Death: 3. Interpretation: The results of this trial indicate that concomitant tricuspid valve repair at the time of mitral valve surgery among patients with These are interesting findings.
Indeed, in this trial,. Share via:. Mitral Valve Surgery Alone. Of note, our prior analysis of post-operative infections identified pneumonia as the most frequent infection [ 11 ]. Respiratory bundling strategies to reduce pneumonia risk include: ventilator bundles, respiratory physiotherapy, and early ambulation [ 17 ]. Primary surgical site infections were the first and third most common source of infection-related readmission and similarly demonstrate the need for greater attention to processes of care.
Relatively simple measures such as appropriate timing and dosing of antibiotics, attention to skin preparation, discontinuation of antibiotics after 24 hours, and hand washing have been demonstrated to reduce surgical site infections [ 18 ].
Unfortunately, previous studies have demonstrated that compliance with the aforementioned bundling strategies and process of care performance measures is poor [ 19 ].
With a growing focus on reducing readmissions, greater adoption of and attention to these strategies will be critical. Arrhythmias, volume overload, and pleural effusions also served as common etiologies for readmission. Previous studies have demonstrated that a significant fraction of cardiac surgery patients experience postoperative atrial fibrillation and that such patients are susceptible to continuing arrhythmias after discharge [ 20 ].
There is wide variation in the management of post-operative atrial fibrillation, including the use of anti-arrhythmic medications and anticoagulants during and after hospitalization.
Furthermore, patient compliance with post-operative anti-arrhythmic drug therapy is unknown. Post-operative atrial fibrillation is a common complication which, in our analysis, is also a common cause of readmission.
Future, prospective studies directed at the peri-operative and post-discharge management of atrial fibrillation are necessary. Readmissions for volume overload and pleural effusions identify the need for more careful attention to post-operative fluid management. Patients undergoing cardiac surgery are subject to wide fluctuations in fluid balance.
Diurectics are commonly used to achieve a net negative fluid balance, but the degree to which patients are diuresed is often arbitrary and in response to pre-operative weight measurement and chest x-ray or physical exam findings demonstrating volume overload. Moreover, there are no specific guidelines for the dose and duration of diuretics upon discharge. Thus, greater attention to fluid balance in a more objective and consistent manner may allow for reductions in readmissions for volume overload and pleural effusions.
This area also warrants further investigation in prospective studies. Several studies have focused on the use of explicit and well documented transition in care plans as means of reducing hospital readmissions. Given the high volume of cardiac surgery in the United States and the cost of such interventions, focusing readmission interventions on high-risk populations might make readmission reduction strategies more feasible across a broader range of hospitals.
We demonstrate an association between complexity of the index surgical procedure and risk of readmission, with isolated CABG demonstrating the lowest readmission rate. Patients undergoing placement of ventricular assist devices and heart transplantation, however, demonstrated the highest risk of readmission.
Thus, patients undergoing more complex surgical procedures would appear to derive relatively greater benefit from readmission reduction programs. When baseline characteristics were studied, female gender, treated diabetes mellitus, COPD, elevated creatinine, lower hemoglobin, and longer surgery correlated with increased risk of readmission. Several of the aforementioned risk factors observed in our analysis have been identified by other investigators and correlate with the most common etiologies for readmission [ 21 ].
Patients with diabetes mellitus have a higher risk of readmission for infections. Patients with COPD may also be at higher risk for developing pneumonia after surgery. Individuals with ventricular assist devices, prolonged surgery duration, and elevated serum creatinine are sensitive to fluid management and at higher risk for readmission for volume overload.
Gender has been reported previously though its correlation with increased risk of readmission is less clearly understood [ 22 ]. These baseline factors as well as the influence of baseline hemoglobin on readmission risk require further exploration. Hospital readmissions place strain on resource utilization with patients who are readmitted spending a median of 5 additional days in the hospital.
Future readmission reduction initiatives will be necessary given the need for quality improvement and the anticipated expansion of readmission penalties to cardiac surgery. Future studies will be needed to determine which readmission strategies are most effective for cardiac surgical patients.
Given the fact that median time from surgery to first readmission in our study was 22 days, one simple solution might be for patients to return to the hospital earlier for their first scheduled post-operative visit, as is now commonly applied to patients after hospitalization for decompensated heart failure.
In-patient educational initiatives focused on high risk patients is a second strategy that could reinforce medication compliance and early reporting of worrisome symptoms.
Lastly, return visit educational programs or telephone outreach are additional, albeit more costly, programs for readmission reduction. Many of these strategies are already utilized in high volume surgical centers. There are several limitations to our analysis. First, data are representative of readmission rates at academic medical centers and do not include outcomes at non-academic centers. Second, in our analysis, we did not consider the impact of socioeconomic status as this information was not collected.
In addition, complications that occurred during the index hospitalization may be risk factors for future readmissions. We did not collect non-infection related complications during the index hospitalization in this prospective study, and, therefore, did not include any complications including infection in the model.
Lastly, since the primary purpose of the infections observational study was to capture infections within 65 days of cardiac surgery, the timing and numbers of readmissions were constrained by the index length of stay. Overall readmissions after cardiac surgery remain relatively high with infections serving as a leading cause for readmission. Patient undergoing complex cardiac surgical procedures are at higher risk of readmission with additional risk factors including female gender, diabetes, COPD, elevated creatinine, lower hemoglobin, and longer surgery time.
Our analysis not only demonstrates the timing and etiology of readmissions in a prospective cohort of patients but also identifies high risk groups of patients that may ultimately benefit from more focused readmission reduction strategies. Heart failure, ejection fraction, previous cardiac surgery, hypertension, baseline VAD, baseline intra-aortic balloon pump.
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National Center for Biotechnology Information , U. Ann Thorac Surg. Author manuscript; available in PMC Oct 1. Alexander , MD, 3 A. Moskowitz , MD, 2 and Patrick T. John H. Marc Gillinov. John D. Michael A. Bruce Ferguson. Louis P. Karen C. Joseph J.
Kim T. Alan J. Smith, M. It has been involved in about 20 trials over the years. Today, as more people become vaccinated against COVID and restrictions are lifted, the CTSN is beginning once again to resume its original mission of conducting clinical trials in cardiac surgery and using the findings to improve patient outcomes.
July 12, Its work did not slow down for long, however.
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