Predicting In-Hospital Mortality After Redo Cardiac Operations: Development of a Preoperative Scorecard

doi:10.1016/j.athoracsur.2012.04.062

The Annals of Thoracic Surgery

Volume 94, Issue 3, September 2012, Pages 778-784

https://doi.org/10.1016/j.athoracsur.2012.04.062 Get rights and content

Background

The present study generated a risk model and an easy-to-use scorecard for the preoperative prediction of in-hospital mortality for patients undergoing redo cardiac operations.

Methods

All patients who underwent redo cardiac operations in which the initial and subsequent procedures were performed through a median sternotomy were included. A logistic regression model was created to identify independent preoperative predictors of in-hospital mortality. The results were then used to create a scorecard predicting operative risk.

Results

A total of 1,521 patients underwent redo procedures between 1995 and 2010 at a single institution. Coronary bypass procedures were the most common previous (58%) or planned operations (54%). The unadjusted in-hospital mortality for all redo cases was higher than for first-time procedures (9.7% vs. 3.4%; p < 0.001). Independent predictors of in-hospital mortality were a composite urgency variable (odds ratio [OR], 3.47), older age (70–79 years, OR, 2.74; ≥ 80 years, OR, 3.32), more than 2 previous sternotomies (OR, 2.69), current procedure other than isolated coronary or valve operation (OR, 2.64), preoperative renal failure (OR, 1.89), and peripheral vascular disease (PVD) (OR, 1.55); all p < 0.05. A scorecard was generated using these independent predictors, stratifying patients undergoing redo cardiac operations into 6 risk categories of in-hospital mortality ranging from < 5% risk to > 40%.

Conclusions

Reoperation represents a significant proportion of modern cardiac surgical procedures and is often associated with significantly higher mortality than first-time operations. We created an easy-to-use scorecard to assist clinicians in estimating operative mortality to ensure optimal decision making in the care of patients facing redo cardiac operations.

Section snippets

Patients

This single-center retrospective cohort study included all patients who underwent a redo cardiac surgical procedure in which the initial and subsequent procedures were performed through a median sternotomy at the Queen Elizabeth II Health Sciences Centre in Halifax, Canada from March 1995 to December 2010. Thoracotomy procedures, ventricular assist device implantations, and transplantations were excluded from the study population. Indications for redo procedures were based on a weekly peer

Patient Population

Between March 1995 and December 2010, 17,645 patients underwent cardiac procedures at the Queen Elizabeth II Health Sciences Centre. Of these patients, 1,521 (8.6%) underwent a redo cardiac surgical procedure in which the first and subsequent procedures were performed through a median sternotomy; these patients were included in the analysis. The majority of the patients were men (69.5%) and the average age was 63.3 years ± 14.3 years; 17.7% of patients who underwent redo procedures had an EF

Comment

We identified a large group of patients undergoing redo cardiac procedures (n = 1521) and reported an unadjusted in-hospital mortality rate of 9.7%, significantly higher than the mortality rate of patients undergoing a first-time procedure at the same institution during the study period, which was 3.4%. Several independent predictors of mortality were identified, including the composite urgency variable, older age, number of redo procedures, current procedure type, preoperative renal failure,

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To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest.
From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect.
Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2).
Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.
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Citation Excerpt :
In addition to incorporating institutional case volume, our models offer risk prediction for patients undergoing reoperation and thoracic aorta surgery. Reoperation is considered an important predictive factor for mortality for cardiac surgery patients and had been incorporated in a mortality prediction models.22 Without separate consideration for reoperation, the risk for these patients may be underestimated as reoperations would be considered equal to operations that did not require reoperation.
Most risk prediction models predicting short-term mortality after cardiac surgery incorporate patient characteristics, laboratory data, and type of surgery, but do not account for surgical experience. Considering the impact of case volume on patient outcome after high-risk procedures, we attempted to develop a risk prediction model for mortality after cardiac surgery that incorporates institutional case volume.
Adult patients who underwent cardiac surgery from 2009 to 2016 were identified. Patients who underwent cardiac surgery (n = 57,804) were randomly divided into the derivation cohort (n = 28,902) or the validation cohorts (n = 28,902). A risk prediction model for in-hospital mortality and 1-year mortality was developed from the derivation cohort and the performance of the model was evaluated in the validation cohort.
The model demonstrated fair discrimination (c-statistics, 0.76 for in-hospital mortality in both cohorts; 0.74 for 1-year mortality in both cohorts) and acceptable calibration. Hospitals were classified based on case volume into 50 or less, 50–100, 100–200, or more than 200 average cardiac surgery cases per year and case volume was a significant variable in the prediction model.
A new risk prediction model that incorporates institutional case volume and accurately predicts in-hospital and 1-year mortality after cardiac surgery was developed and validated.
Reoperative Cardiac Surgery Is a Risk Factor for Long-Term Mortality
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Citation Excerpt :
Adverse events during reoperative cardiac surgery are related to the complexity of the procedure and have been associated with a lack of preventative strategies for sternal reentry.39 Protocol-driven approaches (eg, routine femoral cannulation access and preoperative computed tomography angiography) have shown some promise in reducing associated mortality from sternal reentry,40 and standardized preoperative risk assessment can aid in operative planning.14 Beyond efforts to minimize perioperative morbidity and mortality, it is important to consider the long-term impact of multiple cardiac reoperations on the patient and the hospital system.
Reoperative cardiac surgery has been associated with increased morbidity and mortality. Large propensity-matched series comparing all first-time and redo cardiac operations are lacking. The primary objective of the current study was to provide detailed outcomes and risk factors for mortality and readmissions after reoperative cardiac surgery.
All patients who underwent cardiac surgery from 2011 to 2017 were included. Propensity matching yielded equitable cohorts. Multivariable Cox regression analysis was performed to identify independent predictors of 30-day, 1-year, and 5-year mortality and readmissions.
A total of 14,151 patients underwent cardiac surgery, of which 1700 (12%) had reoperative cardiac surgery. There were significantly (P < .001) more comorbidities in the reoperative cardiac surgery group. Propensity matching yielded 1696 patients in each cohort. After propensity matching, operative mortality (8.37% vs 6.07%; P = .01), blood product transfusion (54.7% vs 46.2%; P < .001), and prolonged ventilator requirements (>24 hours) (20% vs 17%; P = .02) were increased for the reoperative cohort. On multivariable analysis for propensity-matched cohorts, reoperation was an independent predictor of mortality at 30 days (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.05-1.75; P = .02), 1 year (HR, 1.30; 95% CI, 1.09-1.55; P = .004), and 5 years (HR, 1.30; 95% CI, 1.14-1.5; P = .002).
After risk-adjusting for baseline characteristics, the need for reoperation was an independent predictor of both short-term and long-term mortality after reoperative cardiac surgery. These data are relevant when considering alternative therapies such as percutaneous coronary or transcatheter valve interventions.

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Original articleAdult cardiacPredicting In-Hospital Mortality After Redo Cardiac Operations: Development of a Preoperative Scorecard

Background

Methods

Results

Conclusions

Section snippets

Patients

Patient Population

Comment

Contemporary results show repeat coronary artery bypass grafting remains a risk factor for operative mortality

Ann Thorac Surg

The 1996 coronary artery bypass risk model: the Society of Thoracic Surgeons Adult Cardiac National Database

Ann Thorac Surg

A model that predicts morbidity and mortality after coronary artery bypass graft surgery

J Am Coll Cardiol

Reoperative coronary artery bypass grafting: analysis of early and late outcomes

Ann Thorac Surg

In-hospital and long-term outcome after reoperative coronary artery bypass graft surgery

Circulation

Analysis of mortality within the first six months after coronary reoperation

Ann Thorac Surg

The changing pattern of reoperative coronary surgery: trends in 1230 consecutive reoperations

J Thorac Cardiovasc Surg

Reoperative coronary artery bypass procedures: risk factors for early mortality and late survival

Eur J Cardiothorac Surg

Is reoperation still a risk factor in coronary artery bypass surgery?

Ann Thorac Surg

Original article
Adult cardiac
Predicting In-Hospital Mortality After Redo Cardiac Operations: Development of a Preoperative Scorecard