[HSF] RE: risk adjusted mortality

[Ani Anyanwu]

Michael
 
We get three or so patients a year transferred from other centers with a BiVAD for postcardiotomy shock. As a rule they die, so salvage rate is extremely low (not managed to save one yet). Prognosis is poor usually because one of two conditions usually precipitated the postcardiotomy shock either i) the patient was undergoing the wrong surgery - typically redo CABG in low EF patient rather than referring patient for transplant, so potential of recovery is zero and chances of bridge to transplant at this stage low because of sepsis and multiorgan dysfunction in the background of a 'dead' heart or ii) postcardiotomy failure arising from medical misadventure such as an occluded coronary artery or poor preservation which results in irreversible cardiac damage. While I always try to say no to these transfers and the end of the day I say yes because on balance the chances of survival (even if ultraslim) would be better if the patient was in a VAD/transplant center, so we are there best chance.  These patients however haemorrhage resources and money and are often a financial loss to the institution so no one wants them. 
 
I pay no attention to state or STS reports so have no idea where these mortalities stand. Only surgeons who have impeccable results and ultra low mortalities tend to care about statistics. I do not aspire for a zero-mortality. I know I have deaths and always will so far as I am in the business of VADs, heart failure and low-EF surgery so does not bother me whether a death goes under my name or someone else's. Few great surgeons, department chiefs etc have these ultralow mortalities - they give all comers a chance and try and try and try to save life and in the process many die but a few are saved. They never say no.  
 
I find the whole thing (mortality tables) to be a farce - as Hal points out more often than not patient selection (or rejection) rather than superior provision of surgery is responsible for these ultra-low mortalities. Maybe a good study will be to look at mortality by patients' zip code rather than by surgeon or center and i suspect you will find that in many of these zero mortality hospitals, the true mortality rates for the disease (e.g. severe AS) in that community will be higher because the sicker or higher risk patients are turned down and die without surgery, or go elsewhere and some end up dying. Sometimes the selection, unbeknownst to the surgeon who states he never turns patients down, is done by cardiologists who send all the nice or easy cases to his center (which then ends up with ultralow mortality) and sends the technically-difficult or high risk cases to center B (who will have a higher mortality). Risk adjustment does not deal with this effect as technical difficulties (for example 4th time sternotomy, infected graft, prior homograft, congenital anomalies etc), patient factors (e.g. jehovah's witness in redo patient) and non-cardiac diseases (e.g. awaiting liver transplant) that drive such tertiary referrals are not factored into risk models. One can easily get a feel for such selection process by inquiring on the duration of ICU stay or tracheostomy. A center where 9 of 10 are out of ICU in a day and the ICU gets empty on a Sunday cannot be doing much complex or high-risk surgery as it is impossible to do these cases, such as the triple valve in cachetic lady Hal described today, without the majority needing extended (>24h) ICU stay and some needing protracted ICU stay and tracheostomy. Yet if you looked at risk scores most centers will appear to have similar complexity and risk load.
 
The Boston meeting (international society for heart and lung transplantation) was okay. Some new stuff on VADs mainly - I am sure your colleague will feed back to you - but reassuring to know we all get the same disaster patients and all have the same problems! Two things you can think of though was a paper from Texas heart with several fatalities and major thormbotic events from Factor VII administration and a comment from a Vancouver surgeon that they run all ECMO cases (longest duration 2 weeks) without heparin (using bonded circuits only).
 
Ani
 
 



> From: msfirst at gmail.com> Subject: Re: [HSF] RE: risk adjusted mortality> Date: Sun, 13 Apr 2008 07:58:49 -0400> To: OpenHeart-L at lists.hsforum.com> CC: > > Ani,> Being a major VAD center - how many post-op failure to weans do you > get? How many of those survive?> and those that dont - do they show up on the local (or STS for that > matter) reports?> > Hope you enjoyed Boston - too bad we didnt meeting - but anything in > particular catch your eye?> > -michael> On Apr 13, 2008, at 7:01 AM, Hgrmd at aol.com wrote:> > > Ani,> > It is frustrating to have the docs in the community braying > > about their> > great results when it's a dirty little secret that they are also > > depriving a> > few deserving patients an operation. Last week, I did a redo > > triple valve maze> > on a cachectic 81 yo lady who had been turned down by another > > surgeon in> > town 2 years earlier. According to the daughter, the surgeon said > > the CT showed> > too much aortic calcification to do the operation safely. Well, I > > got a> > cath and did note there was heavy calcification of the root with a > > line of> > calcium going up the right side of the ascending aorta. However, > > the aorta was> > definitely not porcelain. I did the operation uneventfully (AVR, > > mitral and> > tricuspid repairs, C-M). There was no problem clamping the aorta, > > and she woke> > up neurologically intact. Unfortunately, she was so cachectic, I > > couldn't> > wean her from the vent (good O2 on 35% and +5). She was trached > > last Friday,> > and I predict she will eventually recover. The lessons? I've > > found CT> > generally overestimates the amount of clinically relevant > > calcification. Fluoro> > is a much better predictor. Finally, surgeons can keep their > > records> > pristine if they cherry pick. However, unless their are guys like > > me to take care> > of a lot of their rejects, the community suffers from unnecessary > > deaths of> > omission.> >> > Hal> >> >> >> > **************It's Tax Time! Get tips, forms and advice on AOL Money &> > Finance. (http://money.aol.com/tax?NCID=aolcmp00300000002850)> > _______________________________________________> > OpenHeart-L mailing list> >> > Send postings to:> > OpenHeart-L at lists.hsforum.com> >> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> > http://mmp.cjp.com/mailman/listinfo/openheart-l> >> > All messages transmitted by the OpenHeart-L are subject to the > > policies and> > disclaimers posted at:> > http://www.hsforum.com/listdisclaim> > -----------------------------------------> > _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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