Research Spotlight

Curcio, N., L. Philpot, M. Bennett, J. Felius, M. B. Powers, J. Edgerton and A. M. Warren (2018). “Anxiety, depression, and healthcare utilization 1year after cardiac surgery.” Am J Surg Dec 11. [Epub ahead of print].

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BACKGROUND: While it is known that depression and anxiety influence cardiac surgery recovery, the mechanisms of such remain unclear. We examined the influence of anxiety and/or depression on health care utilization and quality of life (QOL) in the 12 months following cardiac surgery. METHODS: (N=306) patients at two North Texas hospitals were assessed pre-operatively, at 30 days, and one year post-operatively using the Hospital Anxiety and Depression Scale and Kansas City Cardiomyopathy Quality of Life measures. Patient healthcare utilization metrics included length of stay, outpatient visits, hospital stays, emergency department (ED) visits, and home healthcare. RESULTS: At 12 months post-surgery, anxious patients sustained more outpatient visits (p = 0.0129) than those without anxiety. Depressed patients differed significantly from non-depressed patients with significantly lower QOL (p<0.01), as well as more readmissions, ED visits, home healthcare use, and a longer length of stay (all p<0.05). CONCLUSIONS: Depressed patients utilized more expensive healthcare services and had lower QOL at 12 months follow up compared to non-depressed patients. Targeting depressed patients for intervention may foster a faster recovery and reduce excessive healthcare burden.

Colbert, G. B. and H. M. Szerlip (2019). “Euvolemia-A critical target in the management of acute kidney injury.” Semin Dial 32(1): 30-34.

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It has been clearly established that critically ill patients with sepsis require prompt fluid resuscitation. The optimal amount of fluid and when to taper this resuscitation is less clear. There is a growing evidence that fluid overload leads to acute kidney injury, and increased morbidity and mortality. A clinician’s best intentions in resuscitating a patient can lead to too much of a good thing. Currently, there are several bedside tools to aid in determining a patient’s response to a fluid challenge as well as in the assessment of the current volume status. Guidelines are not available on the exact rate of fluid overload removal and what medicinal or mechanical modality is most favorable. We discuss our experience and an examination of the literature on the problems with fluid overload, and how a patient may benefit from forced fluid removal.

Blackstone, E. H., H. L. Chang, J. Rajeswaran, M. K. Parides, H. Ishwaran, L. Li, J. Ehrlinger, A. C. Gelijns, A. J. Moskowitz, M. Argenziano, J. J. DeRose, Jr., J. P. Couderc, D. Balda, F. Dagenais, M. J. Mack, G. Ailawadi, P. K. Smith, M. A. Acker, P. T. O’Gara and A. M. Gillinov (2019). “Biatrial maze procedure versus pulmonary vein isolation for atrial fibrillation during mitral valve surgery: New analytical approaches and end points.” J Thorac Cardiovasc Surg 157(1): 234-243.e239.

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OBJECTIVE: To use novel statistical methods for analyzing the effect of lesion set on (long-standing) persistent atrial fibrillation (AF) in the Cardiothoracic Surgical Trials Network trial of surgical ablation during mitral valve surgery (MVS). METHODS: Two hundred sixty such patients were randomized to MVS + surgical ablation or MVS alone. Ablation was randomized between pulmonary vein isolation and biatrial maze. During 12 months postsurgery, 228 patients (88%) submitted 7949 transtelephonic monitoring (TTM) recordings, analyzed for AF, atrial flutter (AFL), or atrial tachycardia (AT). As previously reported, more ablation than MVS-alone patients were free of AF or AF/AFL at 6 and 12 months (63% vs 29%; P < .001) by 72-hour Holter monitoring, without evident difference between lesion sets (for which the trial was underpowered). RESULTS: Estimated freedom from AF/AFL/AT on any transmission trended higher after biatrial maze than pulmonary vein isolation (odds ratio, 2.31; 95% confidence interval, 0.95-5.65; P = .07) 3 to 12 months postsurgery; estimated AF/AFL/AT load (ie, proportion of TTM strips recording AF/AFL/AT) was similar (odds ratio, 0.90; 95% confidence interval, 0.57-1.43; P = .6). Within 12 months, estimated prevalence of AF/AFL/AT by TTM was 58% after MVS alone, and 36% versus 23% after pulmonary vein isolation versus biatrial maze (P < .02). CONCLUSIONS: Statistical modeling using TTM recordings after MVS in patients with (long-standing) persistent AF suggests that a biatrial maze is associated with lower AF/AFL/AT prevalence, but not a lower load, compared with pulmonary vein isolation. The discrepancy between AF/AFL/AT prevalence assessed at 2 time points by Holter monitoring versus weekly TTM suggests the need for a confirmatory trial, reassessment of definitions for failure after ablation, and validation of statistical methods for assessing atrial rhythms longitudinally.

Beteck, B., W. Shutze, B. Richardson, R. Shutze, K. Tran, A. Dao, G. O. Ogola and G. Pearl (2019). “Comparison of Athletes and Nonathletes Undergoing Thoracic Outlet Decompression for Neurogenic Thoracic Outlet Syndrome.” Ann Vasc Surg 54: 269-275.

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BACKGROUND: Neurogenic thoracic outlet syndrome (NTOS) is the most common form of thoracic outlet syndrome (TOS) and may occur from injury, occupational stress, or athletic endeavors. Although most patients with NTOS will improve after first-rib resection and scalenectomy (FRRS), the prognostic risk factors for success remain unclear. Athletes are a very motivated and disciplined demographic and therefore should be a group more likely to respond to FRRS for NTOS than nonathletes. We hypothesized that athletes would do better after FRRS than nonathletes despite the added physical stress that sporting activity imposes. METHODS: We reviewed our office records for all patients treated for TOS from July 2009 to May 2014 and extracted demographic, historical, procedural, and follow-up data. We contacted these patients to complete a survey to assess patient-centered outcomes of FRRS and compared athlete versus nonathlete survey responses. RESULTS: Five hundred sixty-four patients had FRRS for NTOS, and 184 (33%) responded to the survey. Of the 184 who responded, 97 were athletes (53%) and 87 were nonathletes (47%). Survey results suggested that 87% were improved in pain medication use (athletes 93% vs. nonathletes 80%, P = 0.013), 77% would undergo FRRS on the contralateral side if needed (athletes 75% vs. nonathletes 79%, P = 0.49), 73% had resolution of TOS symptoms (athletes 80% vs. nonathletes 65%, P = 0.02), and 86% could perform activities of daily living without limitation (athletes 95% vs. nonathletes 77%, P = 0.0004). Although 24% of respondents required another non-TOS procedure (athletes 27% vs. nonathletes 22%, P = 0.6), 89% felt that they had made the right decision (athletes 93% vs. nonathletes 80%, P = 0.09). Multivariable analysis of age, race, gender, previous surgery, preoperative physical therapy, preoperative narcotic use, and athletic status confirmed that athletic status was a significant predictor for improvement in pain medication use, complete TOS resolution, and the ability to perform activities of daily living. CONCLUSIONS: Most patients undergoing FRRS for NTOS are improved and satisfied with the result and indicate they made the correct choice to have FRRS. Although being an athlete was an independent variable for better outcomes in activity and pain medication use, their satisfaction after FRRS was similar to that in nonathletes. Further investigation is needed to determine if these findings are due to physical and/or psychosocial factors.

Asrani, S. K. and J. Hasse (2018). “Bariatric surgery and long-term outcomes.” Liver Transpl Dec 24. [Epub ahead of print].

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We appreciate the interest in our work by Professor Yildiz looking at the association between bariatric surgery and outcomes among patients evaluated for liver transplantation.(1) We share the sentiment that some of the outcomes noted in the study may be related to malabsorptive rather than restrictive weight reduction surgery. As reflected in the results, rates of delisting or death were high for gastric bypass versus non-gastric bypass patients (44% vs. 16.7%, p<0.01). However, rates of moderate or severe malnutrition were similar between the groups (68% vs. 57%, p=0.5). Hence, in this analysis of historical data it is hard to assess whether it is the surgery itself of consequence of malnutrition regardless of surgery type that are driving the effect.