal-Wallis, and χ 2 , as appropriate., Results: There were 4768 admissions with CHD and cardiac surgery: 4285 (90%) with no NPD, 93 (2%) with cognitive deficits, 390 (8%) with mood/behavior deficits. Patients with NPD had a longer length of stay and higher mean charges (P < .001 for both). Patients with mood/behavior deficits were older and patients with cognitive deficits were more likely female (P < .001 for both)., Conclusions: Children and adolescents with moderate or severe CHD and NPD who undergo cardiac surgery incur longer hospital stays and higher charges. Recognizing and addressing the underlying NPDs may be important to improve postoperative progression for children and adolescents with CHD hospitalized for cardiac surgery., (© 2020 Wiley Periodicals LLC.)

Background: Microplegia has been studied during isolated coronary artery bypass grafting and valve surgery but not in more complex operations. Objectives of this study were to demonstrate safety and effectiveness of microplegia relative to Buckberg cardioplegia during these operations., Methods: From January 2012 to January 2017, 242 patients underwent multicomponent operations with simplified microplegia delivered via syringe pump and 10,512 with modified Buckberg cardioplegia. Operations included aortic root, arch, or ascending aorta replacement in 424 (94%) patients, aortic valve surgery in 324 (72%) patients, and concomitant coronary artery bypass grafting in 47 (10%) patients. Outcomes were compared in 226 propensity-matched pairs., Results: There was no difference in median postoperative troponin T between groups after adjusting for aortic clamp time. Microplegia patients received significantly less crystalloid with their cardioplegia (mean 27 ± 8.0 mL/operation vs 735 ± 357 mL/operation; P < .001) and had lower peak intraoperative glucose (196 ± 40 mg/dL vs 248 ± 69 mg/dL; P < .001). Microplegia and Buckberg groups had similar in-hospital mortality (2.7% [n = 6] vs 2.2% [n = 5]; P = .8), stroke (2.2% [n = 5] vs 3.6% [n = 8]; P = .4), renal failure (8% [n = 18] vs 5.8% [n = 13]; P = .4), prolonged ventilation (23% [n = 51] vs 24% [n = 54]; P = .7), median postoperative length of stay (both 8.1 days; P > .9), and median red cell units administered to patients requiring transfusion (4 units vs 3 units; P = .14). The mean cost of cardioplegia per case with microplegia was 1/26th that of Buckberg cardioplegia., Conclusions: Our simplified microplegia technique offers several advantages over Buckberg cardioplegia without compromising myocardial protection or safety in complex, multicomponent operations with extended aortic clamp times., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

This review summarizes a systematic analysis of 216 randomized trials of cardiovascular interventions performed during 2008-2019, according to the source of trial funding. The systematic analysis showed that on average the results of each trial would change significance if only 5 patients experienced different outcomes. Industry-sponsored trials were more likely to use composite endpoints, noninferiority designs, and twice as likely as nonindustry trials to report results favoring the device arm. Over 80% of industry trials used reporting strategies or "spin" suggesting the device arm was advantageous versus fewer than half of non-industry trials. The review discusses the implications of these findings.

Background: Optimal methods to assess resource utilization in congenital heart surgery remain unclear. We compared traditional cost-to-charge ratio methods with newer standardized cost methods that aim to more directly assess resources consumed., Methods: Clinical data from The Society of Thoracic Surgeons Database were linked with resource use data from the Pediatric Health Information Systems Database (2010 to 2015). Standardized cost methods specific to the congenital heart surgery population were developed and compared with cost-to-charge ratio methods. Resource use in the overall population and variability across hospitals were described using hierarchical mixed effect models adjusting for case-mix., Results: Overall, 43 hospitals (65,331 patients) were included. There were minimal population-level differences in the distribution of resource use as estimated by the two methods. At the hospital level, there was less apparent variability in resource use across centers with the standardized cost vs cost-to-charge ratio method, overall (coefficient of variation 20% vs 25%) and across complexity (The Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT]) categories. When hospitals were categorized into tertiles by resource use, 33% changed classification depending on which resource use method was used (26% by one tertile and 7% by two tertiles)., Conclusions: In this first evaluation of standardized cost methodology in the congenital heart population, we found minimal differences vs traditional methods at the population level. At the hospital level, the magnitude of variation in resource use was less with standardized cost methods, and approximately one third of centers changed resource use categories depending on the methodology used. Because of these differences, care should be taken in future studies and in benchmarking and reporting efforts in selecting optimal methodology., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Duration of mechanical ventilation is an important variable used by German Diagnosis-Related Groups (G-DRG) system to establish cost weight values for reimbursement after congenital heart surgery. Infants are commonly ventilated after open heart surgery. As of year 2015, we strived to achieve early postoperative extubation. This work studies how this approach impacted reimbursement after infant open heart surgery., Methods: Data of infants who underwent surgery on cardiopulmonary bypass (CPB) from 2014 to 2018 were reviewed. Successful early extubation was defined as end of mechanical ventilation within 24 hours postoperatively, without reintubation at a later point. Mean cost weight values (case mix index [CMI]) of achieved DRGs were used for estimation of reimbursement. Evolutions over years of early extubation and of reimbursement were compared., Results: A total of 521 infants underwent operations on CPB. Of these, 161 (31%) procedures were of higher risk Society of Thoracic Surgery and the European Association for Cardio-Thoracic Surgery (STAT) categories 3 and 4. Early extubation was achieved in 205 (39%) patients. The rate increased from 14% (year 2014) to 57% (year 2018). Case mix index amounted to 8.87 ± 7.00 after early extubation, and 12.37 ± 7.85 after late extubation: P value <.0001. It was 8.77 ± 6.09 after early extubation in patients undergoing lower risk STAT categories 1 and 2 operations, and 8.09 ± 2.95 when categories 3 and 4 procedures were performed ( P = .18). An overall 14.4% decrease in hospital reimbursement per patient was observed., Conclusion: Early extubation could be progressively obtained in the majority of infants. This resulted in lower reimbursement. Surgical complexity was disregarded. The current G-DRG system appears to favor longer mechanical ventilation durations after infant open heart surgery.

Objectives: Objective measures of cardiac surgery trainee progress are limited despite a push for competency-based assessments. We hypothesized that the cumulative sum failure technique could provide a risk-adjusted, quantitative measure of resident learning curves and competence., Methods: Records of all coronary artery bypass grafting and valve operations performed by cardiac-track residents from 2007 to 2017 at a single institution were stratified by operative resident. Multivariable regression evaluated the association among resident, case number, and postoperative outcomes. To evaluate performance over time, risk-adjusted cumulative sum failure analysis was performed, taking into account institutional expected values and comparing residents with study-defined "early alert" and "concern" boundaries., Results: A total of 3937 Society of Thoracic Surgeons Predicted Risk of Mortality cases were evaluated from 19 residents. Observed-to-expected ratios for mortality and combined morbidity-mortality were 0.66 and 0.72, respectively, and each individual resident exhibited better than predicted outcomes (all observed:expected ratios <1). When evaluating cumulative sum failure learning curves, residents exhibited an initial slight increase in complications, followed by improvement and better than expected performance. The "early alert" boundary was crossed by 36.8% of residents at any point in training, with 94.7% of residents under this boundary at the end of training. The higher "concern" boundary was crossed by 2 residents (10.5%), although all residents ended their training below this boundary., Conclusions: Outcomes for trainee-performed cardiac surgery procedures were excellent, with no association between individual trainees and adverse events. Cumulative sum failure analysis based on postoperative outcomes is a potential tool for objective evaluation of resident proficiency., (Copyright © 2019. Published by Elsevier Inc.)

Background: Left atrial appendage closure (LAAC) is frequently performed during cardiac operations, but the impact of LAAC on patient outcomes is not fully known. We hypothesized that the addition of LAAC would increase morbidity and resource utilization., Methods: All patients undergoing cardiac surgery from a multi-institutional Society of Thoracic Surgeons database from 2011 to 2016 were stratified by LAAC. The effect of LAAC on risk-adjusted outcomes was assessed by hierarchical regression modeling accounting for preoperative risk factors, planned surgical procedure, hospital, and year., Results: Concomitant LAAC was performed on 2384 of 28,311 patients (9.3%), who were older, with a greater burden of preoperative atrial fibrillation and heart failure. Although the addition of LAAC increased the risk of new-onset postoperative atrial fibrillation (OR 1.69, P < 0.01), it did not increase rates of major morbidity (OR 1.00, P = 0.970), stroke (OR 0.92, P = 0.787), or mortality (OR 0.93, P = 0.684). Although cardiopulmonary bypass time was not significantly increased by LAAC, patients' total hospitalization costs were $3035 higher (P = 0.018)., Conclusions: Although concomitant LAAC was not associated with major complications, there were higher risk-adjusted rates of new-onset postoperative atrial fibrillation. Furthermore, LAAC added approximately $3000 to a patient's total hospital cost. These short-term risks and costs should be weighed against potential long-term benefits of left atrial appendage closure., (Copyright © 2019. Published by Elsevier Inc.)

Background: Cardiac surgery results in complications for some patients that lead to a longer hospital stay and higher costs. This study identified the presurgery characteristics of patients that were associated with the cost of their hospital stay and estimated how much of that cost could be attributed to a bleeding event, defined as requiring 3 units or more of packed red blood cells or returning to the operating room for bleeding. We also identified the presurgery characteristics that were associated with the bleeding event., Methods: This prospective cohort of patients (n = 1459) underwent cardiac surgery at 3 tertiary referral hospitals in Australia during 2014 and 2015. Clinical data included the variables held by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons registry. Cost data were collected as part of a state-level hospital data collection., Results: Many of the baseline patient characteristics were associated with the total cost of cardiac surgery. After adjusting for these characteristics, the cost of cardiac surgery was 1.76 (confidence interval, 1.64-1.90) times higher for patients who had a bleeding event (P < .001), thus resulting in a median increase in costs (in Australian dollars) of $33,338 (confidence interval, $21,943-$38,415). Several baseline characteristics were strongly associated with a bleeding event., Conclusions: The impact of a bleeding event on the cost of cardiac surgery is substantial. This study identified a set of risk factors for bleeding that could be used to identify patients for discussion at the heart team level, where measures to minimize the risk of transfusion may be initiated., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Cardiovascular disease is the leading cause of death worldwide, responsible for 17.5 million deaths every year, of which 80% occur in low- and middle-income countries. Some 75% of the world does not have access to cardiac surgery when needed because of lack of infrastructure, human resources, and financial coverage. This study aims to map access to cardiac surgery around the world., Methods: A scoping review was done on access to cardiac surgery for an undifferentiated population. Workforce data were collected from the Cardiothoracic Surgery Network database and used to calculate numbers and ratios of adult and pediatric cardiac surgeons to population., Results: A total of 12,180 adult cardiac surgeons and 3858 pediatric cardiac surgeons were listed in the Cardiothoracic Surgery Network in August 2017, equaling 1.64 (0-181.82) adult cardiac surgeons and 0.52 (0-25.97) pediatric cardiac surgeons per million population globally. Large disparities existed between regions, ranging from 0.12 adult cardiac surgeons and 0.08 pediatric cardiac surgeons per million population (sub-Saharan Africa) to 11.12 adult cardiac surgeons and 2.08 pediatric cardiac surgeons (North America). Low-income countries possessed 0.04 adult cardiac surgeons and 0.03 pediatric cardiac surgeons per million population, compared with 7.15 adult cardiac surgeons and 1.67 pediatric cardiac surgeons in high-income countries., Conclusions: This study maps the current global state of access to cardiac surgery. Disparities exist between and within world regions, with a positive correlation between a nation's economic status and access to cardiac surgery. Low early mortality rates in low-resource settings suggest the possibility of high-quality cardiac surgery in low- and middle-income countries. There is the need to increase human and physical resources, while focusing on safety, quality, and efficiency to improve access to cardiac surgery for the 4.5 billion people without., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Single ventricle congenital heart disease (SV CHD) patients are at risk of morbidity and mortality between the first and second palliative surgical procedures (interstage). When these patients present acutely they often require invasive intervention. This study sought to compare the outcomes and costs of elective and emergent invasive cardiac procedures for interstage patients. Retrospective review of discharge data from The Vizient Clinical Data Base/Resource Manager™, a national health care analytics platform. The database was queried for admissions from 10/2014 to 12/2017 for children 1-6 months old with ICD-9 or ICD-10 codes for SV CHD who underwent invasive cardiac procedures. Demographics, length of stay (LOS), complication rate, in-hospital mortality and direct costs were compared between elective and emergent admissions using t test or χ 2 , as appropriate. The three most frequently performed procedures were also compared. 871 admissions identified, with 141 (16%) emergent. Age of emergent admission was younger than elective (2.9 vs. 4 months p < 0.001). Emergent admissions including cardiac catheterization or superior cavo-pulmonary anastomosis had longer LOS (58.7 vs. 25.8 day, p < 0.001 and 54.8 vs .22.6 days, p < 0.001) and higher costs ($134,774 vs. $84,253, p = 0.013 and $158,679 vs. $81,899, p = 0.017). Emergent admissions for interstage SV CHD patients undergoing cardiac catheterization or superior cavo-pulmonary anastomosis are associated with longer LOS and higher direct costs, but with no differences in complications or mortality. These findings support aggressive interstage monitoring to minimize the need for emergent interventions for this fragile patient population.

Background: Recombinant factor VIIa (rFVIIa) (Novoseven®) is utilized for the reversal of anticoagulation-associated bleeding and refractory bleeding in cardiac surgery. In August 2015, rFVIIa was transferred from the blood bank to the pharmacy at New York University (NYU) Langone Health. Concordantly, an off-label dosing guideline was developed. The objective of this study was to describe utilization and cost of rFVIIa and assess compliance to our dosing guideline., Methods: We performed a retrospective, observational review of rFVIIa administrations post-implementation of an off-label dosing guideline. All patients who received rFVIIa between September 2015 and June 2017 were evaluated. For each rFVIIa administration, anticoagulation and laboratory values, indications for use, dosing, ordering and administration times, concomitant blood products, and adverse events were collected. Adverse events included venous thromboembolism, stroke, myocardial infarction, and death due to systemic embolism and mortality. The primary endpoint was the utilization of rFVIIa in accordance with the off-label dosing guideline. Secondary endpoints included hemostatic efficacy of rFVIIa, adverse events, blood products administered, and cost-effectiveness of rFVIIa transition to pharmacy., Results: A total of 63 patients [pediatric ( n  = 6), adult ( n  = 57)] received rFVIIa, with the majority of use for refractory bleeding after cardiac surgery. The utilization of rVIIa decreased after development of the off-label dosing guideline and transition from blood bank to pharmacy. The total incidence of thromboembolic events within 30 days was 19.6%; 17.6% arterial and 2% venous; 70% of patients with an adverse event were over 70 years of age. Use of rFVIIa reduced the median number of units of blood products administered., Conclusion: Administration of rFVIIa for cardiac surgery appears to be effective for hemostasis. Transitioning rFVIIa from the blood bank to pharmacy and implementation of a dosing guideline appears to have reduced utilization. Patients receiving rFVIIa should be monitored for thromboembolic events. Elderly patients may be at higher risk for thromboembolic events.

Purpose: This study examined postoperative heart failure (HF) and respiratory failure (RF) complications and related healthcare utilization for one year following cardiac surgery., Methods: This study identified adult patients undergoing isolated coronary artery bypass graft (CABG) and/or valve procedures from the Cerner Health Facts® database. It included patients experiencing postoperative HF or RF complications. We quantified healthcare utilization using the frequency of inpatient admissions, emergency department (ED) visits with or without hospital admission, and outpatient visits. We then determined direct hospital costs from the determined healthcare utilization. We analyzed trends over time for both HF and RF and evaluated the association between surgery type and HF complication., Results: Of 10,298 patients with HF complications, 1,714 patients (16.6%) developed persistent HF; of the 10,385 RF patients, 175 (1.7%) developed persistent RF. Healthcare utilization for those with persistent complications over the one-year period following index hospital discharge comprised an average number of the following visit types: Inpatient (1.49 HF; 1.55 RF), Outpatient (2.02, 0.51), ED without hospital admission (0.33, 0.13), ED + Inpatient (0.08, 0.06). Per patient annual costs related to persistent complications of HF and RF were $20,857 and $30,745, respectively. There was a significant association between cardiac surgical type and the incidence of HF, with risk for isolated valve procedures (adjusted OR 2.60; 95% CI: 2.35-2.88) and CABG + valve procedures (adjusted OR 2.38; 95% CI: 2.17-2.61) exceeding risk for isolated CABG procedures., Conclusions: This study demonstrates that HF and RF complication rates post cardiac surgery are substantial, and complication-related healthcare utilization over the first year following surgery results in significant incremental costs. Given the need for both payers and providers to focus on healthcare cost reduction, this study fills an important gap in quantifying the mid-term economic impact of postoperative cardiac surgical complications., Competing Interests: This work was supported financially by Edwards Lifesciences. MS is an employee of Edwards Lifesciences. ADS works as a consultant for Edwards Lifesciences. SHM works as a consultant and AVS, BLAG, XZ, and HOY as employees, for Boston Strategic Partners, Inc., who received funds from Edwards Lifesciences to perform the research. This does not alter our adherence to PLOS ONE policies on sharing data and materials. The data that support the findings of this study are available as the Cerner Health Facts® database from the Cerner Corporation, which is available to the public through licensure with Cerner Corporation.

Aims: The objective of the study is to evaluate the cost-effectiveness of percutaneous mitral valve repair (TMVr) with the MitraClip NT system (MitraClip procedure) for patients with symptomatic severe mitral regurgitation (MR) at high surgical risk in line with the methodological guideline for cost-effectiveness evaluation by the Ministry of Health, Labour and Welfare. Material and Methods: The cost-effectiveness of MitraClip procedure was evaluated using a Markov model. Patients are classified into four New York Heart Association classes in each cycle. The model considered MitraClip complication ("major vascular complication", "major bleeding complication", "non-cerebral thromboembolism"), adverse events, re-implantation with MitraClip device, mitral valve surgery, and congestive heart failure hospitalization. For the evidence on additional benefits, a study compared with propensity score-matched medical therapy group was used in the analysis. The analysis was conducted from the perspective of a public healthcare payer with a discount rate of 2% for both cost and effectiveness. Results: In the base-case analysis, total cost and quality-adjusted life year (QALY) gained (Life year (LY) gained) were 7,541,151 JPY and 3.23 QALYs (3.85 LYs) for MitraClip group, and 4,699,692 JPY and 1.79 QALYs (2.43 LYs) for medical therapy group, respectively. The incremental cost-effectiveness ratio (ICER) of MitraClip procedure versus medical therapy was 1.97 million JPY/QALY (US$18,570/QALY, US$1 = 106 JPY), which was evaluated to be cost-effective. The probability of ICER of MitraClip procedure versus medical therapy being 5 million JPY/QALY was 96.7%. Limitations: There are two limitations. Firstly, the parameters for the comparators were based on some assumptions. However, it was a conservative setting against MitraClip group. Secondary, the mortality rate and adverse events of MitraClip group in a lifetime were estimated from data during a year after the procedure. Conclusions: MitraClip procedure improved life-years and quality of life in patients at high surgical risk and it was also a cost-effective treatment option.

Pulmonary hypertension is one of the most challenging complications in congenital heart surgery. The purpose of this study was to characterize inhaled nitric oxide administration in children with and without pulmonary hypertension who underwent congenital heart surgery and to describe the effect of nitric oxide administration on admission outcomes. This is a cross-sectional study utilizing data from the Pediatric Health Information System (PHIS) and PHIS + databases from 2004 to 2015. Pediatric patients with a congenital heart disease diagnosis were included and divided into groups with pulmonary hypertension that received and not received inhaled nitric oxide and patients without diagnosis of pulmonary hypertension who received and did not receive inhaled nitric oxide. For all admissions, the following were captured: age of admission, gender, year of admission, length of stay, billed charges, inpatient mortality, the presence of specific congenital malformations of the heart, specific cardiac surgeries, and comorbidities. Comparisons between groups were completed using a Mann-Whitney-U test and Fisher's exact test. Outcomes evaluation was completed using univariate and regression analyses. A total of 40,194 pediatric cardiac surgical admissions without pulmonary hypertension were identified. Of these, 726 (1.8%) received inhaled nitric oxide. Regression analyses demonstrated that inhaled nitric oxide was independently associated with increased length of stay, billed charges, and inpatient mortality. A total of 1678 pediatric cardiac surgical admissions with pulmonary hypertension were identified. Of these, 195 (11.6%) received inhaled nitric oxide. Regression analyses demonstrated that inhaled nitric oxide was independently associated with a significant increase in length of stay and billed charges. There was no statistically significant association between inhaled nitric oxide and decrease mortality. Administration of inhaled nitric oxide after pediatric cardiac surgery increases length of stay and billed charges while not providing improved inpatient mortality. In fact, administration of inhaled nitric oxide was associated with increased mortality in those without pulmonary hypertension while not impacting mortality in any way in those with pulmonary hypertension.

Background: The cost of performing cardiac surgery in the public health system in Australia is unclear. This paper analyses the cost of cardiac surgery performed at Flinders Medical Centre (FMC), South Australia, comparing cost by procedure, rheumatic valvular heart disease status, Aboriginality and location., Methods: This study is a retrospective, population-based analysis of cardiac surgery data held in the Cardiac Surgery Registry cross-referenced to cost data provided by the FMC Department of Finance and Patient Travel, Accommodation and Transport Services at the Royal Darwin Hospital. Seven hundred ninety-five (795) patients who underwent cardiac surgery at FMC from 1 July 2014 to 30 June 2016 were included., Results: Across all procedures, Northern Territory (NT) Aboriginal patients had a mean total cost of $78,506 which was $24,113 more than NT non-Aboriginal, $28,443 more than South Australian (SA) Aboriginal and $22,955 more than SA non-Aboriginal patients. The total cost of a patient undergoing a repeat sternotomy (reoperative procedure) was found to be significantly higher than a primary procedure ($85,797 versus $59,097). In patients undergoing valve surgery procedures, those identified with rheumatic heart disease had a higher mean total cost than those without (a difference of $25,094). Significantly, the rheumatic patient group showed a higher proportion of reoperative procedures (19% versus 5%)., Conclusions: The cost of treating NT Aboriginal cardiac surgical patients remotely has a significant financial impact upon the health care delivery system, as does the impact of rheumatic heart disease. This study found that the cost for the NT Aboriginal patient group was substantially higher than the NT non-Aboriginal, SA Aboriginal and SA non-Aboriginal patient groups. The additional cost to family and dislocation of social structures is not able to be calculated, but would also clearly weigh heavily on both patient groups. These findings suggest that future health funding models should recognise Aboriginality, remoteness and rheumatic heart disease., (Crown Copyright © 2018. Published by Elsevier B.V. All rights reserved.)

Objective: Management of chest tubes in adult and pediatric patients is highly variable. There are no published guidelines for pediatric cardiac surgical patients. Our center undertook a quality improvement project aimed at reducing chest tube duration and length of stay in postsurgical pediatric cardiac patients., Methods: A work group identified 2 opportunities for reducing chest tube duration: standardizing removal criteria and increasing frequency of assessment for removal. An algorithm was created, and chest tube assessments were increased to twice daily. All postsurgical cardiac patients were managed according to the algorithm. Outcome measure reporting was limited to patients age 1 month to 18 years with a biventricular surgical procedure. Outcome measures included chest tube duration, cardiac intensive care unit and hospital length of stay, and cost of hospitalization. Process measure was documentation of chest tube assessments. The balancing measure was chest tube reinsertions., Results: Between April 2016 and July 2018, 126 patients aged 1 month to 18 years underwent a biventricular surgical procedure. Mean chest tube duration decreased from 61 to 47 hours. Cardiac intensive care unit length of stay decreased from 141 hours to 89 hours, hospital length of stay decreased from 266 to 156 hours, and average hospitalization cost decreased from $75,881 to $48,118. There was no increase in chest tube reinsertions., Conclusions: Implementation of a chest tube removal algorithm for pediatric cardiac surgery patients resulted in decreased chest tube duration and was associated with decreased length of stay and costs without an increase in reinsertions. More significant impact may be attainable with more aggressive approach to removal., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Children with Down syndrome (DS) often have congenital heart disease that requires surgical repair in the first year. Anecdotally, we have noted that patients with DS seem to have a higher rate of culture-negative postoperative fever. The objective was to evaluate the prevalence of postoperative fever and recovery among patients with DS undergoing cardiac surgery., Methods: We conducted a retrospective, case-control study of all patients at our institution less than one year of age with DS undergoing surgical repair of an atrioventricular septal defect or ventricular septal defect between 2010 and 2016. The control group was patients with no chromosomal anomalies who were age and surgery matched to the DS group. Temperatures were recorded for the first 72 hours postoperatively, with duration and degree of fever being assessed using the area under the curve., Results: Patients with DS (n = 34) had a significantly higher prevalence of fever than the control group (59% vs 24%, P = .003), longer ventilator time, and longer length of stay. Among the DS group, those who developed fever tended to be older at the time of surgery (146 ± 63 vs 103 ± 45 days, P = .04). The DS group with fever had similar cardiopulmonary bypass times, intensive care unit and total lengths of stay, ventilator days, and hospital costs compared to patients with DS without fever., Conclusions: Patients with DS have a higher incidence of culture-negative fever within the first 72 hours. The presence of fever in these patients, however, does not affect their overall postoperative course.

Background: The aim of this study was to identify hospital-level predictors of increased cost following index adult cardiac operations in a statewide registry., Methods: The Pennsylvania Health Care Cost Containment Council (PHC4) database was queried for isolated coronary artery bypass grafting (CABG), isolated valve surgery, or CABG plus valve surgery performed between 2014 and 2016. Charge-to-cost ratios for each individual hospital were used to estimate cost. Expected (predicted) operative mortality and 30-day readmission were evaluated using multivariable risk models and linear regression analysis was utilized to evaluate the risk-adjusted impact of multiple hospital-level characteristics on costs., Results: During the study period, 29 578 patients underwent isolated CABG (n = 16,641), isolated valve surgery (n = 8618), or CABG plus valve surgery (n = 4319) at 60 hospitals. The median cost of CABG was $61 573 (interquartile range [IQR] $50 780 to $77 482). The median cost of isolated valve surgery was $68,835 (IQR $56 039 to $89 465) and CABG plus valve surgery $83 574 (IQR $69 806 to $114 407). Hospital-level predictors of increasing costs in isolated CABG included higher predicted mortality rates, higher observed-to-expected (OE) mortality ratios, and nonteaching status. No hospital-level independent predictors of increased costs were identified for isolated valve or CABG plus valve surgery., Conclusions: Hospitals that performed higher risk cases and had higher OE ratios for operative mortality in isolated CABG were found to have increased costs. These data collectively suggest that attention to risk assessment and outcome optimization efforts in isolated CABG would likely result in programmatic advantages not only from a clinical standpoint but also economic., (© 2019 Wiley Periodicals, Inc.)

Objective: Regionalization directs patients to high-volume hospitals for specialized care. We investigated regionalization trends and outcomes in pediatric cardiac surgery., Data Sources/study Setting: Statewide inpatient data from eleven states between 2000 and 2012., Study Design: Mortality, length of stay (LOS), and cost were assessed using multivariable hierarchical regression with state and year fixed effects. Primary predictor was hospital case-volume, categorized into low-, medium-, and high-volume tertiles., Data Collection/extraction Methods: We used Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) to select pediatric cardiac surgery discharges., Principal Findings: In total, 2841 (8.5 percent), 8348 (25.1 percent), and 22 099 (66.4 percent) patients underwent heart surgeries in low-, medium-, and high-volume hospitals. Mortality decreased over time, but remained higher in low- and medium-volume hospitals. High-volume hospitals had lower odds of mortality and cost than low-volume hospitals (odds ratio [OR] 0.59, P < 0.01, and relative risk [RR] 0.91, P < 0.01, respectively). LOS was longer for high- and medium-volume hospitals, compared to low-volume hospitals (high-volume: RR 1.18, P < 0.01; medium-volume: RR 1.05, P < 0.01)., Conclusions: Regionalization reduced mortality and cost, indicating fewer complications, but paradoxically increased LOS. Further research is needed to explore the full impact on health care utilization., (© Health Research and Educational Trust.)

Background Recent publications reached conflicting conclusions about the cost-effectiveness of left atrial appendage closure (LAAC) with the Watchman device (Boston Scientific, Marlborough, MA) for stroke risk reduction in nonvalvular atrial fibrillation (AF). This analysis sought to assess the cost-effectiveness of LAAC relative to both warfarin and nonwarfarin oral anticoagulants (NOACs) using pooled, long-term data from the randomized PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) and PREVAIL (Prospective Randomized Evaluation of the Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long-Term Warfarin) trials. Methods and Results A Markov model was constructed from a US payer perspective with a lifetime (20-year) horizon. LAAC clinical event rates and stroke outcomes were from pooled PROTECT AF and PREVAIL trial 5-year data. Warfarin and NOAC inputs were derived from published meta-analyses. The model was populated with a cohort of 10 000 patients, aged 70 years, at moderate stroke and bleeding risk. Sensitivity analyses were performed. LAAC was cost-effective relative to warfarin by year 7 ($48 674/quality-adjusted life-year) and dominant (more effective and less costly) by year 10. LAAC became cost-effective and dominant compared with NOACs by year 5. Over a lifetime, LAAC provided 0.60 more quality-adjusted life-years than warfarin and 0.29 more than NOACs. In sensitivity analyses, LAAC was cost-effective relative to warfarin and NOACs in 98% and 95% of simulations, respectively. Conclusions Using pooled, 5-year PROTECT AF and PREVAIL trial data, LAAC proved to be not only cost-effective, but cost saving relative to warfarin and NOACs. LAAC with the Watchman device is an economically viable stroke risk reduction strategy for patients with AF seeking an alternative to lifelong anticoagulation.

There has been tremendous evolution in the care of cardiac surgical patients in 2018. In this article, 4 topics of considerable impact on cardiac surgical care in the current landscape are reviewed based on recent publications. The first topic reviews the recent paradigm shift to value-based payments and the potential role of bundled payments on health care and physician reimbursement. The second topic highlights the impact of the opioid crisis on cardiac surgery. The third topic demonstrates the increasing utilization and expanding role of novel percutaneous suction thrombectomy technique in the extraction of caval and right-sided intracardiac thrombi and vegetations with veno-venous bypass. The final topic reviews the current trend of minimally invasive left ventricular assist device placement. Each of these topics addresses the contemporary issues in cardiac surgery with the reasoning for evolution in our current practices in 2018.

Background The contemporary incidence of and reasons for early readmission after infective endocarditis ( IE ) are not well known. Therefore, we analyzed 30-day readmission demographics after IE from the US Nationwide Readmission Database. Methods and Results We examined the 2010 to 2014 Nationwide Readmission Database to identify index admissions for a primary diagnosis of IE with survival at discharge. Incidence, reasons, and independent predictors of 30-day unplanned readmissions were analyzed. In total, 11 217 patients (24.8%) were nonelectively readmitted within 30 days among the 45 214 index admissions discharged after IE . The most common causes of readmission were IE (20.5%), sepsis (8.7%), complications of device/graft (8.1%), and congestive heart failure (7.6%). In-hospital mortality and the valvular surgery rates during the readmissions were 8.1% and 9.1%, respectively. Discharge to home or self-care, undergoing valvular surgery, aged ≥60 years, and having private insurance were independently associated with lower rates of 30-day readmission. Length of stay of ≥10 days, congestive heart failure, diabetes mellitus, renal failure, chronic pulmonary disease, peripheral artery disease, and depression were associated with higher risk. The total hospital costs of readmission were $48.7 million per year (median, $11 267; interquartile range, $6021-$25 073), which accounted for 38.6% of the total episodes of care (index+readmission). Conclusions Almost 1 in 4 patients was readmitted within 30 days of admission for IE . The most common reasons were IE , other infectious causes, and cardiac causes. A multidisciplinary approach to determine the surgical indications and close monitoring are necessary to improve outcomes and reduce complications in in-hospital and postdischarge settings.