Advising complex patients who require complex heart operations

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Presentation transcript:

Advising complex patients who require complex heart operations Gösta B. Pettersson, MD, PhD, Derlis Martino, MD, Eugene H. Blackstone, MD, Edward R. Nowicki, MD, MS, Penny L. Houghtaling, MS, Joseph F. Sabik, MD, Bruce W. Lytle, MD The Journal of Thoracic and Cardiovascular Surgery Volume 145, Issue 5, Pages 1159-1169.e3 (May 2013) DOI: 10.1016/j.jtcvs.2012.11.035 Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Evolution of patient complexity. Each circle represents a 1-year average (mean for continuous variables and percentage for categorical variables). A, Age. B, Female gender. C, Treated diabetes mellitus and body mass index (BMI). D, Patients in New York Heart Association (NYHA) functional classes III and IV. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Evolution of surgical complexity. A, Surgical complexity illustrated as percentage of patients undergoing operations with 1 (filled circles), 2 (open circles), 3 (triangles), or ≥ 4 (squares) components. B, Percentage of patients undergoing isolated coronary artery bypass grafting (CABG) or CABG plus other components (CABG+). C, Percentage of patients undergoing procedures for which risk adjustment equations have been developed by the Society of Thoracic Surgeons (STS) and those more complex than these (Other). The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Prevalence of multicomponent operations (≥2 components, filled circles) and percent hospital mortality (open circles). The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Receiver–operator curves for logistic regression analysis of patient (short-dash line) and surgical complexity (long-dash line). The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Bubble plot of predicted risk of hospital mortality calculated by isolated surgical components versus surgical groups. Bubbles distant from line of identity (outliers) represent important interactions. The size of each bubble represents size of the surgical group, with the largest being isolated coronary artery bypass grafting. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 6 Predicted decline in hospital mortality for different patient risk profiles. A, For a fixed preoperative patient risk profile of 0.05, predicted mortality for 1-, 2-, and 4-component operations. B, For a preoperative patient risk profile of 0.30, predicted mortality for 1-, 2-, and 4-component operations. C, For a range of preoperative patient risk profiles, mortality for a 4-component operation. D, Univariable effect of aortic clamp time for 4 eras. CABG, Coronary artery bypass grafting; MV, mitral valve surgery; AV, aortic valve surgery; TV, tricuspid valve surgery. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 7 Contemporary complexity: Distribution of patient comorbidities. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 8 Contemporary complexity and hospital mortality. A, Hospital mortality according to number of comorbidities (patient complexity). B, Hospital mortality according to number of surgical components (surgical complexity). The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 9 Nomogram for hospital mortality according to number of comorbidities for patients undergoing 1-, 2-, 3-, or ≥4-component operations. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 10 Hospital mortality according to number of surgical components for operations including (A) coronary artery bypass grafting (CABG), (B) aortic valve procedure (AV), (C) mitral valve procedure (MV), or (D) aortic root, ascending aorta, or arch procedure. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 11 Survival after cardiac operations. Symbols at yearly intervals are Kaplan-Meier estimates accompanied by vertical bars representing asymmetric confidence limits equivalent to ±1 standard error. Solid lines within dashed confidence bands represent parametric estimates. A, Unadjusted mortality stratified by the number of patient comorbidities (0-1, 2, 3-4, 5-6, 7-8, or ≥9; because of the small number of events in the 0-1 group, there are no parametric estimates). B, Unadjusted mortality stratified by the number of surgical components (1, 2, 3, 4, or ≥5). The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions

Figure 12 Percentage of patients in each patient complexity group (as demonstrated by number of comorbidities) undergoing 1-, 2-, 3-, 4-, or ≥5-component operations. The Journal of Thoracic and Cardiovascular Surgery 2013 145, 1159-1169.e3DOI: (10.1016/j.jtcvs.2012.11.035) Copyright © 2013 The American Association for Thoracic Surgery Terms and Conditions