49.03 Impact of Primary Tumor Resection in Colorectal Cancer with Unresectable Metastasis

Posted on January 31, 2019

N. Ichikawa1, S. Homma1, T. Yoshida1, F. Kawamata1, T. Mitsuhashi2, H. Iijima3, S. Shibasaki1, H. Kawamura1, K. Ogasawara4, K. Kazui5, Y. Kamiizumi6, A. Taketomi1  1Hokkaido University,Department Of Gastroenterological Surgery 1,Sapporo, HOKKAIDO, Japan 2Hokkaido University Hospital,Department Of Surgical Pathology,Sapporo, HOKKAIDO, Japan 3Hokkaido University Hospital,Clinical Research And Medical Innovation Center,Sapporo, HOKKAIDO, Japan 4Kushiro Rosai Hospital, Japan Labour Health and Welfare Organization,Department Of Surgery,Kushiro, HOKKAIDO, Japan 5Hokkaido Hospital, Japan Community Healthcare Organization,Department Of Surgery,Sapporo, HOKKAIDO, Japan 6Iwamizawa Municipal Hospital,Department Of Surgery,Iwamizawa, HOKKAIDO, Japan

Introduction: The prognostic benefit of primary tumor resection in colorectal cancer patients with unresectable distant metastasis remains unclear. We aimed to assess whether palliative primary tumor resection in colorectal cancer patients with unresectable metastasis is associated with improved survival.

Methods: The survival period of 123 colorectal cancer patients diagnosed from January 2010 to December 2015 in 4 Japanese hospitals was analyzed. Sixty-four patients with and 59 without primary tumor resection were compared, retrospectively. In the patients with primary tumor resection, the survival period of 39 patients with lymphocyte:monocyte ratio (LMR) increase after primary tumor resection (LMR-increase) and 25 patients with LMR decrease (LMR-decrease) was also compared.

Results: Eighty nine colon cancer and 34 rectal cancer patients were eligible for the analysis. The mean age was 63 years old and male to female ratio was 63: 60. In the resection group, more patients were accompanied by non-differentiated adenocarcinoma (36% vs 15%, p <0.01), obstructive symptom (80% vs 51%, p <0.01), high serum albumen (3.8 vs 3.6 mg/dL, p =0.02) and no lymph node metastasis (20% vs 2%, p <0.01) than the non-resection group. The patients who underwent primary tumor palliative resection had prolonged median survival compared with patients never resected (24.5 vs 14.5 months, p =0.01). Multivariate analysis identified possible independent prognostic variables as the pathology containing non-differentiated adenocarcinoma (Hazard Ratio, 3.7), non-resection of primary lesion (2.7), and no use of irinotecan (2.6). Moreover, in the patients with primary tumor resection, the median survival times of the LMR-increase and LMR-decrease groups were 27.3 and 20.8 months, respectively (p =0.02, Figure). The preoperative lymphocyte population and LMR in peripheral blood of the LMR-increase group were significantly less than those of LMR-decrease group. There were no differences in any other patient characteristics and the extent of metastases between the 2 groups. When assessed the resected specimen in available cases, there were more CD163+ and CD8+ cells invaded into tumor stroma, significantly. (n=5)

Conclusion: Palliative primary tumor resection in colorectal cancer patients with unresectable metastasis is possibly associated with improved survival, especially in the case with lymphocyte:monocyte ratio  increase after primary tumor resection.

 

49.02 Chasing Zero Cuff: Robotic Distal Dissection Superior to Laparoscopy in Ileal Pouch Anal Anastomosis

Posted on January 31, 2019

A. W. Elias1, R. G. Landmann2  1Mayo Clinic – Florida,General Surgery,Jacksonville, FL, USA 2MD Anderson Cancer Center, Baptist Health,Colon & Rectal Surgery,Jacksonville, FL, USA

Introduction: Improved rectal dissection allows more distal transection and minimization of the rectal cuff during pouch procedures. Data is limited comparing robotic versus laparoscopic ileal J pouch-anal anastomosis (IPAA) procedures. Herein, we sought to compare robotic versus laparoscopic ileal pouch-anal anastomosis outcomes.

Methods: A prospectively maintained database was utilized to perform a retrospective matched cohort study. 44 consecutive patients who underwent ileal pouch-anal anastomosis between 2008-2017 at a US tertiary care hospital via robotic approach were matched to 72 laparoscopic controls by surgeon, age, gender, BMI, comorbidities, and operative history. Distal extent of dissection, intraoperative, and postoperative outcomes were analyzed.

Results: 116 patients (58% male) with median age 37.8 years [range 1716-68], BMI 24.5 [range 16.1-40.7], ASA score II [range I-III] underwent restorative ileal pouch-anal anastomosis (44 robotic, 72 laparoscopic), predominantly (90%) for ulcerative colitis. Distal extent of dissection (distance from dentate line) was significantly improved robotically (0 versus 1.3cm) (p<0.001). There were no significant differences in blood loss, complications, number of bowel movements at 30-days, 1 and 2 years, or use of pre-operative immunomodulators, steroids, ASA-derivatives, or TPN; however, more robotic patients utilized biologics (p = 0.007). Robotic procedure length was 20 minutes longer. Robotic median time to diet resumption was shorter (1 versus 2 days) (p<0.001). Despite equal medians, robotic admission length (4 days) and time until ostomy function (1 day) was significantly shorter (p = 0.02 and p=0.005, respectively). There were no reoperations or mortalities.

Conclusion: Robotic surgery enables superior total mesorectal excision and distal transection with elimination of the at-risk rectal cuff with improved postoperative outcomes in patients undergoing IPAA for ulcerative colitis and familial adenomatous polyposis. This technique can be applied to inflammatory and oncologic operations to improve negative margin rates and improve rates of sphincter preservation/intestinal continuity.

 

49.01 Robotic Natural orifice IntraCorporeal anastomosis and transrectal Extraction (NICE) procedure

Posted on January 31, 2019

R. O. Minjares-Granillo1, B. Dimas1, J. P. LeFave1,2, E. M. Haas1,2  1University of Texas Medical School at Houston,Department Of Surgery, Division Of Minimally Invasive Colon And Rectal Surgery,Houston, TEXAS, USA 2Houston Methodist Hospital,Division Of Colon And Rectal Surgery,Houston, TEXAS, USA

Introduction: Numerous studies have confirmed significant benefits of intracorporeal anastomosis (ICA) following colorectal procedures however technical challenges have limited this approach following conventional laparoscopic surgery.

The robotic Xi platform serves as an enabling technology and has resulted in a surge of reports for right-sided intracorporeal anastomosis, however, there are no reports involving more complex left-sided procedures such as for diverticulitis. Furthermore, there are no reports of natural orifice assisted techniques using robotic Xi in which the specimen can be removed and the anvil can be placed thereby completely eliminating the need for an abdominal wall incision other than the port sites. 

We present a pilot study to investigate the safety, feasibility and short term outcomes of robotic Natural orifice-assisted IntraCorporeal anastomosis with transrectal Extraction of specimen, called the robotic NICE procedure.

Methods:  Consecutive patients presenting for elective resection for diverticulitis with formation of a colorectal anastomosis were entered into an IRB database.  All patients underwent the robotic NICE procedure.  Demographic data, intraoperative data and outcomes data were assessed and analyzed.  

Results: Ten patients (5 male and 5 female) underwent resection. The mean age, ASA and BMI was 56 (range 43-66), II (I-III) and 29 (21-35).  All procedures were successfully completed including transrectal extraction of the specimen and formation of an ICA.  The mean operative time was 198 min (146–338) and mean EBL was 35 ml (15 –50). Mean time to first flatus was 16 hours (10-22) and mean length of stay was 1.9 days (1.6 – 2.6).  There were no intraoperative or post-operative complications.  There were no unexpected ICU stay, reoperation or readmission. 

Conclusion:  Colorectal left-sided resections such as for diverticulitis can be safely accomplished using natural-orifice assisted extraction of the specimen as well as complete intracorporeal anastomosis in this pilot study.  The NICE procedure resulted in early return of bowel function, short length of stay and low complications. The complete elimination of abdominal wall incision likely accounts for these findings and larger cohorts of patients are to be investigated to explore this promising approach afforded by robotic technology.

48.20 Management of Moderate Functional Mitral Regurgitation in Severe Aortic Insufficiency Patients

Posted on January 31, 2019

K. YIN1,2, Y. Lin1, Z. Zhang1, C. Wang1  1Zhongshsn Hospital of Fudan University,Department Of Cardiac Surgery,Shanghai, SHANGHAI, China 2Harvard T.H.Chan School Of Public Health,Boston, MA, USA

Introduction:
The optimal management strategy of moderate functional mitral regurgitation among severe aortic insufficiency patients who underwent aortic valve surgery is still not well-defined. We aimed to evaluate and compare the clinical outcomes between three mitral valve treatment strategies: valve repair, valve replacement, and no intervention.

Methods:
From January 2010 to October 2014, 136 consecutive patients (age 54.5 ± 12.4 years, male 77.2%) who underwent aortic valve procedure for severe aortic insufficiency with coexisting moderate mitral regurgitation were evaluated. Seventy-one patients (52.2%) received concomitant mitral valve repair, 11 patients (8.1%) underwent mitral valve replacement, and the other 54 patients (39.7%) received no intervention. The mean follow-up time was 38.2 ± 22.6 months with a completeness of follow-up of 97%. Demographic, echocardiographic and operative data were reviewed. Follow-up valve function and survival time were also compared between groups.

Results:
Mitral valve repair or replacement procedures were associated with longer aortic cross-clamp time and cardiopulmonary bypass time. There was no significant difference between three groups in regards of ICU and hospital stay, transfusion rate, in-hospital mortality, 1-year, 3-year and 5-year survival, and post-operative NYHA function classes. During follow-up, 16.7% (9/54) in the no intervention group patients developed moderate to severe residual mitral regurgitation, while no patient in the mitral repair and replacement groups had residual regurgitation. Patients with moderate or more residual mitral regurgitation had larger preoperative left atrium size (45.7 ± 5.9 vs 40.1 ± 6.3 mm, p = 0.03).

Conclusion:
Intervention of moderate functional mitral regurgitation in patients with severe aortic insufficiency adds no extra benefits in regards of post-operative recovery, NYHA function class and survival. Dilated left atrium is a risk factor of residual mitral regurgitation and may require concomitant mitral intervention. 
 

48.19 Delayed Treatment of Retained Cardiac and Intrathoracic Vascular Missile Injuries

Posted on January 31, 2019

D. Smego1, N. Djordjevic1, K. Karlson2, K. Yin2, N. Dobrilovic1,2  1Rush University Medical Center,Cardiovascular And Thoracic Surgery,Chicago, IL, USA 2Boston University,Cardiovascular And Thoracic Surgery,Boston, MA, USA

Introduction:

Cardiac and intrathoracic vascular missile injuries (CIVMI) are highly lethal.  Patients arriving to a medical facility are most commonly hemodynamically compromised and/or in extremis.  Rarely, are these patients stable without signs of major compromise.  In this report, we examine the role of delayed treatment for stable patients with CIVMI.

Methods:

This study was conducted as a retrospective review at a major level-1 trauma center.  All patients suffering CIVMI were examined.  Hemodynamically stable patients that did not require immediate operative intervention were selected for inclusion.  Treatment strategies, operative findings, and corresponding outcomes are reported for this group of patients that underwent delayed operative intervention.

Results:

Ten patients fit inclusion criteria.  Mean age was 22 years (range of 13-43).  Various imaging modalities documented a retained cardiac missile (RCM) in all 10 patients.  Transthoracic echocardiography and chest computed tomography angiogram were the most commonly performed diagnostic studies.  Each was performed in 9/10 (90%) study patients.  Transesophageal echocardiography was performed in 3/10 (30%) patients.  Operative intervention occurred in 9/10 (90%) patients; 1/10 (10%) refused.  The duration from time of injury to time of operation was a mean of 4.7 days, median 2 days.  Operative findings included a bullet lodged in the ventricular septum (n=3), free floating bullet in the pericardial space with no associated cardiac wounds except for a pericardial entrance site (n=2), brachiocephalic vein injury (n=1), left common carotid / left subclavian vein injury (n=1), ascending aortic pseudoaneurysm (n=1), infracardiac, supradiaphragmatic inferior vena cava injury with bullet migration to the left main pulmonary artery (n=1).  The single patient refusing surgery was diagnosed with a left ventricle to right atrium communication with significant heart failure.  Cardiopulmonary bypass was required in 4/9 (44%) of operative patients and deep hypothermic circulatory arrest in 1/9 (11%).  A RCM was retrieved in all (9/9) operative cases.  There were no mortalities.

Conclusion:

Stable patients with retained cardiac or intrathoracic vascular missile injuries can be safely managed in delayed fashion.  Such a delayed treatment strategy may benefit the trauma patient suffering from multisystem injury and may be viewed as analogous to the strategy of selective, delayed intervention adopted in the treatment of traumatic aortic disruption.
 

48.18 Long-term resolution of symptoms following vascular ring repair?

Posted on January 31, 2019

C. P. Callahan1, T. Merritt1, H. Jalal1, S. Lange1, M. Canter1, P. Eghtesady1, P. Manning1, A. Abarbanell1  1Washington University,Pediatric Cardiothoracic Surgery,St. Louis, MO, USA

Introduction: Vascular ring is often diagnosed after extensive evaluation for swallowing and breathing difficulties.  There is a paucity of data regarding the long-term status of symptoms following vascular ring repair.

Methods: We retrospectively reviewed the records of 63 patients who underwent open vascular ring repair from July 2007 to May 2018.  Preoperative demographics, symptoms, and confirmed chromosomal abnormalities were reviewed. Vascular anatomy was confirmed with available preoperative imaging and operative records. Post-operative data included freedom from reoperation, 30-day mortality and complications. Records were abstracted for most recent follow-up and symptom resolution.

Results: Demographic data are shown in Table 1. The median age at the time of surgical intervention was 439 days (2.4 mo. – 16.1 yrs.) for a single aortic arch with an aberrant subclavian artery and 172 days (0.2 mo. – 10.6 yrs.) for a double aortic arch. All patients were symptomatic except two single aortic arches. There was no operative mortality. Post-operatively, three patients required thoracic duct ligation. Aortopexy was required in three patients. Two patients had a cardiac arrest postoperatively due to airway malacia. At last follow-up, 42% (16/38) of single aortic arches and 64% (16/25) of double aortic arches had documented post-operative symptoms. Persistent breathing and swallowing difficulties remained in 37% (14/38) single aortic arches and 60% (15/25) double aortic arches.

Conclusion: Open vascular ring repair remains a safe intervention.  Our data suggests that further investigation of long-term symptoms in these patients is merited which could impact the future standard-of-care for these patients.

 

48.16 Single Center Outcome with a Percutaneous Right Ventricular Device in Right Ventricular Failure

Posted on January 31, 2019

B. Badu1, M. T. Cain1, Z. R. Laste2, L. Durham1, L. Joyce1, D. Ishizawar3, M. Saltzberg3, N. Gaglianello3, A. Mohammed3, D. L. Joyce1  1Medical College Of Wisconsin,Cardiothoracic Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Radiology,Milwaukee, WI, USA 3Medical College Of Wisconsin,Cardiology/Medicine,Milwaukee, WI, USA

Introduction:

Severe right ventricular (RV) failure requiring right ventricular assist device (RVAD) implantation is encountered following severe acute pulmonary hypertension secondary to acute respiratory distress syndrome or pulmonary embolism, and left ventricular assist device (LVAD) implantation.  Mortality at 1-year reach 30% and 40%, respectively1. Percutaneous RVAD technology is emerging, but understudied2.

Methods:

Patient charts were retrospectively reviewed for demographic and perioperative cardiac hemodynamic data, etiology of RV failure, and comorbid conditions in all patients receiving percutaneous RVAD support at our academic institution between April 2017 and August 2018. The primary outcomes we assessed were in-hospital mortality, duration of RVAD support, ICU length of stay, and device related complications such as bleeding, stroke, and the need for surgical revision.

Results:

Percutaneous RVAD was used in 23 patients (16 men, 70%); median age, 58 [19 to 66] years). Indications for implantation included RV failure post LVAD implantation (n=11, 48%), acute respiratory distress syndrome (n=5, 22%), myocardial infarction (n=5, 22%), post cardiac transplant (n=1, 4%), and viral cardiomyopathy (n=1, 4%).  Median duration of support was 14 (3 to 23) days and 18 (78%) patients were successfully weaned or underwent cardiac transplantation. Overall in-hospital mortality was 34.8%. In-hospital mortality among patients with RV failure after permanent LVAD was 0 % with 1 late death at 150 days.  Mortality among patients with primary pulmonary etiology was 40%. There was no mortality with RV failure post-transplant or after viral cardiomyopathy. Severe postoperative bleeding requiring reoperation was noted in 3 (13%) patients. Superior vena cava obstruction occurred in 2 (8%) patients and device migration in 1 (4%) patient. No device-related infection or pulmonary emboli were noted.

Conclusion:

Percutaneous RVAD support appears to be a versatile and effective tool in treating patients with severe RV failure, with particular benefit after LVAD implantation. These findings support the need for additional investigation into the benefits of this device.

 

References:

1. Kirklin JK, Naftel DC, Pagani FD, Kormos RL, Stevenson LW, Blume, et al. Seventh INTERMACS annual report: 15,000 patients and counting. J Heart Lung Transplant. 2015;34;1495-504.

2. Ravichandran AK, Baran DA, Stelling K, Cowger JA, Salerno CT. Outcomes with the Tandem Protek Duo dual-lumen percutaneous right ventricular assist device. ASAIO J. 2018;64:570-2.

48.17 The Impact of Hospital Teaching Status on Clinical Outcomes After Major Cardiac Surgery

Posted on January 31, 2019

A. A. Haider2, A. Azim2, M. Bravo2, R. Latifi2, J. Goldberg2  2New York Medical College,Department Of Surgery,Valhalla, NY, USA

Introduction:  Surgical residents and medical student play a major role in patient care at teaching hospitals with varying degrees of involvement. It is often feared that trainee involvement in patient care may adversely affect clinical outcomes. The effect of trainee involvement on patient clinical outcomes after major cardiac procedures remain unknown. The aim of our study was to evaluate if trainee involvement in major cardiac surgery such as coronary artery bypass graft (CABG) is associated with worse outcomes.

Methods:  The National Inpatient Sample was abstracted for 3 years for all patients (≥18 years) who underwent CABG. Data was abstracted for patient demographics (age and gender), disease severity, co-morbidities, nature of admission (elective versus emergent), and hospital volumes (low, medium, and high). Patients were divided into two groups: Teaching hospital (TH) and non-teaching hospitals (non-TH). Outcome measures were mortality and failure-to-rescue (death after a complication). Multivariate logistic regression analysis was performed.

Results: A total of 141,392 patients from 589 hospitals were included. Mean age was 65.9 ± 10.8 years, 72.3% were male, and mean Charlson Comorbidity Index was 1.39 ±1.42. 58.1% (n=80,688) patients were treated at TH and 41.9% (n= 58,128) were treated at non-TH. Overall mortality rate in the population was 2.5 % and failure-to-rescue rate was 2.1%. Unadjusted mortality rate (2.6% vs. 2.4%; p=0.04) and FTR (2.1% vs. 2.0%; p=0.04) at TH was higher compared to non teaching. However, after adjusting for confounders with multivariate regression analysis, the odds of mortality (OR: 1.02; CI: 0.95- 1.10) and FTR (OR: 1.02 ; CI: 0.94-1.11) were similar between TH and non-TH.

Conclusion: Unadjusted rates of mortality and failure to rescue at teaching hospitals are slightly higher compared to non-teaching hospitals. This difference may likely be due to difference in disease severity and hospital volume as this effect disappears after adjusting for these factors. With adequate supervision, teaching hospitals can achieve similar outcomes to non-teaching hospitals after major cardiac procedures such as CABG.

 

48.15 Outcomes of Primary Repair of Tetralogy of Fallot in Adolescents and Adults

Posted on January 31, 2019

A. H. Siddiqui1, H. Fatima2, F. Safi2, M. Amanullah1  1Aga Khan University Medical College,Department Of Surgery,Karachi, Sindh, Pakistan 2Aga Khan University Medical College,Medical College,Karachi, Sindh, Pakistan

Introduction:
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease in the world, and survival into adulthood is well known. Patients with untreated disease seldom present in the developed world; however, it is not uncommon in developing countries. Over time the development of comorbidities give rise to a major surgical challenge. We aimed to establish the relationship between pre-operative characteristics and post-operative course in these patients.

Methods:
We conducted a retrospective chart review of all patients older than the age of 10 years who underwent surgical repair of TOF between July 2006 and February 2017. Primary outcome measures were early (30-day) and late (greater than 30-day) mortality, morbidity, and need for reintervention. Data was analyzed using SPSS v 21.

Results:
A total of 59 patients meeting the inclusion criteria underwent surgical repair of TOF. The mean age at repair was 18.81 (±5.53) years. 6 (10.0%) patients had a pre-operative New York Heart Association (NYHA) functional class of I, 29 (48.3%) were NYHA class II, 12 (20.0%) were NYHA class III and 3 (5.0%) were NYHA class IV. All patients had atrial and ventricular arrythmias on electrocardiogram. Cyanotic spells were seen in 30 (50.8%) patients. 11 (18.6%) patients reported pre-operative palpitations, 11 (18.6%) had chest pain, whereas 9 (15.3%) had a history of infective endocarditis. 11 patients had undergone a previous Blalock-Taussig shunt (BT shunt) procedure.

There was 1 (1.69%) 30-day mortality seen, which was due to a ventricular arrythmia. No late mortalities were seen. The most common post-operative complication was pneumonia, seen in 8 (13.6%) patients, followed by sepsis seen in 6 (10.2%) patients. The mean length of ICU stay was 2.5 (±2.1) days. 3 (5.08%) patients needed a reintervention: one for severe post-operative pulmonary stenosis, one for residual ventricular septal defect (VSD) and pulmonary regurgitation and one for residual atrial septal defect (ASD).

Conclusion:
A significant number of adults with Tetralogy of Fallot are surgically treated in Pakistan, as in other developing countries. The overall morbidity and mortality of surgical intervention in this cohort is acceptable at our institution and comparable to that reported in other studies.

48.14 "Impact of a Thoracic Multidisciplinary Cancer Conference on Lung Cancer Care"

Posted on January 31, 2019

A. C. Sykes1,2, C. Gaudioso3, P. E. Whalen3, K. Attwood3, C. Nwogu4  1Upstate Medical University,Syracuse, NY, USA 2Roswell Park Comprehensive Cancer Center,Summer Research Experience Program In Cancer Science,Buffalo, NY, USA 3Roswell Park Comprehensive Cancer Center,Biostatistics & Bioinformatics,Buffalo, NY, USA 4Roswell Park Comprehensive Cancer Center,Thoracic Surgery,Buffalo, NY, USA

Introduction:  Lung Cancer, as the leading cause of cancer deaths in the U.S. remains a major health challenge. With the increasing complexity of lung cancer care, the multidisciplinary approach has taken on an increasingly prominent role in the care of lung cancer patients. This study aims to capture how a thoracic multidisciplinary conference (MDC) impacts lung cancer care and survivorship, to determine if there is a quantifiable advantage of applying formalized multidisciplinary care. 

Methods:  All patients registered with ICD 10 codes C34.0-9 “lung cancer” between January 1, 2010 and December 31, 2016 were identified from the cancer registry system. A total of 936 patients presented at the MDC were compared to a matched subset of the patients not discussed at the MDC. We used the REDCap electronic data capture tools hosted at Roswell Park Comprehensive Cancer Center (RPCCC). From the entire cohort, the top 600 patients with matched demographics and clinical presentations were used to generate intervention and control groups of 300 patients each. The survival rates and treatment plans of patients in both groups were retrospectively reviewed to quantify the benefits of the thoracic MDC. To objectively compare the quality of each treatment plan, the National Comprehensive Cancer Network (NCCN) guidelines were used to define the standard of care at each stage of the treatment process. The changes made to each treatment plan after the MDC were documented and compared to the final treatment plan to determine how the MDC influenced each case.

Results: There was an improvement in overall survival for lung cancer patients discussed at the Thoracic MDC (p<0.03). However, there was no significant improvement in lung cancer specific survival rates for these patients (p=0.12). MDC discussion made a statistically significant difference in the NCCN guidelines compliance rate of the final treatment received by patients (Table 1). 82 of 185 patients (44.3%) underwent treatment plan changes by the MDC, including 18 patients whose treatment plans were ‘uncertain’ prior to the MDC. Post-MDC recommendations included changes in the type of systemic therapy, surgical procedure, radiotherapy or a change in the sequence of multimodality therapy. 

Conclusion: A large proportion of patients had their treatment plans altered after MDC discussion. The final treatments that patients received were more compliant with NCCN guidelines after such discussions. Though our results showed an improvement in overall survival for the lung cancer patients discussed at the Thoracic MDC, an improvement in lung cancer specific survival as a result of MDC discussion could not be demonstrated in this limited cohort of matched patients. 
 

48.13 Predictors of 30-Day Outcomes Following Mitral Valve Repair

Posted on January 31, 2019

A. Reisman1, A. Thomas1, P. Boateng1, I. Leitman1  1Icahn School of Medicine at Mount Sinai,New York, NY, USA

Introduction: Mitral valve repair has been established as the preferred treatment option in the management of degenerative mitral valve disease. Compared with other surgical treatment options, mitral valve repair is associated with increased survival and decreased rates of both complications and reoperations. However, among patients undergoing mitral valve repair, little is known about the predictors of postoperative outcomes. The purpose of this study was to identify preoperative patient risk factors associated with morbidity and mortality within 30 days of mitral valve repair.

 

Methods:  Data were derived from the American College of Surgeons National Surgical Quality Improvement Program database to assess patients who underwent mitral valve repair from 2011 through 2016. Preoperative risk factors were analyzed to determine their association with a variety of postoperative 30-day outcome measures.

Results: One thousand two hundred and thirty-four patients underwent mitral valve repair; 763 (61.8%) males and 471 (38.2%) females. Ages ranged from 18 to 89 years, with a median age of 65 years. The overall 30-day mortality was 3% (37 patients). Among the 12 identified risk factors associated with increased mortality, pre-operative hematocrit level was the only variable significantly correlated with mortality after undergoing multivariate analysis. 235 patients (19.2%) were discharged to a location other than home, an outcome associated with 21 identified risk factors. Among these risk factors, female gender, age, hypertension requiring medication, dialysis, pre-operative serum sodium, and pre-operative serum albumin remained statistically significant following multivariate analysis. 121 patients (9.8%) experienced unplanned readmission. This outcome was associated with eight risk factors, of which only dyspnea upon mild exertion was significant on multivariate analysis. Reoperation occurred in 99 patients (8.1%). Of the 6 identified variables associated with reoperation, patient age was the only independent predictor on multivariate analysis. 49 patients (4.0%) underwent reintubation, which was associated with 13 identified risk factors. Among them, patient age and pre-operative INR value were predictive of reintubation on multivariate analysis. 

Conclusion: Outcomes are good following mitral valve repair. Although a substantial number of risk factors were found to be associated with adverse outcomes, only a small subset remained significantly significant following multivariate analysis. Identification of these risk factors may help guide clinical decision making with respect to which patients are the best candidates to undergo mitral valve repair. 
 

48.12 Redo Lung Transplantation: Is Age a Factor in Survival Outcome?

Posted on January 31, 2019

J. N. Levy1, M. A. Kashem1, N. Shigemura1, J. Gomez-Abraham1, S. Keshavmurthy1, Y. Toyoda1  1Temple University,Cardiovascular Surgery,Philadelpha, PA, USA

Introduction:
Currently, the number of elderly recipients for lung transplantation (LTx) is increasing. However, fewer patients receiving primary single or double LTx with graft failure outcome are sometimes offered redo-LTx. We investigated the survival outcome of single or double redo-LTx in elderly recipients analyzing the UNOS database.  

Methods:

We reviewed the UNOS database and included patients who received single and/or double redo- LTx based on three different age cohorts from 1987 to 2014: recipient age – ≤69, 70-74, and ≥75 years old. Kaplan-Meier survival outcome was compared among the different age cohorts using variables such as age, gender, ethnicity, BMI, length of stay (LOS), ECMO, blood type, and transplantation procedure. Using SAS program, data were expressed as Mean ± standard deviation and p<0.05 was considered significant.

Results:

There were 594 had double and 498 had single redo-LTx out of total 1,092 redo-LTx patients. Demographics data showed 52% male, 87% white, 6% black, 5% Latino, and 2% others, mean age (50±5) years, BMI (20±5) kg/m2, median LOS 15 days, and blood groups: O-46%, A-40%, B-10%, AB-4%, ECMO-4%. Within the age cohorts, 1,069 patients were ≤69 years of age, 20 patients were 70-74 years old, and 3 patients were over ≥75 years old. Log-rank test for equality of survival between the three different age groups showed no significant difference in survival for single redo-LTx (p=0.89), but demonstrated significance between the age cohorts for double redo-LTx (p=0.004). There was no significant age discrimination between individuals receiving single redo-LTx based on age: ≤69 vs. 70-74 years old (p=0.63), ≤69 vs. ≥ 75 years old (p=0.94), 70-74 vs. ≥75 years old (p=0.91).

Conclusion:
Age was not a factor in survival outcome of the elderly patients undergoing single redo-LTx, but was statistically significant in double redo-LTx. Further study is warranted due to limited number of patients.

48.11 Outcomes after CABG or Valvuloplasty are Worse in Cardiac Transplant Centers?

Posted on January 31, 2019

M. M. Jamil1, W. Qu1, F. C. Brunicardi1, M. M. Nazzal1, J. Ortiz1  1University Of Toledo Medical Center,Surgical Education,Toledo, OH, USA

Introduction:

The purpose of the study is to determine if the outcomes after CABG or valvuloplasty are different among centers that perform cardiac transplant and centers that do not.

Methods:

Centers performing cardiac transplants during 2008-2014 were identified from the National Inpatient Sample. All CABGs and valvuloplasties within this period were stratified by whether they were performed at a cardiac transplant center (CTC) or a non-transplant center (NTC). Demographics and comorbidities were extracted using ICD-9 codes. Outcomes were in-hospital mortality, acute stroke, acute renal failure (ARF), deep sternal wound infection (DSWI), reoperation, and length of stay (LOS) >14 days. Χ2, Mann Whitney tests were used for comparison. The effect of being in CTC vs NTC on each outcome was derived from logistic regression and expressed as Odd’s ratio (OR) with 95% confidence interval (CI), after adjustment for covariates. 

Results:

2,003,765 cases of CABGs or valvuloplasties were identified. 18% (n=366,877) of these were in CTC and 82% (n=1,636,888) in NTC. The mean age in CTC vs. NTC was 65 and 66 years, respectively.  33% of cases in CTC were females vs. 31% in NTC (p<0.01). African Americans comprised of 9.3% of cases in CTCs and 6.5% of cases in NTCs (p<0.01). Among comorbidities, cases in CTC had higher rates of congestive cardiac failure (2.2% vs. 1.3%), renal failure (16% vs. 14%), atrial fibrillation (38.1% vs. 32.5%), with all p<0.01. Cases in CTC had lower rates of obesity (16.6% vs. 19.6%), HTN (71.6% vs 74.3%), COPD (18.6% vs. 22.1%), and diabetes (25.5% vs. 31.1%) compared to NTC (all p<0.01). Fewer cases in CTC had intra-aortic balloon pump (6.6% vs. 8.5%, p<0.01). NTC had more emergent cases (47.5% vs. 41.8%, p<0.01) than CTC. Cases in CTC had a higher in-hospital mortality (3.2% vs. 2.7%, p<0.01) than NTC. The adjusted OR for mortality for cases in CTC was 1.13 (95% CI 1.07-1.18). CTC cases also had a higher rate of ARF (17.4% vs. 15.3%, p<0.01) with adjusted OR 1.05 (95% CI 1.03-1.08, p<0.01); reoperation (2.6% vs. 2.0%, p<0.01) with adjusted OR 1.19 (95% CI 1.13-1.26, p<0.01); deep sternal wound infection (1.1% vs. 0.8%, p<0.01) with adjusted OR 1.35 (95% CI 1.24-1.46, p<0.01); and LOS>14 days (23.3% vs. 16.8%, p<0.01) with adjusted OR 1.47 (95% CI 1.44-1.50, p<0.01). CTC cases had a lower rate of acute stroke (7.8% vs. 8.1%, p<0.01), but adjustment for covariates revealed an OR of 1.00 (95% CI 0.97-1.04, p=0.82).

Conclusion:

CABGs and valvuloplasties performed in CTCs have worse outcomes than those in NTCs with higher rates of in-hospital mortality, acute renal failure, reoperation, deep sternal wound infection, and LOS>14 days.

 

48.10 Ivor-Lewis vs McKeown Esophagectomy: Analysis of Operative Outcomes from the ACS-NSQIP Database

Posted on January 31, 2019

M. J. Sabra1, h. Xu1, A. D. Cassano1, L. G. Wolfe1, B. Kaplan1, R. D. Shah1  1Virginia Commonwealth University,Surgery,Richmond, VA, USA

Introduction:
The decision to perform an Ivor Lewis or a McKeown technique for esophagectomy is usually based on surgeon’s preference and their comfort level with the two procedures, usually based on their training and personal experience. In this study we aim to compare these 2 approaches.

Methods:
We identified patients who underwent either approaches to esophagectomy in the American College of Surgeons?National Surgical Quality Improvement Project (ACS?NSQIP) database (2005-15). We compared both groups using a bivariate analysis.

Results:
We identified 4283 patients with esophagectomy and divided them into 2 groups based on whether they received a Mckeown (1279; 29.86%) or an Ivor Lewis (3004; 70.14%) esophagectomy. Basic preoperative characteristics including age, race, gender, BMI, hemoglobin, albumin, creatinine, weight loss, comorbidities, and functional status were not different between groups. General surgeons performed 65% of the Mckeown operations vs. only 50% of the Ivor Lewis operations (p <.0001). The Mckeown operation group had a higher mean operative time (415 vs 393 minutes, p <.0001), higher frequency of sepsis (9.61% vs 7.35%, p= .0129), more patients with prolonged intubation (15.31% vs 12.01%, p= 0.0035), higher rate of re-intubation (14.92% vs 11.68%, p=0.0035), and higher re-admission rate (25% vs 20.92%, p=0.0108). The mortality rate and hospital length of stay (LOS) were not different

Conclusion:
Both techniques are comparable in 30-day mortality and LOS. However, McKeown esophagectomy is a longer operation and it is associated with more unplanned intubation, increased difficulty weaning from the ventilator, more sepsis, and higher chance of readmission.
 

48.09 Opioid and Adjunct Pain Medication Utilization after Robotic Versus Open Transhiatal Esophagectomy

Posted on January 31, 2019

L. R. Franko2, C. M. Gilbert2, A. A. Brescia1, J. Caceres2, L. Azzouz2, A. A. Mazurek2, A. C. Chang1, P. W. Carrott1, J. Lin1, W. R. Lynch1, M. B. Orringer1, R. M. Reddy1, K. H. Lagisetty1  1University Of Michigan,Thoracic Surgery,Ann Arbor, MI, USA 2University Of Michigan,Medical School,Ann Arbor, MI, USA

Introduction:
Transhiatal esophagectomy (THE) can be performed via an open or robotic-assisted (RA) approach. The reported benefits of RA THE include more complete lymph node sampling and direct visualization during dissection. However, the impact of RA THE on postoperative acute pain management is unknown. This study compares the impact of RA THE versus open THE on postoperative pain management. 

Methods:
All patients undergoing THE at our institution between 03/2017-03/2018 were identified (n=57). Retrospective chart review and our institutional STS database were utilized to collect data regarding surgical approach, demographics, complications and pain management. Patients undergoing McKeown or Ivor Lewis esophagectomies were excluded. Pain management strategy and utilization, including opioids, adjuncts, epidural, and patient controlled analgesia (PCA), were recorded from postoperative day (POD) 0-10 as well as day prior to discharge. The mean oral morphine equivalents (OMEs) per POD were based on OMEs taken (oral and IV rescue dose) after epidural, PCA, or opioid infusion was discontinued. Descriptive data were analyzed, and 2-tailed t-test or Chi-squared was utilized as appropriate. 

Results:
Open THE was performed in 41 patients with 3 conversions to open. RA THE was successful in 16 patients. An epidural was utilized in 38 (92.7%) of open patients versus only 1 (6.3%) RA patient (p<0.001). Of note, 15 (93.8%) RA patients received a PCA compared to 18 (43.9%) open (p<0.001), 3 of whom did not also receive an epidural. PCA and/or epidural was discontinued on POD 4.6 for open and 3.8 for RA patients (p=0.003). Mean daily OME use from POD 3-10 on average trended higher in RA patients with only POD 8 showing a significant difference (p=0.015; Figure 1). On the day prior to discharge, mean OME per patient was significantly higher in the RA group (35.1) versus open (17.3; p=0.029). Age, procedure time, length of stay, postoperative event rate, prior benzodiazepine or opioid use, number of adjunct doses per day, gabapentin or lidocaine patch use, discharge prescription OME, and number of patients requiring refills did not differ.  

Conclusion:
This study demonstrated mean daily OME use for the first ten PODs after THE did not differ between the open or RA; however, day prior to discharge OME use was higher in the RA cohort. This suggests that opioid use following RA THE may equal or exceed opioid use following open THE.  Further investigation with a larger cohort of patients is needed to identify risk factors for higher use in RA patients, such as lack of epidural use.

 

48.08 Minimally-Invasive Single Vessel Coronary Bypass: Outcomes from a Single-Institution STS Database

Posted on January 31, 2019

N. J. Smith1, M. Cain1, B. Miles1, P. Pearson1, L. Joyce1, L. Durham1, G. Raikar1, C. Rokkas1, D. Joyce1  1Medical College Of Wisconsin,Cardiothoracic Surgery,Milwaukee, WI, USA

Introduction:  Coronary artery bypass grafting (CABG) can be performed through a variety of approaches. Minimally invasive, non-sternotomy CABG has been proposed as a technique to reduce perioperative morbidity. Early data demonstrate improvements in perioperative metrics, however, adoption has been limited due to limited institutional experience.

Methods:  The Society of Thoracic Surgeons (STS) database at a single academic institution was queried for all isolated single-vessel left internal mammary to left anterior descending artery (LIMA-LAD) bypass procedures performed between January 2011 and March 2018. Patients were grouped based on operative approach, comparing conventional sternotomy to non-sternotomy (minimally-invasive) approaches. Patients who underwent concomitant valvular, aortic, or ablative procedures were excluded. Patient characteristics, perioperative variables, and short term outcomes were compared between groups. Primary outcome included mortality and major adverse cardiac events, with postoperative morbidity as secondary outcomes.

Results: A total of 48 minimally-invasive and 68 conventional sternotomy single-vessel LIMA-LAD CABG procedures were performed. Minimally-invasive approaches were more often elective (81.3 vs 52.9%, p=0.002). Patient characteristics were similar between groups. STS predicted risk scores demonstrated similar predicted mortality between groups with significantly lower predicted rates of prolonged ventilation, renal failure, and long length of stay in the minimally-invasive group. No significant difference was noted in major adverse cardiac events (0.0 vs 7.4%, p=0.076), STS composite morbidity (2.1 vs 8.6%, p=0.237), and postoperative myocardial infarction (4.2 vs 1.5%, p=0.569). Minimally-invasive approach was associated with fewer pulmonary (0.0 vs 10.3%, p=0.040) complications and decreased ICU (34.95 vs 58.7 hours, p<0.001) and total length of stay (4.54 vs 8.04 days, p<0.001). There were no observed strokes or graft occlusion reoperation in either group. There was a trend toward reduced 30-day mortality (100 vs 92.6%, p=0.076). These are consistent with previous experiences.

Conclusion: Minimally-invasive single-vessel LIMA-LAD CABG demonstrates improved perioperative outcomes regarding length of stay and pulmonary complications while performing comparably to conventional sternotomy in mortality and major adverse cardiac events. In select patients, minimally-invasive approaches to single-vessel grafting may be beneficial and a safe alternative to conventional approaches.   

 

48.07 Thymectomy Modality Impacts Readmission and Length of Stay: A National Cancer Database Study

Posted on January 31, 2019

B. S. Hendriksen1, M. F. Reed1, C. S. Hollenbeak2, M. D. Taylor1  1Penn State Health Milton S Hershey Medical Center,Hershey, PA, USA 2Pennsylvania State University,University Park, PA, USA

Introduction:  
Minimally invasive thymectomy operations are increasing and the impact on readmission and hospital length of stay merits contemporary evaluation. This study assessed surgical modality and other risk factors associated with 30-day unplanned readmission and hospital length of stay following thymectomy.

Methods:
The National Cancer Database was used to identify patients 18 years and older who underwent thymectomy between 2010 and 2015. Patient characteristics were compared using analysis of variance. Logistic regression and generalized linear modeling were used for multivariable analysis. Propensity score matching was used to control for covariate imbalance between modalities.

Results: 
3,145 patients underwent thymectomy: 2,360 open, 379 VATS, and 406 robotic assisted. VATS and robotic approaches were less likely to have readmissions compared to open (OR=0.32, p=0.015, and OR=0.30, p = 0.0110, respectively). Length of stay for VATS was 1.2 days less than for open (p < 0.0001) and robotic had a length of stay 1.3 days less than open (p < 0.0001). Propensity score matching corroborated that unplanned readmission was increased in open vs VATS (p = 0.0100) and decreased in robotic vs open (p = 0.0180). Length of stay was significantly shorter for robotic compared to open (p = 0.0070).

Conclusion: 
Minimally invasive surgery offers important benefits when compared to an open approach for thymectomy. VATS is associated with fewer readmissions and a robotic-assisted approach is associated with a shorter length of stay and fewer readmissions.

 

 

48.06 Surgery for Recurrent Pulmonary Metastases of Sarcoma Versus Non-Sarcoma

Posted on January 31, 2019

G. J. Haro1, J. Reza3, A. Sammann1, M. Hudnall2, K. Jones1, D. Jablons1, M. J. Mann1  1University Of California – San Francisco,San Francisco, CA, USA 2Northwestern University,Chicago, IL, USA 3Florida Hospital,Orlando, FL, USA

Introduction:

Pulmonary metastases frequently recur after metastasectomy.  There is limited evidence to guide surgical decision-making following recurrence, but a particularly aggressive approach to metastasectomy has been advocated for sarcoma. We studied outcomes associated with an aggressive surgical approach to recurrent pulmonary metastases from sarcoma and other primary malignancies.

Methods:

We retrospectively identified 556 consecutive pulmonary metastasectomies at our center between 1991-2015 among 192 sarcoma and 252 non-sarcoma patients.  The most common non-sarcoma subtypes were colorectal adenocarcinoma (n=80), melanoma (n=49), and renal cell carcinoma (n=34).  Indications for initial metastasectomy were substantially more liberal for sarcoma than non-sarcoma.  Patients were all followed with standard surveillance imaging.  Kaplan-Meier analysis with a right-censored dataset assessed recurrence and overall survival from time of metastasectomy.  Multivariable Cox proportional hazards models were developed in sarcoma and non-sarcoma patients with recurrent pulmonary metastasis based upon age, sex, race, non-sarcoma cancer type, number/size lesions, time to recurrence, surgery date, anatomic resection, minimally invasive procedure, and chemo/radiotherapy.

Results:

Median survival was 3.1 (95% CI 2.4-3.9) years for sarcoma and 4.7 (95% CI 3.6-6.8) years for non-sarcoma.  Seventy percent (135/192) sarcoma and 42.1% (106/252) non-sarcoma patients recurred and sarcoma patients recurred with a greater number of lesions (mean 4.5 vs 2.5).  Median time to recurrence was 7.2 (95% CI 4.8-9.6) and 10.8 (95% CI 8.4-13.2) months in sarcoma and non-sarcoma, respectively.  In those who recurred, 49.6% (67/135) sarcoma and 38.7% (41/106) non-sarcoma underwent repeat metastasectomy.  Sarcoma patients whose recurrences remained resectable experienced similar survival to those who did not recur (Figure, P=0.47), whereas those with resectable recurrence from non-sarcoma had worse survival (P=0.02).  Multivariable models identified recurrence <6 months (HR 2.7 95% CI 1.8-4.1) and need for anatomic resection (HR 1.7 95% CI 1.0-2.9) as predictors of worse survival among sarcoma patients.  Delayed recurrence >2 years (HR 0.2 95% CI 0.1-0.5; HR 0.4 95% CI 0.2-0.8) and largest lesion <2cm (HR 0.5 95% CI 0.3-0.7; HR 0.6 95% CI 0.4-0.9) were associated with improved survival in sarcoma and non-sarcoma, respectively.

Conclusion:

Although recurrences of pulmonary metastasis tend to be more virulent in sarcoma, aggressive repeat resection when possible may better preserve survival in patients with sarcoma compared to non-sarcoma.  Patients with a longer time to recurrence and smaller lesions may be more likely to benefit from repeat surgical resection

48.05 Surgical Outcomes After CABG in Octogenarians: Does Higher Experience Equate Better Outcomes?

Posted on January 31, 2019

A. A. Haider1, A. Azim1, M. Bravo1, R. Latifi1, J. Goldberg1  1New York Medical College,Department Of Surgery,Valhalla, NY, USA

Introduction: As the US population ages, the number of octogenarian (≥80 years) population with coronary artery disease undergoing coronary artery bypass graft (CABG) is increasing. Studies have suggested that centers who manage a higher proportion of these patients may have better outcome for this high risk population. The aim of this study was to determine if centers that manage higher proportion of octogenarian patients undergoing CABG have better outcomes.

Methods:  The National Inpatient Sample was abstracted for all patients undergoing CABG for 3 years. Hospitals were divided into 4 groups of quartiles based on the percentage of their total CABG patient’s ≥80 years. Outcome measures were mortality and failure-to-rescue (death after a complication) and overall complications (Stroke, UTI, pneumonia, respiratory failure, DVT, PE, iatrogenic PTX etc). Multivariate regression models were created adjusting for age, gender, Charlson comorbidity index, disease severity, hospital volume, and nature of admission (elective/emergent).

Results: A total of 141,392 patients from 589 hospitals were included. Mean age was 65.9 ± 10.8 years, 72.3% were male, and mean Charlson Comorbidity Index was 1.39 ±1.42. Overall 10.8% (n=15,265) of the population that underwent CABG was octogenarian. The proportion of octogenarian patients in these hospitals undergoing CABG ranged from 6.7% in the lowest quartile group to 18.3% in the highest quartile group. The overall mortality rate in the octogenarian group was 5.1% and failure-to-rescue rate was 4.2%. Odds of mortality (OR, 0.97; 95% CI, 0.91–1.07) and FTR (OR, 0.99; 95% CI, 0.91–1.09) after CABG were similar at centers with lowest proportion of octogenarian patients compared with centers with higher proportion of octogenarians. Unadjusted rate of complications was higher in centers with higher proportion of octogenarian patients (43.7% vs. 39.8%; p=0.03) however, using multivariate analysis, the adjusted odds of complications remained similar (OR, 1.02; 95% CI, 0.98–1.07)

Conclusion: The overall proportion of octogenarian patients that undergo CABG at a center does not significantly affect its outcome for this group of patients. Octogenarian patients who are managed at hospitals that manage a lower proportion of these patients have similar outcomes. This evidence does not support the need for treating octogenarian patients at centers with higher proportion of CABG patients.

48.04 Are Post-Cardiac Surgery Outcomes Worse in End-Stage Renal Disease or Acute Kidney Injury Patients?

Posted on January 31, 2019

P. D. Kohtz1, B. R. Griffin2, S. Faubel2, S. Ambruso2, J. Teixeira2, M. Bronsert3, M. Wells1, C. Matter1, M. J. Weyant1, T. Reece1, J. D. Pal1, D. A. Fullerton1, J. C. Cleveland1, M. Aftab1  1University Of Colorado Denver,Cardiothoracic Surgery,Aurora, CO, USA 2University Of Colorado Denver,Division Of Nephrology,Aurora, CO, USA 3University Of Colorado Denver,Adult And Child Consortium For Health Outcomes Research And Delivery Science And Surgical Outcomes And Applied Research,Aurora, CO, USA

Objective: Patients with End Stage Renal Disease (ESRD) requiring hemodialysis are increasing worldwide. Cardiac surgery is reluctantly offered to these patients. ESRD is an established risk factor for patients undergoing surgery requiring cardiopulmonary bypass. Acute Kidney Injury (AKI) after cardiac surgery leads to a significant increase in post-operative mortality and morbidity. The objective of this study is to evaluate the influence of ESRD on post-operative outcomes. We further compared adjusted complications rates in ESRD patients to matched counterparts without any kidney disease, as well as to those who develop severe AKI following cardiac surgery.

Method: Using our local STS database from 2011-2016, we identified 2,536 surgical cases, of which 1,584 met inclusion criteria (Figure 1A).Within this group, 35 patients had ESRD at the time of surgery and 102 patients developed severe AKI (doubling of creatinine) following surgery. We performed unadjusted, multivariate, and propensity matched analyses comparing ESRD patients to those without renal injury and those who developed severe AKI following surgery. A 2:1 greedy match was used. All statistical tests were considered to be significant at a 2-sided p < .05.

Results: The in-hospital mortality was 2.9%. vs 2.5% (p = 0.9) in patients with and without ESRD. On bivariate analysis, there were no significant differences in preoperative cardiogenic shock (p=0.5), mean Charlson comorbidity index (p=0.9) and cardiopulmonary bypass time (p=0.7) between the groups. In both models, propensity matching was successful, as defined by standard error values < 0.1 in all variables. There was no difference in propensity matched post-surgical infection (p=0.46), intensive care unit (ICU) length of stay (p=0.77), or 30-day readmission rate (p=0.58) in the ESRD patients compared to those with normal renal function. When compared to patients with severe AKI following surgery, on propensity-matched analysis, ESRD patients had dramatically lower risks of post-surgical infection (p=0.005) and ICU LOS (p=0.03) (Figure 1B-C). Median follow up of ESRD group was 21.5 months (Range: 1-71 months) and 5-year KM-estimated survival for ESRD patients was 61% (Figure 1D).

Conclusion: In dialysis dependent patients with ESRD, major cardiac surgery procedures can be performed with acceptable perioperative risks and early mortality. There is no significant difference in post-surgical complications compared to those with normal renal function or post-operative AKI. ESRD patients had much lower rates of infections and ICU length of stay compared to those who developed severe post-operative AKI following surgery.

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