Background: While liver disease increases surgical risk, it is not accounted for in the Society for Thoracic Surgeons (STS) risk calculator. This study assessed the impact of Model for End-stage Liver Disease (MELD) on outcomes after cardiac surgery and the additional predictive value of MELD in the STS risk model. Methods: De-identified records of 21,272 patients were extracted from a regional STS database. Inclusion criteria were any cardiac operation with a risk score available (2011)(2012)(2013)(2014)(2015)(2016). Exclusion criteria included missing MELD (n=2,895) or preoperative anticoagulation (n=144). Patients were stratified into three categories, MELD <9 (low), MELD 9-15 (moderate), and MELD >15 (high). Univariate and multivariate logistic regression assessed risk-adjusted associations between MELD and operative outcomes.Results: Increasing MELD scores were associated with greater comorbid disease, mitral surgery, prior cardiac surgery and higher STS predicted risk of mortality (1.1%, 2.3%, 6.0% by MELD category, p<0.0001). The operative mortality rate increased with increasing MELD score (1.6%, 3.9%, and 8.4%, p<0.0001). By logistic regression, MELD score was an independent predictor of operative mortality (OR 1.03 per MELD score point, p<0.0001) as were the components total bilirubin (OR 1.22 per mg/dL, p=0.002) and INR (OR 1.40 per unit, p<0.0001). Finally, MELD score was independently associated with STS major morbidity, and the component complications renal failure and stroke.
The COVID-19 pandemic has had significant ramifications for provider well-being. During these unprecedented and challenging times, one institution's Department of Surgery put in place several important initiatives for promoting the well-being of trainees as they were redeployed to provide care to COVID-19 patients. In this article, the authors describe these initiatives, which fall into 3 broad categories: redeploying faculty and trainees, ensuring provider safety, and promoting trainee wellness. to have a plethora of human resources at their institution that made the significant efforts described in this article possible. The authors want to thank institutional leadership and staff for their important work. They also want to acknowledge departmental and program director leadership of general, vascular, thoracic, oral and maxillofacial, and plastic surgery who provided steadfast support. Finally, the authors want to acknowledge the wonderful leadership of the 2020 general, vascular, thoracic, oral and maxillofacial, and plastic surgery chief residents.
Introduction With the increased demand for veno-venous extracorporeal membrane oxygenation (VV ECMO) during the COVID-19 pandemic, guidelines for patient candidacy have often limited this modality for patients with a body mass index (BMI) less than 40 kg/m2. We hypothesize that COVID-19 VV ECMO patients with at least class III obesity (BMI ≥ 40) have decreased in-hospital mortality when compared to non-COVID-19 and non-class III obese COVID-19 VV ECMO populations. Methods This is a single-center retrospective study of COVID-19 VV ECMO patients from January 1, 2014, to November 30, 2021. Our institution used BMI ≥ 40 as part of a multi-disciplinary VV ECMO candidate screening process in COVID-19 patients. BMI criteria were not considered for exclusion criteria in non-COVID-19 patients. Univariate and multivariable analyses were performed to assess in-hospital mortality differences. Results A total of 380 patients were included in our analysis: The COVID-19 group had a lower survival rate that was not statistically significant (65.7% vs.74.9%, p = .07). The median BMI between BMI ≥ 40 COVID-19 and non-COVID-19 patients was not different (44.5 vs 45.5, p = .2). There was no difference in survival between the groups (73.3% vs. 78.5%, p = .58), nor was there a difference in survival between the COVID-19 BMI ≥ 40 and BMI < 40 patients (73.3, 62.7, p= .29). Multivariable logistic regression with the outcome of in-hospital mortality was performed and BMI was not found to be significant (OR 0.99, 95% CI 0.89, 1.01; p = .92). Conclusion BMI ≥ 40 was not an independent risk factor for decreased in-hospital survival in this cohort of VV ECMO patients at a high-volume center. BMI should not be the sole factor when deciding VV ECMO candidacy in patients with COVID-19.
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