47.14 Decision Making in Advanced Surgical Illness: The Surgeons Perspective in Shared Decision Making

Posted on January 18, 2018

R. S. Morris1, J. Ruck2, A. Conca-Cheng2, T. Smith2, T. Carver1, F. Johnston2  1Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA 2Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction:  While surgical patients increasingly have more comorbid disorders and older age, surgeons face difficult decisions in emergent situations. Little is known about surgeon perceptions on the shared decision making process in these urgent settings.

Methods:  Twenty semi-structured interviews were conducted with practicing surgeons at two large academic medical centers. Thirteen questions and two case vignettes were used to assess participant perceptions, considerations when deciding to offer surgery and communication patterns with patients and families.

Results:Thematic analysis revealed six major themes and numerous subthemes related to end-of-life decision-making for critically ill patients: responsibility for the decision to operate, futility, surgeon judgment, surgeon introspection, pressure to operate and costs of surgery. Futility was universally reported as a contraindication to surgical intervention. However, an inability to definitively declare futility led some participants to emphasize patient self-determined risk-benefit analysis to determine whether to proceed with surgical intervention. Other participants who felt their gestalt about futility was reliable described greater comfort communicating to a patient that their condition was not amenable to surgery and reserved the right to refuse surgical intervention. Most participants desire objective metrics to determine risk and futility in order to more clearly communicate with patients and families, and perhaps temper the pressure to operate from external sources. 

Conclusion:Due to external pressures and uncertainty, some providers err on the side of continuing care despite suspected futility. Surgeons with greater experience and those who report more institutional support of their decisions are often more able to withstand external pressures, feel confident in their assessments of futility, and guide patients and their families away from futile interventions. Greater support from colleagues, institutional culture, research literature, and objective measures of futility can support surgeons in shared decision making and providing the best care for their patients. 

 

46.20 Parathyroidectomy in Primary vs Secondary/Tertiary Hyperparathyroidism Patients: Different Outcomes?

Posted on January 18, 2018

S. K. Chung1, A. A. Asban1, C. Balentine1, H. Chen1  1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA

Introduction:
Surgical treatment is the definitive therapy for primary, secondary and tertiary hyperparathyroidism (HPT). However, each type of hyperparathyroidism has a different etiology and differing patient populations. We hypothesize that despite these differences, parathyroidectomy is equally effective in treating all types of HPT and result in similar outcomes.

Methods:
We retrospectively reviewed the records of patients with primary, secondary or tertiary HPT referred for parathyroidectomy to one surgeon at a tertiary care center between November 2015 and June 2017. We used Chi Square test for categorical variables and Student T-test for difference between means to identify differences between the two groups.

Results:
We identified 221 patients with primary (181, 82%), or secondary/tertiary HPT (40, 18%) who underwent parathyroidectomy. The mean ages for patients with primary and secondary/tertiary HPT were 60 years (SD 13.6 ) and 52.5 years (SD 11.7), respectively (p<0.001). There was a statistically significant difference in gender: 79% females with primary HPT and 53% females with secondary/tertiary HPT (p=0.001). Racial distribution was also significantly different (p=0.001) with 16% African Americans with primary HPT and 45% African Americans with secondary/tertiary HPT. High cure rates with no statistical difference (p=0.49) were seen between the two groups: 99% for primary HPT and 97% for secondary/tertiary HPT. There was no statistically significant difference between groups in length of stay (0.2 days), rates of transient or permanent hoarseness, transient or permanent hypocalcemia, or wound complications.

Conclusion:
Despite the difference in comorbidities and pathology in patients with primary versus secondary/tertiary HPT, there were no differences in cure rate, complications, or hospital length of stay. Patients with all types of HPT can be managed with outpatient parathyroidectomy.
 

46.15 Incidental Thyroid Carcinoma in Patients Undergoing Surgery for Benign Thyroid Disease

Posted on January 18, 2018

M. Manasa1, O. Picado1, M. L. Mao1, R. Minami1, J. C. Farra1, J. I. Lew1  1University Of Miami Leonard M. Miller School Of Medicine,Division Of Endocrine Surgery, DeWitt Daughtry Family, Department Of Surgery,Miami, FL, USA

Introduction: Patients with benign thyroid disease undergo thyroidectomy for a variety of reasons including compressive symptoms, hyperthyroidism and cosmesis. Although patients are referred for benign disease, underlying thyroid malignancy may be incidentally discovered on final pathology. This study examines the association between benign indication for thyroid surgery and incidental thyroid cancer.

Methods: A retrospective review of 1,040 patients undergoing thyroid surgery at a tertiary referral center was performed. Surgical indications for benign thyroid disease (n=357) included compressive symptoms, hyperthyroidism, goiter size >4 cm, substernal goiter, cosmesis, and patient preference. A dominant or “index” thyroid nodule was defined as a nodule >1 cm or the largest/most suspicious thyroid nodule in a multinodular goiter (MNG). An “incidental” thyroid carcinoma was defined as any cancer incidentally discovered outside the index nodule. Patients with previous thyroid surgery, indeterminate or malignant preoperative FNA results were excluded.

Results: Of 916 patients who underwent thyroidectomy, 559 were referred for malignancy and 357 for benign disease. Patients with benign disease were referred most commonly for non-toxic MNG (n=223, 63%) followed by Graves’ disease (n=46, 13%), non-toxic solitary nodule (n=40, 11%), toxic MNG (n=32, 9%), and substernal goiter (n=16, 4%). Final pathology demonstrated incidental thyroid carcinoma in 97 patients (27%): 39 (40%) had a malignant index nodule, 36 (37%) had incidental thyroid carcinoma, and 23 (23%) had both index and incidental malignancy. The median size of malignant index nodules was 2 cm (range: 0.1-6 cm) and the median size of incidental carcinomas was 0.4 cm (range: 0.1-5.8 cm). Lymphovascular invasion was present in 20% (19/97) and extrathyroidal extension was present in 8% (8/97) of patients. Patients with non-toxic solitary nodule (n=18, 45%) most commonly had incidental carcinoma followed by non-toxic MNG (n=69, 31%), substernal goiter (n=4, 25%), toxic MNG (n=5, 16%) and Graves’ disease (n=4, 9%). The most common malignancy found on final pathology was papillary thyroid carcinoma (PTC, n=93, 96%) followed by follicular (n=2, 2%), medullary (n=1, 1%), and anaplastic (n=1, 1%) thyroid cancer. The majority of PTC were follicular variant (n=69, 74%) followed by classical (n=20, 22%), tall cell (n=2, 2%), and diffuse sclerosing (n=2, 2%) variants.

Conclusion: Patients undergoing surgery for benign thyroid disease have significant rates of occult malignancy on final pathology. Despite these high rates of underlying malignancy, the majority of these tumors are low risk thyroid malignancies based on American Thyroid Association risk stratification and thus do not warrant further extensive surgical or clinical management. Nevertheless, careful evaluation and counseling by a surgeon may be necessary in managing patients with benign thyroid disease.

46.13 Factors Affecting Readmission Following Pediatric Thyroid Resection: A NSQIP-P Evaluation

Posted on January 18, 2018

I. I. Maizlin1, H. Chen2, R. T. Russell1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,General Surgery,Birmingham, Alabama, USA

Introduction: Thyroid neoplasms are among the most common endocrine pathologies in the pediatric population and their incidence has increased over the last several decades. Many of these conditions require surgical resection. We aimed to determine pre-operative and intraoperative factors that affect unplanned post-operative readmission (UPOR) among pediatric patients undergoing thyroidectomy.

Methods: Utilizing the 2015 NSQIP-P Public-Use-File (first year to include these procedures), pediatric thyroidectomy patients were collated. We evaluated demographics, comorbidities, peri-operative variables and post-operative morbidities, performing a multivariate analysis comparing individuals that required UPOR within 30 days of surgery to those that did not.

Results: 658 pediatric thyroidectomies were identified, of whom 2.6% required UPOR. Following multivariate analysis, male gender (3.7%, p=0.027), African American race (5.7%, p=0.038) and pre-operative inpatient status (3.1%, p=0.015) were associated with increased rates of UPOR. Patients with thyroiditis were significantly more likely to have UPOR (4.4%, p=0.023). Similarly, higher UPOR rates were seen in patients with a history of asthma (8.3%, p=0.030), cardiac comorbidities (7.1%, p=0.001), developmental delay (3.6%, p=0.047) and hematological disorders (9.1%, p=0.021).  In addition, figure 1 demonstrates that patients operated by general surgeons had a lower rate of UPOR (0.5%) when compared to otolaryngology surgeons (4.3%) (p=0.019), as well as lower rates of surgical site infections (p=0.041) and shorter operative times (p<0.001).

Conclusion: The number of children readmitted after thyroid surgery is low.  Several factors, however, including underlying etiology of thyroid disease and surgeon subspecialty, highly determine the rate of unplanned post-operative readmission after thyroid surgery in children. 

 

46.12 Influence of Concurrent Thyroid Pathology on Parathyroidectomy for Primary Hyperparathyroidism

Posted on January 18, 2018

B. Sunkara1, M. Cohen2, B. Miller2, P. Gauger2, D. Hughes2  1University Of Michigan,Medical School,Ann Arbor, MI, USA 2University Of Michigan,Department Of General Surgery,Ann Arbor, MI, USA

Introduction: The influence of concurrent thyroid pathology on parathyroidectomy for primary hyperparathyroidism (PHPT) has not been established. The hypothesis of this study is that concurrence of thyroid pathology and PHPT will influence various factors in parathyroidectomy. 

Methods: This is retrospective cohort study of consecutive parathyroidectomy patients for PHPT. Patients were stratified according to presence or absence of thyroid pathology and then analyzed for effect of specific thyroid pathology on preoperative imaging, intraoperative factors and outcomes of parathyroidectomy. 

Results: Of the 1001 patients:  534 (53.4%) had no thyroid pathology, 266 (26.6%) had thyroid nodules, 240 (24.0%) had hypothyroidism, 83 (8.3%) had Hashimoto’s thyroiditis, 39 (3.9 %) had previous thyroid surgery, and 21 (2.1%) had thyroid cancer (some had >1 pathology). The presence of thyroid pathology did not significantly influence intraoperative PTH results or rates of persistent PHPT.   The localization accuracy of ultrasound was greater than sestamibi when any thyroid pathology was present (63% vs 50%; p<0.02).  Sestamibi was used more frequently in patients with history of thyroidectomy (74% vs 56%; p=0.03) and hypothyroidism (68% vs 56%; p<0.02); however sestamibi was least accurate when hypothyroidism was present (41% vs 52%; p=0.03). Patients without thyroid pathology had a higher rate of successful focused parathyroidectomy (63%) compared to patients with hypothyroidism (53%; p<0.02) and nodules (48%; p<0.02).  A bilateral exploration (planned or converted) was performed in 37% of patients without thyroid pathology compared to hypothyroidism (47%; p<0.02), Hashimoto’s (48%; p=0.04) and thyroid nodules (51%; p<0.02). The correlation between thyroid pathology and the total weight of the excised glands is less pronounced with the only significant difference being found in the group with a history of thyroid cancer (0.485gm vs no pathology 0.845gm; p<0.02). 

Conclusion: Concurrent thyroid pathology influences use and accuracy of preoperative imaging for PHPT as well as the need for bilateral exploration, but does not affect the overall success rates of parathyroidectomy. 

 

46.09 Timely Evaluation and Management of Primary Hyperparathyroidism in Patients with Kidney Stones

Posted on January 18, 2018

A. A. Perez1, D. F. Schneider1, S. C. Pitt1, K. L. Long1, A. Chu1, R. S. Sippel1  1University Of Wisconsin,Endocrine Surgery,Madison, WI, USA

Introduction:

Kidney stones are a common manifestation of primary hyperparathyroidism (PHPT), and a strong indicator for surgical treatment of PHPT. Effective detection and treatment of PHPT is critical for managing the risk of recurrent stone disease and other complications of unmanaged PHPT. In this study, we examined predictors of kidney stones in PHPT patients and determined how effectively the diagnosis of PHPT is made in patients who first present with stones.

Methods:

We performed a retrospective analysis of surgically treated PHPT patients, comparing 247 patients who were kidney stone-formers (SF) and 1,047 patients with no stones (NS). We identified 51 SF patients who presented with a stone before their PHPT diagnosis, and whose stone evaluation and treatment was completed entirely within our health system for further analysis. Extracted data included clinical assessment and treatment of stones as well as timing of PHPT evaluation.

Results:

Compared to NS patients, SF patients were more likely to be male (28.6% vs 19.7%, p=0.002) and to be normocalcemic (26.6% vs. 16.9%, p=0.001) than the NS patients. SF patients also had higher alkaline phosphatase (92 IU/L vs. 85 IU/L, p=0.012) and higher 24-hour urinary calcium levels (342 mg/day vs 304 mg/day, p=0.005). On multivariate analysis, being male and having a higher 24-hour urine calcium and alkaline phosphatase were independently associated with a greater incidence of kidney stone formation. Despite these differences, 52.7% of SF had 24-hour urinary calcium levels within the normal range at the time of surgery. Of the 51 SF patients with full chart available for review, 72.5% (n=37) had a serum calcium drawn within 6 months of the first stone episode. Hypercalcemia was present in 43.2% of these patients (n=16), but only 10 (62.5%) of these patients had a serum PTH ordered within 3 months of their elevated calcium. Patients that had both a calcium and PTH drawn within 9 months of their first episode of kidney stones had a significantly shorter time from their first stone to surgical treatment than the other patients (median 8.5 months vs. 49.1 months, p=0.001).

Conclusion:

SF patients were found to be stronger excreters of calcium, but elevated urinary calcium and serum alkaline phosphatase levels did not identify the majority of PHPT patients at risk of forming kidney stones. Many patients with kidney stones had normal serum calcium levels and normal urinary calcium levels highlighting the need to carefully evaluate all SF for the possible treatable cause of hyperparathyroidism. Timely consideration of PHPT as well as prompt serum calcium and PTH evaluation significantly reduces time to treatment and minimize the risks of complications of longstanding PHPT.

46.10 Hypervascular Pancreatic Lesions: Neuroendocrine Tumor Cannot Be Assumed

Posted on January 18, 2018

S. M. Wcislak1, Z. E. Stiles1, J. L. Deneve1, E. S. Glazer1, S. W. Behrman1, M. Ismail2, F. T. Farees3, P. V. Dickson1  1University Of Tennessee Health Science Center,Division Of Surgical Oncology, Department Of Surgery,Memphis, TN, USA 2University Of Tennessee Health Science Center,Division Of Gastroenterology, Department Of Medicine,Memphis, TN, USA 3Gastro One,Gasteroenterology,Memphis, TN, USA

Introduction: Although pancreatic neuroendocrine tumors (PNETs) typically have a solid, hypervascular appearance on contrast-enhanced imaging, other non-PNET lesions may have a similar appearance.  Preoperative recognition of non-PNET diagnoses may alter further staging and treatment plans.

Methods:  Patients from our institutional pancreatic surgery database who underwent pancreatectomy for suspected PNET were identified.  Demographics as well as results of pre-operative contrast-enhanced CT and/or MRI, endoscopic ultrasound-fine needle aspiration (EUS-FNA), and pathology data were collected.  Patients with documented distant metastases, functional tumors, and hereditary PNET syndromes were excluded.

Results:  From 2007-2017, 55 patients with pre-operative contrast-enhanced CT and/or MRI had pancreatectomy for a suspected diagnosis of sporadic, localized, non-functional PNET.  Final pathology revealed PNET in 42 (76%) and a non-PNET diagnosis in 13 (24%).  Of patients with a diagnosis of PNET, the lesion on CT/MRI was solid in 31 (74%) and cystic in 11 (26%).  Solid PNETs were hypervascular in 26 (84%), hypodense in 4 (13%), and isodense in 1(3%) on contrast-enhanced imaging.  Hypervascular solid lesions were appreciated in 13 non-PNET patients with a final diagnosis of intrapancreatic splenule (4), metastatic renal cell carcinoma (2), solid pseudopapillary tumor (2), serous cystadenoma (1), duodenal GIST (1), adenocarcinoma (1), focal pancreatitis (1), and no tumor present (1). There were no significant differences in age, gender, race, tumor size, tumor location, pancreatic or biliary duct dilation, or contrast enhancement patterns (homogenous vs heterogeneous) between patients with PNET vs non-PNET diagnoses.  Patients with a non-PNET diagnosis on final pathology were significantly less likely to have undergone EUS-FNA than patients with a final diagnosis of PNET (15% vs 79%, p<0.001).  EUS-FNA was found to have a sensitivity of 79%.  Accurate pre-operative diagnosis would have spared pancreatectomy in 7(13%) patients with benign pathology and may have altered the staging or preoperative treatment plan in 4(7%) with non-PNET malignancies.

Conclusion:  Although typically hypervascular, PNETs may appear isodense, hypodense, or cystic on contrast-enhanced imaging.  Importantly, a number of other benign and malignant non-PNET diagnoses may have a solid, hypervascular appearance.  EUS-FNA and additional diagnostic modalities should be routinely performed to confirm a diagnosis prior to pancreatectomy. 

 

46.11 High Rate of Incidental Thyroid Carcinoma found in Contralateral Thyroid Lobes

Posted on January 18, 2018

R. Minami1, O. Picado1, M. Mao1, M. Manasa1, J. Lew1, J. C. Farrá1  1University Of Miami Leonard M. Miller School Of Medicine,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Background: Current American Thyroid Association (ATA) guidelines recommend thyroid lobectomy (TL) alone for low risk papillary thyroid carcinomas up to 4cm. This represents a paradigm shift from completion thyroidectomy (CT) to allow for radioactive iodine ablation and use of thyroglobulin levels for surveillance. However, little data is available on rates of incidental and multifocal malignancy in contralateral thyroid lobes and its clinical significance. This study examines the rate of underlying malignancy in index thyroid nodules and incidental cancers in contralateral lobes of patients who undergo initial or staged total thyroidectomy (TT).

Method: A retrospective review of 1048 patients who underwent thyroidectomy at a single institution from 2010-2017 was performed. An “index” thyroid nodule was defined as either a solitary nodule >1 cm or the largest/most suspicious nodule in a multinodular goiter. An “incidental” thyroid cancer was defined as incidentally discovered outside of the index nodule. CT was performed at least 3 months after initial lobectomy. In patients with staged TT, pathology reports were reviewed for cancer in TL and correlated to reports from subsequent CT. Overall rate of malignancy in index thyroid nodules was determined and rates of incidental carcinoma within the contralateral lobe to the index nodule were established.

Results: Of 1048 patients who underwent thyroidectomy, 567 (54%) had malignant index thyroid nodules. Of patients with malignant index nodules, 35% (196/567) had incidental cancers on the contralateral lobe. In these patients the breakdown of pathology for the index nodule was as follows: 91% papillary thyroid cancer (n=179), 6% follicular thyroid cancer (n=11) 2% medullary thyroid cancer (n=4) 1% microcarcinoma (n=2). Lymphovascular invasion was found in 36% (70/196) of these patients, extrathyroidal extension in 15% (30/196), and multifocality in 58% (114/196). Initial total thyroidectomy was performed in 470 (83%) of patients with thyroid cancer: 60% (283/470) had a malignant index nodule only and 28% (131/470) had incidental carcinoma in the contralateral lobe to the index malignancy. Initial thyroid lobectomy was performed in 97 (17%) of patients with thyroid cancer, of which 66 underwent CT and 98% (65/66) had an incidental cancer in the contralateral lobe on final pathology.

Conclusion: There is a clinically significant rate of malignancy in the contralateral lobes of index malignant thyroid nodules in both patients who undergo initial and staged TT. Although current ATA guidelines recommend no further surgery for patients who undergo TL with thyroid cancer, the long-term significance of these remaining multifocal microcarcinomas in retained contralateral lobes remains unknown, and further active surveillance and evaluation is warranted.

46.06 An Additional 20 Minute ioPTH Measurement Minimizes Bilateral Neck Exploration

Posted on January 18, 2018

Z. F. Khan1, R. Teo1, M. L. Mao1, J. C. Farrá1, J. I. Lew1  1University Of Miami,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery, University Of Miami Leonard M. Miller School Of Medicine,Miami, FL, USA

Introduction:
Parathyroidectomy (PTX) guided by intraoperative parathormone (ioPTH) monitoring for primary hyperparathyroidism (pHPT) confirms removal of all hyperfunctioning parathyroid glands. A >50% ioPTH drop criterion at 10 minutes after abnormal parathyroid gland excision predicts operative success in 98% of patients. However, ioPTH levels may be influenced by gland manipulation and PTH half-life variability between patients. This study evaluates the utility of an additional 20 minute ioPTH measurement when a 10 minute value has not dropped by >50% during PTX in patients with pHPT.

Methods:
A retrospective review of prospectively collected data of 739 patients with pHPT confirmed by elevated serum calcium and PTH levels who underwent ioPTH monitoring guided PTX at a single institution was performed. When a >50% ioPTH drop from the highest either pre-incision or pre-excision level was achieved after 10 minutes, PTX was completed. If this >50% ioPTH drop criterion was not met, however, bilateral neck exploration (BNE) was performed, or an additional 20 minute ioPTH measurement was obtained. Operative success was defined as eucalcemia ≥6 months whereas recurrence was defined as calcium and PTH levels above normal range >6 months after successful PTX. Multiglandular disease (MGD) was defined as persistently elevated PTH and calcium levels despite removal of one hypersecreting gland at the initial operation, or when removal of a single gland resulted in operative failure.

Results:
Of 739 patients with a mean follow up of 41 months, overall operative success was 98.5% with a recurrence rate of 1.1%. Within this group, 79 (11%) patients did not meet the >50% ioPTH drop at 10 minutes criterion. Of these patients, 63% (50/79) patients underwent immediate further exploration, while a 20 minute ioPTH measurement was drawn in 37% (29/79). There were no significant differences in preoperative calcium, PTH or creatinine in these two groups. Of patients with a 20 minute ioPTH level with no further exploration, 38% (11/29) had a >50% ioPTH drop at 20 minutes, and 62% (18/29) did not. There were no significant differences between operative success, failure, recurrence or MGD between patients who had a 20 minute ioPTH measurement and those who underwent immediate further exploration. Of the 79 patients that did not meet the >50% ioPTH drop criterion at 10 minutes, there was a statistically significant lower rate of BNE in the group with a 20 minute ioPTH level measured compared to the group that underwent immediate further exploration (38% 11/29 vs. 64% 32/50, p<0.05). By obtaining a 20 minute ioPTH level, BNE was avoided in 38% (11/29) of patients that had a ≤50% ioPTH drop at 10 minutes. 

Conclusion:
A 20 minute ioPTH measurement is useful in preventing unnecessary BNE and its associated risk for complications in patients with a delayed >50% ioPTH drop due to parathyroid gland manipulation and PTH half-life variability during PTX. 
 

46.08 Gene Expression Classification has Limited Utility in the Evaluation of AUS/FLUS Thyroid Nodules

Posted on January 18, 2018

K. D. Klingbeil1, R. L. Deitz1, M. L. Mao1, J. C. Farrá1, J. I. Lew1  1University Of Miami Miller School Of Medicine,Division Of Endocrine Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA

Introduction: The current management for thyroid nodules remains a challenge for physicians due to the underlying risk of malignancy. With the Bethesda System for Reporting Thyroid Cytopathology (BSRTC), atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS), known as Bethesda III, has an unclear rate of malignancy. Gene expression classification (GEC) testing was developed to further stratify patients with AUS/FLUS nodules. Given its known variability between institutions, this study examines the utility of GEC testing in predicting malignancy in patients with AUS/FLUS thyroid nodules. 

Methods:  A retrospective review of prospectively collected data for patients with index thyroid nodules who underwent FNA and thyroidectomy at a single institution was performed. GEC testing utilized in patients with AUS/FLUS by FNA was reported as benign or suspicious for malignancy. Patients with AUS/FLUS nodules underwent initial thyroid lobectomy for definitive diagnosis unless there was a history of known risk factors and/or patient preference for which total thyroidectomy was performed. AUS/FLUS nodules were subdivided into malignant or benign groups based on final pathology. Among patients who underwent GEC testing, final pathology was compared to initial GEC results.

Results: Of 863 patients who underwent FNA and thyroidectomy, 224 patients (26%) were found to have AUS/FLUS nodules. Following thyroidectomy, 120 patients (54%) were shown to have thyroid cancer (Papillary, n=110; Follicular, n=8; Medullary, n=2) on final pathology. The remaining 104 patients had benign final pathology, most commonly presenting as multinodular hyperplasia, n=31. GEC testing was performed in 102 patients with AUS/FLUS testing, of which 96 had suspicious results. The rate of malignancy for patients with AUS/FLUS nodules and suspicious GEC results was 51% (49/96) whereas the rate of malignancy for AUS/FLUS nodules without GEC testing was 55% (67/122). Of the 6 patients with benign GEC results, 4 were found to be malignant (66%). The positive predictive value (PPV) for GEC testing in AUS/FLUS nodules was 51%.  

Conclusion: Surgical patients with AUS/FLUS nodules had a high malignancy rate compared to the general population. GEC testing demonstrated a high frequency of suspicious results in AUS/FLUS thyroid nodules, yet had limited utility of predicting malignancy. There was no significant difference in malignancy rates when comparing AUS/FLUS nodules without GEC testing to those with suspicious GEC results. In addition, GEC testing failed to rule out malignancy in AUS/FLUS nodules with benign results. Thus, the application of GEC testing has limited utility in surgical decision-making. Surgeons should assess their local institutional experience to determine if there is added utility of GEC testing for AUS/FLUS nodules in their everyday clinical practice. 

46.01 Quality of Life in Patients with MEN-2 Compared to US Normative and Chronic Disease Populations

Posted on January 18, 2018

M. N. Mongelli1, I. Helenowski1, S. Yount1, C. Sturgeon1  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA

Introduction:  Patient-Reported Outcomes (PROs) are being measured in many chronic disease states to inform decisions about intervention and management of disease while minimizing patient suffering and side effects. There is a paucity of data on health-related quality of life (HRQOL) and PROs in patients with Multiple Endocrine Neoplasia Type-2 (MEN-2). We hypothesized that HRQOL in MEN-2 patients would be lower than that of the general United States (US) population, but similar to that of patients suffering from other chronic diseases.

Methods:  Adults ≥ 18 years were recruited from an online MEN support group and completed the PROMIS-29 questionnaire (n=46). Responses were converted into t-scores for each of the seven health domains. T-scores of PROMIS domains were compared to US normative data using a one-sample t-test. PROMIS scores for other conditions, including low back pain, cancer, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), major depressive disorder, rheumatoid arthritis (RA), neuroendocrine tumors (NET), primary hyperparathyroidism (PHPT), and MEN-1 were obtained through literature review. T-scores for health domains were compared to other conditions using a Wilcoxon signed-rank test.

Results: The mean age was 46.1 years and the average time since diagnosis was 14.1 years. Compared to the US normative population, MEN-2 patients reported statistically significantly more anxiety (56.1±11.2, p=.001), depression (54.6±11.2, p=.008), fatigue (61.0±10.4, p<.001), pain interference (55.2±11.1, p =.003), and sleep disturbance (57.0±3.7, p<.001), as well as significantly decreased physical functioning (44.6±9.5, p<.001) and ability to participate in social roles (45.8±9.7, p=.005). MEN-2 patients reported statistically significantly greater fatigue than patients with cancer (p<.0001), COPD (p=.01), RA (p=.0001), NET (p=.0007), and PHPT (p<.0001), greater pain interference than patients with PHPT (p<.0001), and improved physical functioning compared to patients with low back pain (p<.0001), CHF (p<.0001), and COPD (p=.0002).

Conclusion: PROs may be a valuable tool to inform the management of patients with MEN-2. Our study is the first to use the PROMIS-29 metric to directly compare PROs between MEN-2 and other chronic conditions. Individuals with MEN-2 reported worse HRQOL in all 7 domains compared to normative data. There is a pattern of increased fatigue among MEN-2 patients compared to many other chronic conditions, even though MEN-2 patients report greater physical functioning than other chronic diseases.  Prospective longitudinal evaluation of PROs in MEN-2 should be conducted in order to identify treatments associated with the highest HRQOL.

 

45.14 Comparison of Preoperative Workflows for Elective Hiatal Hernia Repair and Effect on Patient Burden

Posted on January 18, 2018

C. E. Kein1, S. S. Yang1, S. Gupta1, A. S. Manjunathan1, A. A. Mazurek1, R. M. Reddy1  1University Of Michigan,Ann Arbor, MI, USA

Introduction: Many studies have shown benefits in studying clinical workflows to improve efficiency and patient satisfaction. We have had different clinics emphasize efficiencies without understanding patient benefit. We hypothesized that a consolidated workflow in the preoperative workup for hiatal hernia repair would be associated with a reduced cost and time burden on patients.

Methods:  A retrospective chart review was performed for all adult patients who underwent elective laparoscopic hiatal hernia repair in the Thoracic and General Surgery (GS) clinics at the same tertiary care institution in 2016. The Thoracic clinic was designed to consolidate preoperative workup into fewer individual appointments. Demographic information, number of preoperative visits, number of phone calls during workup, and number of days from initial consult to surgery were collected. Distance traveled to appointments, cost and hours of travel, and time spent in clinics were estimated using historic data. Descriptive statistics for these variables were compared using t-tests.

Results: The patient cohorts in the Thoracic (N=80) and GS (N=24) services were found to be similar in age at surgery (60.5 vs. 60.4, p=0.9710), and a majority were uninsured or relied on Medicare or Medicaid (68.8% vs. 66.7%, p=1.0000). Patients undergoing workup in the Thoracic clinic required significantly fewer preoperative appointments, compared to patients in the GS clinic who had extra visits for preoperative testing (2.0 vs. 3.5, p=0.0001). There was no significant difference in the average number of patient phone calls received by the Thoracic and GC clinic during the workup period (2.5 vs. 3.5, p=0.0618). Although the average distance in miles traveled to each appointment by Thoracic and MIS patients was not significantly different (72.7 vs. 88.1, p=0.2829), Thoracic patients incurred less burden in the total miles traveled for workup (287.7 vs. 531.5, p=0.0024) and in the associated estimated total cost of gas ($28.11 vs. $51.94, p=0.0024). In addition, Thoracic patients spent fewer estimated hours traveling and being present in clinic when compared to GS patients (8.6 vs. 14.6, p=0.001), and the Thoracic clinic achieved a significantly shorter workup period than GS, as measured in days from first consult to surgery (64.9 vs. 240.1, p=0.0001). 

Conclusion: The efforts of the Thoracic Surgery service to consolidate preoperative workflow are associated with a lower estimated cost and time burden to patients undergoing laparoscopic hiatal hernia repair without an associated increase in the use of clinical resources to field phone calls. A streamlined workflow may decrease cost to this largely financially vulnerable populations (uninsured, Medicaid, or Medicare) while also decreasing the time during which patients remain symptomatic. These results should urge surgical departments to identify and trim inefficiencies that impact patient finances and quality of life.

 

45.12 HOSPITAL-ACQUIRED ASPIRATION: RISK FACTORS FOR MORTALITY

Posted on January 18, 2018

A. L. Lubitz1, T. A. Santora1, A. Pathak1, J. A. Shinefeld2, A. P. Johnson3, A. J. Goldberg1,2, H. A. Pitt2  1Temple University,Department Of Surgery, Lewis Katz School Of Medicine,Philadelpha, PA, USA 2Temple University,Temple University Health System,Philadelpha, PA, USA 3Thomas Jefferson University,Department Of Surgery, Sidney Kimmel Medical College,Philadelphia, PA, USA

Introduction: Hospital-acquired aspiration is an uncommon, but potentially lethal, condition. A recent retrospective analysis from our institution suggests that patients with fatal aspiration are a diverse group. Some common features include advanced age, male gender, and neurologic impairment. However, the clinically important characteristics of patients who aspirate and are at greatest risk for dying remain elusive. Therefore, the aim of this study was to determine the risk factors for hospital-acquired aspiration-related mortality.

Methods: Over a three-year period from 2014 to 2016, patients who experienced a significant aspiration event, verified with coded Vizient data, were included in the data set. Patients who presented with aspiration on admission were excluded. The 100% mortality review process at our institution was utilized to ascertain whether the aspiration event was a major factor in the patient’s demise. Hospital records were abstracted to determine which patient, clinical, and hospital-related factors led to a significant aspiration. The aspiration patients who died were compared to the aspirators who lived. Variables identified as significant (p<0.07) on univariate analysis were entered into a multivariable regression model to determine the independent risk factors for aspiration-related mortality.

Results:Of the 276 aspiration patients, 92 (33%) died over the three-year study period. For all patients, 74% were 55 years or older; 53% had received anesthesia; 35% had diabetes; 34% were prior non-current smokers; 32% were Caucasian; 20% were considered high risk after a speech and swallow evaluation; 19% had COPD; 18% had impaired gastrointestinal motility; 16% had received anticholinergic medications within 24 hours prior to their event; 14% had a pulmonary diagnosis on admission; and 12% had low magnesium levels (Table). Only 31% of the patients were in an ICU at the time of the aspiration, but 41% were in the hospital for more than a week when the aspiration event occurred. Each of these twelve risk factors were utilized in the multivariable analysis (Table). Independent risk factors for fatal aspiration were prior, non-current smoking (OR= 2.18); impaired gastrointestinal motility (OR= 2.17) and hospitalization greater than 1 week (OR=2.43) (Table).

Conclusion:Fatal aspiration is an under recognized hospital-acquired condition. Patients at greatest risk for dying after an aspiration event are prior non-current smokers, have a diagnosis of impaired gastrointestinal motility and/or a prolonged hospitalization. Hospital personnel should use this information to identify high-risk patients and implement strategies to prevent fatal hospital-acquired aspiration.

 

44.18 Late GI Bleeding is More Prevalent With Transcatheter Compared to Surgical Aortic Valve Replacement

Posted on January 18, 2018

A. Iyengar1, E. Aguayo1, Y. Seo1, K. L. Bailey1, Y. Sanaiha3, O. Kwon2, W. Toppen4, P. Benharash2  1University Of California – Los Angeles,David Geffen School Of Medicine,Los Angeles, CA, USA 2University Of California – Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 3University Of California – Los Angeles,General Surgery,Los Angeles, CA, USA 4University Of California – Los Angeles,Internal Medicine,Los Angeles, CA, USA

Introduction:
Late bleeding complications are known to contribute to morbidity in patients undergoing aortic valve repair. In particular, post-hoc analysis of the PARTNER study has highlighted the high prevalence and morbidity of late bleeding complications in both surgical (SAVR) & transcatheter (TAVR) aortic valve replacement in high-risk populations. The purpose of this study was to compare the incidence and financial impact of late gastrointestinal (GI) bleeding in transcatheter and surgical (SAVR) aortic valve replacements.

Methods:

Retrospective analysis of the National Readmissions Database was performed between January 2012 & December 2014 using the International Classification of Diseases, Ninth Revision procedural codes for TAVR (35.05 and 35.06) and SAVR (35.21 and 35.22), and diagnosis codes for GI bleeding (578.9). Costs were standardized to the 2014 US gross domestic product using US Department of Commerce consumer price indices and adjusted for diagnosis related group–based severity. The Kruskal-Wallis and chi-squared tests were used for comparisons between all cohorts. Multivariable logistic regression models were utilized to identify significant predictors for GI bleeding.

Results:

Overall, 32,796 patients were identified who underwent TAVR, while 231,324 patients underwent SAVR. Compared to SAVR, TAVR patients were older (82 vs. 69 years, p<0.001) and more likely to be female (46% vs. 36%, p<0.001). In addition, TAVR patients had higher incidence of congestive heart failure (76% vs. 39%, p<0.001), chronic kidney disease (37% vs. 18%), and higher median Elixhauser Comorbidity Index (6 vs. 5, p<0.001). Hospital length of stay was lower in TAVR compared to SAVR (5 vs. 8 days, p<0.001), but in-hospital mortality rates were similar (p=0.668).

Among the TAVR cohort, 868 (2.6%) of patients were rehospitalized for GI bleeding compared to 2,630 (1.1%) in the SAVR group (p<0.001). Median time to readmission was similar between cohorts (46 vs. 47 days, p=0.948). Average cost of TAVR readmission for GI bleeding was $17,136 compared to $18,737 for SAVR (p=0.392). Amongst the subset of patients over age 80, GI bleeding readmissions remained more prevalent in TAVR vs. SAVR (2.6% vs. 1.5%, p<0.001). After multivariable adjustment, TAVR remained significantly associated with GI bleeding compared to SAVR (AOR 1.73 [1.50-1.99], p<0.001). 

Conclusion:

In this national cohort study, TAVR was associated with more frequent readmissions for late GI bleeding compared to SAVR. After controlling for preoperative comorbidities, TAVR remained a significant predictor of late GI bleeding. Since the optimal anticoagulation regimen for TAVR is not known, strategies to reduce GI bleeding in both groups may serve as suitable targets for improvement in overall quality of care. 

44.12 Hemodialysis as a Predictor of Outcomes After Isolated Coronary Artery Bypass Grafting

Posted on January 18, 2018

R. S. Elsayed1, B. Abt1, W. J. Mack2, A. Liu1, J. K. Siegel1, M. L. Barr1, R. G. Cohen1, C. J. Baker1, V. A. Starnes1, M. E. Bowdish1  1University Of Southern California,Cardiothoracic/Surgery/Keck School Of Medicine,Los Angeles, CA, USA 2University Of Southern California,Preventative Medicine,Los Angeles, CA, USA

Introduction: The need for hemodialysis is a known risk factor for mortality after isolated coronary artery bypass grafting (CABG). This study evaluated outcomes after isolated CABG in hemodialysis-dependent (HDD) and non-HDD patients.

Methods: A retrospective cohort study of 778 patients undergoing isolated CABG between 2006-2016. Patients were grouped by presence or absence of preoperative hemodialysis (696 non-HDD, 82 HDD). Mean follow-up was 20.8±33.3 months. Multivariable logistic regression models were developed to predict 30-day mortality and major adverse cardiovascular events (stroke, myocardial infarction (MI), death, and need for coronary reintervention i.e. MACE). Kaplan-Meier analysis was used to assess survival and multivariable Cox proportional hazard modeling was used to identify factors associated with overall mortality. Propensity scores and 1:1 Greedy matching (1:1) was used to create two groups of 65 non-HDD and 65 HD. Matched groups were compared for the primary outcomes.

Results:  Overall survival was 97.9, 96.5, 96.5, and 95.6% at 1, 3, 5, and 7 years.  Thirty-day mortality was 2.2% (n=17). On multivariable analysis, 30-day mortality was increased in those with diabetes (OR 7.3, 95% CI 1.0-52.2), COPD (OR 4.5, 95% CI 1.1-18.5), on preoperative inotropes (OR 4.8, 95% CI 1.1-21.2), with increasing cross clamp times (OR 1.04, 95% CI 1.0-1.1). MACE at 30 days was 4.1% (n-32). On multivariable analysis, MACE at 30-days was more common in those with diabetes (OR 4.1, 95% CI 1.3-12.5), COPD (3.7, 1.3-11.0), MI within 30 days (2.8, 95% CI 1.0-7.6), on preoperative inotropes (OR 6.1, 95% CI 1.8-19.8), and with increasing cross clamp times (OR 1.4, 95% CI 1.0-1.1). Thirty-day mortality was 1.9 and 4.9% in the non-HDD and HD groups, respectively (odds ratio (OR) 2.7, 95% confidence intervals (95% CI) 0.86-8.47, p=0.09). Median time on hemodialysis in the HD group was 78 weeks (IQR 48-156). Kaplan-Meier estimates of survival between non-HDD and HD patients showed a significant difference in survival (log-rank p = 0.0008, figure). After multivariable adjustment for age, sex, presence of diabetes, presence of COPD, and history of previous cardiac surgery, mortality was higher in the HDD group as compared to the non-HDD group (Hazard Ratio (HR) 3.1, 95% CI 1.05-9.1, P=0.04). After propensity matching, no survival difference was found between groups (unadjusted HR 4.0, 95% CI 0.47-35.1, p = 0.20).

Conclusions: Overall survival after isolated CABG remains excellent, with decreased survival in those with diabetes, COPD, needing preoperative inotropes, and those with longer aortic cross clamp times.  The need for preoperative hemodialysis remains a significant risk factor for long term mortality.

44.11 Atrial Fibrillation After Anatomic Lung Resection: Amiodarone Prophylaxis and Risk Stratification

Posted on January 18, 2018

E. D. Porter2, K. A. Fay1, T. M. Millington1, D. J. Finley1, J. D. Phillips1  1Dartmouth-Hitchcock Medical Center,Department Of Thoracic Surgery,Lebanon, NH, USA 2Dartmouth-Hitchcock Medical Center,Department Of General Surgery,Lebanon, NH, USA

Introduction: Post-operative atrial fibrillation (POAF) is a known complication after anatomic lung resection. Currently, no formal recommendations exist for its prophylaxis nor its management strategies. In this study, we identifiy trends in outcomes and preoperative risk factors at a single center that implemented a protocol of amiodarone prophylaxis after anatomic lung resection.

Methods: Cohort study at a single tertiary referral center. All patients who underwent anatomic lung resection from January 1, 2015 to April 26, 2017 were selected. Those ≥ 65 years of age, or at the discretion of the Attending Surgeon, were assigned to receive a post-operative amiodarone bolus 300mg IV over 1hour followed by 400mg PO TID x 3 days. Patient charts were reviewed for demographics, co-morbidities, and complications.

Results: A total of 227 patients underwent anatomic pulmonary resection and 27 (13.5%) experienced POAF. One hundred and seventeen patients (51.5%) were ≥ 65 years old. Of those 117 patients, 95 (81.2%) received amiodarone prophylaxis post-operatively and 18.8% experienced POAF. Those who developed POAF were more likely to be older (71.1 vs 65.0, p=0.001), have a history of Afib (p=0.019), have undergone a lower lobe lung resection (p=0.002), and/or had an open procedure (p=0.037). POAF significantly increased the post-operative length of stay (6.8 vs 4.4 days, p=0.004).

Conclusion: Post-operative atrial fibrillation continues to be a challenging problem after anatomic lung resection. Further investigation to establish optimal prophylactic medications and to identify high-risk patients for POAF prevention are needed. Our data suggest that POAF is more common in older patients, those with a history of a-fib, patients undergoing a lower lobe resection, and those having an open procedure. Targeted prophylaxis to these groups may be warranted.

44.07 Early Outcomes of Adult Patients Who Undergo Proximal Aortic Surgery with del Nido Cardioplegia

Posted on January 18, 2018

J. L. Liao1,2, M. D. Price2, S. Y. Green2, H. Amarasekara2, J. S. Coselli2, S. A. LeMaire2, O. Preventza2  1Indiana University School Of Medicine,Indianapolis, IN, USA 2Baylor College Of Medicine,Cardiothoracic Surgery,Houston, TX, USA

Introduction: Currently, many cardioplegic solutions exist for myocardial protection during open cardiac operations. del Nido cardioplegia differs from others in that it includes lidocaine, which limits sodium influx in order to produce a depolarizing cardiac arrest. It also generally necessitates fewer doses, sometimes only one, during an operation. Although del Nido is commonly used in pediatric patients, its efficacy in adults is less well established. Recent literature has described promising results in adults undergoing coronary artery bypass. However, the outcomes of using del Nido in proximal aortic surgery—which generally involve substantially longer periods of cardiac ischemia—are not well described. The aim of our study was to characterize early outcomes of patients who underwent proximal aortic surgery with del Nido cardioplegia.

Methods: We retrospectively reviewed data from 59 consecutive patients (mean age 61±15 y; male [n=37, 63%]) who underwent proximal aortic surgery and received del Nido cardioplegia between July 2016 and July 2017. In most cases, an initial dose of approximately 1000 mL was administered, followed by 300-400 mL every 20-30 min. 34 (58%) patients had an aneurysm without dissection, 21 (36%) had DeBakey Type I dissection, and 4 (7%) had Type II dissection. 6 (10%) patients had heritable thoracic aortic disease. 14 (24%) had total arch replacement and 35 (59%) had hemiarch replacement. Concomitant procedures included coronary artery bypass (n=4, 7%) and repair/replacement of the aortic valve (n=33, 56%), aortic root (n=22, 37%), mitral valve (n=1, 2%), and tricuspid valve (n=2, 3%). Hypothermic circulatory arrest (median duration 37 min, 22-55 IQR) and antegrade cerebral perfusion (median duration 34 min, 22-55 IQR) were used in 51 (86%) patients. The median cardiopulmonary bypass and cardiac ischemic times were 140 min (118-176 IQR) and 110 min (87-129 IQR), respectively.

Results: There were 3 (5%) operative deaths. Only 3 (5%) patients required intraoperative defibrillation, and 2 (3%) required intra-aortic balloon pump. 41 (70%) patients required inotropic support immediately postoperatively, but only 9 (15%) required it beyond 24 hours. Of these 9, 3 died—2 due to multiple organ failure and 1 due to stroke—5 recovered completely with no reduction in left ventricular (LV) function, and 1 recovered with mild reduction in LV function. No patients developed myocardial infarction. Stroke occurred in 2 (3%) patients (both persistent). Other postoperative complications included renal dysfunction (n=8, 14%) and renal failure requiring hemodialysis (transient [n=4, 7%]; persistent [n=2, 3%]).

Conclusions: As the use of del Nido cardioplegia becomes more common in adult cardiac cases, it becomes increasingly important to obtain outcomes data. Based on our study, the use of del Nido appears to provide satisfactory myocardial protection in complex proximal aortic cases that tend towards long ischemic times.

 

44.04 Lower Hematocrit Levels are Associated with Neurocognitive Decline after Cardiac Surgery

Posted on January 18, 2018

A. Y. Gorvitovskaia1, L. A. Scrimgeour1, B. A. Potz1, C. D. Gordon1, N. Sellke1, A. Kuczmarski1, J. G. Fingleton1, A. Ehsan1, N. R. Sodha1, F. W. Sellke1  1Brown University School Of Medicine,Division Of Cardiothoracic Surgery,Providence, RI, USA

Introduction:
Cardiopulmonary bypass is associated with post-operative neurocognitive dysfunction; however, risk factors have not been clearly identified. Therefore, we hypothesize that lower hematocrit (Hct) levels may be correlated with post-operative neurocognitive dysfunction. 

Methods:
Thirty patients underwent screening for neurocognitive dysfunction pre-operatively and at post-operative day four (POD4). All patients underwent cardiac surgery utilizing cardiopulmonary bypass including either coronary artery bypass grafting or valvular procedures. Patients with significant liver or renal dysfunction were excluded from the study. Patients were analyzed according to hematocrit and platelet levels at POD4, as well as by whether they received intra- and/or post-operative transfusions of packed red blood cells. Neurocognitive data is presented as a difference in RBANS standardized score based on sex and age from baseline to POD4 and comparisons analyzed by an unpaired Mann-Whitney U test. 

Results:
There was a significant correlation between patients with hematocrit levels <24% and a decline in neurocognitive function at POD4 (p<0.05). While there was a decrease in platelet levels from pre-op to POD4, there was no significant association with lower platelet levels and neurocognitive decline (p=0.71). All patients experienced a decline in hematocrit levels throughout their hospital stay, but a decline in Hct was associated with a measurable neurocognitive decline by POD4. Those that had a lower Hct on POD4 had consistently lower Hct throughout their stay. Thirty percent of patients received transfusions of packed red blood cells at any time during their hospitalization; 20 percent received a transfusion post-operatively. There was no significant difference between those who received a transfusion at any time during their hospitalization and their neurocognitive function at POD4. However, there was a trend towards lower neurocognitive scores in those who attained a hematocrit greater than 24% by POD4 via a post-operative transfusion. 

Conclusion:
Lower hematocrit levels are correlated with neurocognitive decline following cardiopulmonary bypass. While transfusion overall does not correlate with neurocognitive function, there was a trend towards lower neurocognitive function in those who received a post-operative transfusion. This suggests that their hematocrit was low enough at some point during their hospitalization to negatively affect their neurocognitive function. Therefore, despite goals to limit blood transfusions post-operatively, some patients may require transfusion at either a higher threshold or earlier time point to prevent neurocognitive decline.
 

44.05 Effect of HbA1c on Post-Operative Outcomes After On-Pump CABG

Posted on January 18, 2018

S. Kong1, M. Peltz1, L. C. Huffman1, P. Bajona1, M. A. Wait1, N. Doolabh1, R. Correa1, W. Ring1, M. Jessen1, J. Pruszynski1  1UT Southwestern Medical Center,Department Of Cardiovascular And Thoracic Surgery,Dallas, TX, USA

Introduction: Diabetic patients undergoing major cardiac procedures represent a large, complex group with high risks for complications during the post-operative period. Specifically, an elevated glycated hemoglobin (HbA1c) level is known to be an important predictor and indicator of morbidity and mortality risks for CABG patients. We seek to test the hypothesis that pre-operative HbA1c levels, along with significant covariates, impact post-operative outcomes following on-pump CABG.

Methods: Data were prospectively collected from 669 consecutive patients undergoing on-pump CABG at a single institution between July 2011 and March 2017. HbA1c was collected prior to undergoing surgery. Clinical variables were collected based on the definitions in the STS Adult Cardiac Surgery Database version 2.81. Multivariable logistic regression models were used to assess the effect of HbA1c on post-operative outcomes such as the receipt of post-operative blood products, surgical site infection, and prolonged ventilation. Similarly, a Cox proportional hazards regression model was used to assess the effect of HbA1c on time to discharge while accounting for the competing risk of operative death prior to discharge [operative mortality was 1.9%]. All models controlled for the effect of confounding variables such as demographics, comorbidities and risk factors, medication usage, and surgical characteristics.

Results: No association between HbA1c and the outcomes of post-operative blood products and prolonged ventilation was found in the analysis. A significant relationship between HbA1c and the occurrence of surgical site infection was detected (OR: 1.19; 95% CI: 1.00-1.41; p = 0.045) while controlling for covariates of race, BMI, illicit drug use, pre-operative pneumonia, prior MI, CPB time, and intra-operative blood products. Additionally, a significant association between HbA1c and time to discharge was detected (HR: 1.06; 95% CI: 1.01-1.11; p = 0.017) while controlling for age, smoking history, CVD, PAD, cardiogenic shock, recent heart failure, pre-operative albumin level, intraoperative blood products, surgical status, and post-operative creatinine level [see table].

Conclusion: These data show that increased HbA1c is associated with an increased incidence of a variety of adverse post-operative outcomes even when controlling for known risk factors. Diabetic patients have a variety of physiologic and metabolic derangements, and the exact mechanism behind this observation is not established. The study also does not include the efficacy of perioperative glucose control in these patients. Further investigation is warranted to define the biologic basis of the adverse outcomes that are observed in patients with poor pre-operative glucose control.

44.02 Clinical Characteristics and Surgical Outcomes of Quadricuspid Aortic Valve

Posted on January 18, 2018

K. Yin1,2, Z. Zhang1, L. Dong3, Y. Lin1, C. Wang1  3Zhongshan Hospital Of Fudan University,Department Of Echocardiography,Shanghai, SHANGHAI, China 1Zhongshan Hospital Of Fudan University,Department Of Cardiac Surgery,Shanghai, SHANGHAI, China 2Harvard Chan School Of Public Health,Boston, MA, USA

Introduction:  Quadricuspid aortic valve (QAV) is a rare and poorly understood congenital cardiac anomaly. Controversy remains over its association with aortic dilation, and limited evidence is available regarding the surgical outcomes. This study aims to evaluate the clinical features of QAV and examine the surgical outcomes.

Methods:  From January 2011 to December 2016, 35 consecutive QAV patients (mean age, 50.4 ± 11.9 years; male, 54.3%) were identified by echocardiography and confirmed during surgery (frequency, 0.0057%). All patients had significant aortic insufficiency with severe regurgitation in 21 patients (60%). The mean left ventricular end-diastolic dimension was 5.9 ± 0.7 cm, and the mean ejection fraction was 62% ± 7%. Eight patients (22.9%) had aortic stenosis with mild in 7 and moderate in 1. Ascending aortic diameter was ≥ 4 cm in 7 patients (20%) with mean diameter 4.2 ± 0.2 cm. Three patients (8.6%) had endocarditis preoperatively.

Results: All patients received aortic valve replacement with the median valve size 23 mm (range: 19 to 25 mm). Two patients (5.7%) required ascending aorta replacement, and the other concomitant procedures included mitral repair/replacement in 3 (8.6%) and tricuspid repair in 1 (2.9%). There was no early or late death. The median postoperative ICU and hospital stays were 2 and 7 days, respectively. No myocardial infraction, respiratory failure, renal failure or reoperation for bleeding, occurred postoperatively. Mean follow-up time was 25.1 ± 18.0 months and was complete for 94.3% of patients. One patient developed perivalvular leakage and subvalvular abscess two years after the initial aortic valve replacement and received a reoperative Bentall procedure.

Conclusion: Aortic insufficiency is the predominant hemodynamic abnormally in QAV patients. Compared with those in bicuspid aortic valves, the incidence and extent of aortic dilation seem to be uncommon and less severe in QAV. The short- and mid-term outcomes are satisfactory.

 

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