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EGS plus: Predicting futility in LVAD patients with emergency surgical disease

  • Aubrey Place
    Correspondence
    Corresponding author. Department of Surgery, University of Utah School of Medicine, USA
    Affiliations
    Department of Surgery, University of Utah School of Medicine, USA

    Division of General Surgery, University of Utah School of Medicine, 30 N 1900 East, Salt Lake City, UT, 84132, USA
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  • Marta McCrum
    Affiliations
    Department of Surgery, University of Utah School of Medicine, USA

    Division of General Surgery, University of Utah School of Medicine, 30 N 1900 East, Salt Lake City, UT, 84132, USA
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  • Teresa Bell
    Affiliations
    Department of Surgery, University of Utah School of Medicine, USA
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  • Raminder Nirula
    Affiliations
    Department of Surgery, University of Utah School of Medicine, USA

    Division of General Surgery, University of Utah School of Medicine, 30 N 1900 East, Salt Lake City, UT, 84132, USA
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Published:October 16, 2022DOI:https://doi.org/10.1016/j.amjsurg.2022.10.031

      Highlights

      • Morality for EGS patients with LVADs is acceptably low and should not necessarily preclude surgical intervention.
      • Preoperative sepsis and intestinal ischemia are independent predictors of mortality in EGS patients with LVADs.
      • LVAD patients over the age of 70 with sepsis have a conditional probability of death of greater than 80%.

      Abstract

      Background

      While emergent, non-cardiac surgery can be safely performed in LVAD patients, the inherent perioperative challenges of these rare procedures and the perception that these patients may be poor surgical candidates can contribute to reluctance to perform necessary emergency general surgery (EGS) procedures. We, therefore, sought to identify predictors of inpatient mortality to assist perioperative decision-making.

      Methods

      The Nationwide Inpatient Sample (2010-2015Q3) was used to identify patients with previously placed LVADs with a subsequent EGS admission diagnosis. Multivariable logistic regression analysis was performed to identify independent predictors of 30-day mortality, and a risk-adjusted probability of death was calculated for significant patient subgroups across age. Additional demographic variables were included in the regression due to clinical relevance.

      Results

      There were 1805 (weighted) LVAD-EGS patients with an overall mortality rate of 11%. Independent predictors of mortality were intestinal ischemia and sepsis present on admission. Patients older than 70 with sepsis had an 80% probability of in-hospital mortality (10.6 OR, 1.70–65.5 95% CI) while those over 70 presenting with intestinal ischemia had a 38% probability of death (3.6 OR, 1.50–8.78 95% CI). Mortality risk for younger patients with sepsis was still approximately 50%.

      Conclusion

      Older LVAD patients presenting with either sepsis or intestinal ischemia have a substantial mortality risk while younger patients have a modest risk. These results can be used to guide treatment discussions when emergency surgery is being considered in LVAD patients.
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