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Featured Articles: Narrative Review Article

The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes

Del Rio, J. Mauricio MD*; Abernathy, James (Jake) III MD, MPH; Taylor, Mark A. MD; Habib, Robert H. PhD§; Fernandez, Felix G. MD, MSc; Bollen, Bruce A. MD; Lauer, Ryan E. MD#; Nussmeier, Nancy A. MD**; Glance, Laurent G. MD††; Petty, Joseph V. III MD‡‡; Mackensen, G. Burkhard MD, PhD§§; Vener, David F. MD‖‖; Kertai, Miklos D. MD, PhD¶¶

Author Information
doi: 10.1213/ANE.0000000000005093

The Society of Cardiovascular Anesthesiologists (SCA) developed the Adult Cardiac Anesthesiology Section of the Adult Cardiac Surgery Database (ACSD) in collaboration with The Society of Thoracic Surgeons (STS) as an essential step toward improving clinical care and demonstrating value of cardiac surgical team effort in the present era of value-based care reimbursement models.1 SCA leadership recognized that a well-designed, comprehensive, accurate, and accessible global registry would identify critical factors that contribute to safe and high-quality care of cardiac surgical patients. Such a registry would provide data to evaluate anesthetic techniques and their relationship to patient outcomes, thereby informing research efforts and establishing a foundation to define quality of care in cardiac anesthesiology, in connection with thoughtful management and cost containment.

The first STS collaboration with anesthesiologists began in 2010 and was focused on patients enrolled in the STS Congenital Heart Surgery Database in conjunction with the Congenital Cardiac Anesthesia Society.2,3 More recently, from 2015 until 2018, data from adult patients undergoing cardiac surgical procedures has been contributed to the Adult Cardiac Anesthesiology Section of the STS ACSD, with the goal of providing multiinstitutional contemporary information regarding clinical practices, quality measures, and patient outcomes related to the management of cardiothoracic anesthesiology in these patients. Current and future research opportunities are also emphasized. As of December 2019, 1088 groups comprising 3036 surgeons from all 50 states in the United States (US) participate in the Adult Cardiac Surgery Section of the STS Database, and of these, only 70 groups encompassing 797 anesthesiologists participate in the optional STS/SCA Adult Cardiac Anesthesiology Section. Participant institutions and their locations are presented4 in Supplemental Digital Content, Table 1, https://links.lww.com/AA/D164. Given the STS ACSD workflow for data harvest and processing, the data presented and reviewed here were collected between 2015 and 2018.

Historical Perspective

The Institute of Healthcare Improvement summarizes the contemporary goals for health care as a triple aim that includes “improving the experience of care, improving the health of populations, and reducing the per-capita cost of health care.”5 Many stakeholders in the process, including patients, clinicians, multidisciplinary providers, health plans, institutions, and government agencies, share these goals at varying levels and are the ultimate drivers of health care. Indeed, the concept of “value-based health care” was proposed as a comprehensive path that would align the objectives and performance of all parties involved toward improvement of the patients’ health outcomes and experience.6 “Value” in health care is determined by measuring the improvement in a specific patient’s outcome relative to the cost incurred during the process.5–7 Within this framework, to develop solutions that meet the needs of cardiac surgical patients, the aim of the STS and SCA collaboration is to collect data that allows measurement of “value” in specific health outcomes of cardiac surgical patients. However, the purpose of this collaboration is not to capture actual financial or cost data relative to surgical and anesthesia care because this information is subject to frequent changes and regulations.

The creation of an optional Adult Cardiac Anesthesiology Section within the STS ACSD intended to capture data elements needed to address the influence of cardiac anesthesiologists’ involvement on patient outcomes.8 Furthermore, a group of data fields in this optional section documents cardiopulmonary bypass (CPB) management techniques looking to determine potential interactions between anesthetic and clinical perfusion management.9 Participants in the Adult Cardiac Anesthesiology Section could be compared with expected, risk-adjusted benchmarks developed using STS ACDS data to create ratings similar to those provided by STS to surgical programs.

Overview of Quality and Outcomes Metrics

Many quality-of-care measures have been developed in recent decades. The initial intent of such indicators was to develop quality improvement processes that would address specific institutional or departmental deficiencies identified by external reviewers or regulatory bodies. The first institution that developed standards for health care organizations in the US was the Joint Commission on Accreditation of Hospitals, now known as The Joint Commission. Later, the Social Security Amendment Act allowed participation in Medicare and Medicaid to hospitals accredited by the Joint Commission on Accreditation of Hospitals [https://www.jointcommission.org/-/media/tjc/documents/about-us/tjc-history-timeline-through-2019-pdf.pdf, accessed January 28, 2020].

The Centers for Medicare and Medicaid Services (CMS) began releasing unadjusted clinical outcome data to the public in 1986.10 More recently, the Physician Quality Reporting Initiative program by CMS offered incentives to institutions that reported compliance with specific, standardized, and evidence-based supported quality measures. In 2010, the Affordable Care Act introduced penalties for institutions or providers that did not submit qualifying Physician Quality Reporting Initiative data. Now, all CMS-developed quality measurement indicators are included in the Merit-Based Incentive Payment System (MIPS). These measures are revised and updated annually.11 Another organization, the not-for-profit National Quality Forum (NQF), defines best measures and practices in health care. The federal government and many public and private organizations rely on NQF-endorsed measures and recommendations for determination of accountability, public reporting, and incentive programs [http://www.qualityforum.org/what_we_do.aspx, accessed January 29, 2020].

As a leader in patient safety and a major contributor to improving perioperative safe practices and outcomes, the American Society of Anesthesiologists responded to the need for continued improvement in quality of care and patient safety by establishing the Anesthesia Quality Institute (AQI). In turn, the AQI implemented the National Anesthesia Clinical Outcomes Registry as a source of quality data for specific benchmarking in anesthesiology [https://www.aqihq.org/about-us.aspx, accessed January 29, 2020].

Under the conceptual model of perioperative medicine, the performance of surgeons and anesthesiologists, as well as patient-specific and system factors, are all interrelated in determining eventual patient outcome results.12,13 The SCA/STS collaboration through the Adult Cardiac Anesthesiology Section of the STS ACSD is a major development in the emerging concept of “shared accountability”14 regarding perioperative outcomes in surgical patients. In this context, increased Adult Cardiac Anesthesiology Section participation along with collaborative and comprehensive analysis of the global STS ACSD “cardiac team”—as opposed to separate professional groups analysis—could yield further evidence regarding the influence of different practice patterns on patient groups’ outcomes. Importantly, the Adult Cardiac Anesthesiology Section and STS ACSD data fields are adjusted and upgraded every 3 years. This process guarantees that changes and developments in the field are continuously captured and represented.

Quality and Outcome Indicators Relevant to Cardiac Surgery and Anesthesiology Practice

The specific measures relevant to cardiothoracic anesthesiology and surgery and the regulatory organizations endorsing them are described in detail in Supplemental Digital Content, Tables 2–4, https://links.lww.com/AA/D164. Some measures with the same or similar definitions are endorsed or required, or both, for reporting by different regulatory bodies. Thus, there is significant overlap, as summarized in detail in Supplemental Digital Content, Tables 2–4, https://links.lww.com/AA/D164. Specific measures and overlapping endorsement are demonstrated graphically in Figure 1.

Figure 1.
Figure 1.:
Shared performance and outcome measures relevant to cardiothoracic surgery and anesthesia. The Figure depicts the relationship and overlap between measures and outcomes as required by several regulatory organizations. The measures are shown as specified by each organization. AQI indicates Anesthesia Quality Institute; MIPS, Merit-Based Incentive Payment System; NQF, National Quality Forum; SCA, Society of Cardiovascular Anesthesiologists; STS, The Society of Thoracic Surgeons.

The MIPS and NQF measures relevant to cardiothoracic anesthesiologists are focused on specific practice processes and outcomes measures widely supported by the literature (Supplemental Digital Content, Tables 2–3, https://links.lww.com/AA/D164). In addition to these measures, the AQI/National Anesthesia Clinical Outcomes Registry specifically monitors processes well associated with quality in cardiac surgery and anesthesia, as outlined in Supplemental Digital Content, Table 4, https://links.lww.com/AA/D164.

In combination, the Adult Cardiac Anesthesiology Section and the STS ACSD include an extensive and comprehensive group of data points that cover the requirements set by all previously mentioned regulatory and quality organizations (these variables are detailed in Supplemental Digital Content, Table 5, https://links.lww.com/AA/D164). This fact greatly facilitates the standardization of reporting for participant institutions. Furthermore, the use of multiple data fields and availability of some continuous variables represents a significant advantage over other indicators, not only to evaluate the differential impact of particular interventions but also to assess the contribution of specific patterns of anesthesiology practice to cardiac surgical patients’ outcomes. Finally, the Adult Cardiac Anesthesiology Section of the STS ACSD represents a highly valuable resource for the generation of high-impact research and determination of positive value-based practices in cardiac anesthesiology.

Specific data field sections and the reasons for their required reporting and inclusion in this review are described in the following sections.

Anesthesia Care Team Model

The frequency of different anesthesia care team models reported between 2015 and 2018 is represented in Figure 2. These data are captured in the Adult Cardiac Anesthesiology Section of the STS ACSD. The most common team model is “anesthesiologist working alone” (~46%–56%), followed by “attending anesthesiologist teaching/medically directing fellow” (~18%–27%) and “attending anesthesiologist teaching/medically directing certified registered nurse anesthetists (CRNA)” (12%–18%). The predominant frequencies reported may represent differences in team composition between private and academic institutions.

Figure 2.
Figure 2.:
Anesthesia care team model between 2015 and 2018. The frequencies reported here were based on the number of cases for which the data point was available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons’ Adult Cardiac Surgery Database each year. CRNA indicates certified registered nurse anesthetist.

Composition of the anesthesia care team varies and depends on national and state regulations as well as institutional policies. Anesthetic care in the US is typically provided by an anesthesiologist working alone or a team consisting of an anesthesiologist supervising other physicians (eg, those in anesthesiology graduate medical programs) or nonphysician providers, such as CRNAs or certified anesthesiology assistants. The American Society of Anesthesiologists’ statement on the anesthesia care team established “anesthesia care is personally provided, directed and/or supervised by the physician anesthesiologist” (https://www.asahq.org/-/media/sites/asahq/files/public/resources/standards-guidelines/statement-on-the-anesthesia-care-team.pdf?la=en&hash=9674E540AB92E575C1FD8AB9B48159F7656B9AEB, accessed February 7, 2020).

Whether the type of anesthesia care team model or supervision ratios affect outcomes in the cardiac surgical setting is unclear. One recent study in a large sample of US Medicare beneficiaries found no differences in risk-adjusted postoperative outcomes (eg, death rate, length of stay, or medical expenditures) between teams that included CRNAs vs certified anesthesiology assistants after unselected surgical procedures.15 Another recent retrospective study of the effect of the type of anesthesia care team model noted that for cardiac surgical patients, the main contributors to fatality were patient-dependent risk factors, followed by surgeon performance, whereas differences in the anesthesia care team model did not significantly contribute to these outcomes.16 Further information regarding this issue may affect policymaking at national, state, local, and institutional levels.

Perioperative β-Blockers

Supplemental Digital Content, Table 5, https://links.lww.com/AA/D164, describes the STS ACSD quality measures related to β-blocker administration, and Figure 3 depicts the trend of frequencies for reporting compliance of the key measure “β-blockers within 24 hours before surgery.” The Surgery Section of the STS ACSD captures this shared accountability measure, and the reported frequency of β-blockers administration within 24 hours before surgery is consistently achieved in approximately 78% of cases reported.

Figure 3.
Figure 3.:
Frequency of β-blocker use within 24 hours before surgery between 2015 and 2018. The frequencies reported here were based on the number of cases for which the data point was available in the Adult Cardiac Surgery Section of The Society of Thoracic Surgeons’ Adult Cardiac Surgery Database.

Routine use of perioperative β-blocker therapy is recommended in patients undergoing coronary artery bypass grafting (CABG) surgery after early evidence demonstrated possible benefits in these patients,17 including unadjusted 30-day mortality18 and decreased risk of prolonged ventilation and renal failure.19 Although subsequent studies demonstrated conflicting results, in a recent large (>1 million CABG patients) meta-analysis, preoperative β-blockade did show decreased morbidity and mortality.20 Furthermore, a recent Cochrane review noted a reduction in the risk of atrial fibrillation and ventricular arrhythmias in CABG and valvular surgical patients but no differences in mortality or other cardiac events.21 A subsequently published prospective multicenter study suggested that resuming therapy in patients on long-term β-blocker therapy reduces the incidence of postoperative atrial fibrillation.22 Therefore, the 2019 combined SCA/European Association of Cardiovascular Anesthetists practice advisory for management of atrial fibrillation in cardiac surgical patients supports perioperative β-blocker administration as a class I recommendation for the prevention of postoperative atrial fibrillation.23

Nonetheless, taking into consideration all the available evidence, perioperative β-blocker administration remains controversial. Use of large-scale data from the STS ACSD and the Adult Cardiac Anesthesiology Section would aid in defining the best perioperative practices regarding perioperative β-blockers administration. Such practices may differ in specific populations or patients with different risk profile.

Blood Conservation Strategies

The quality measures that capture blood conservation strategies in cardiac operations are included in AQI indicator No. 49 (Adherence to Blood Conservation Guidelines for Cardiac Operations Using CPB) as a composite of 4 submetrics. All 4 variables are captured by data elements in the Adult Cardiac Anesthesiology Section of the STS ACSD (Supplemental Digital Content, Table 5, https://links.lww.com/AA/D164). These quality measures are not required reporting by MIPS. The frequency trends for reporting use of “Blood Conservation Strategies” are shown in Figure 4 and summarized in Supplemental Digital Content, Table 6, https://links.lww.com/AA/D164. The frequencies of most of these processes remained consistent between 2015 and 2018, except for decreasing frequency of aminocaproic acid use and increasing frequency of tranexamic acid use. These results point to opportunities for improvement in several areas of blood conservation and a need for a better understanding of how a change in the frequency of antifibrinolytics use may affect perioperative blood conservation.

Figure 4.
Figure 4.:
Frequencies of blood conservation strategies used between 2015 and 2018. The frequencies reported here were based on the number of cases for which the data point was available in the Adult Cardiac Anesthesiology Section (“heparin management based on,” “transfusion algorithm used,” and “viscoelastic test used”) or the Adult Cardiac Surgery Section (“aminocaproic acid use” and “tranexamic acid use”) of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. For more details see Supplemental Digital Content, Table 6, https://links.lww.com/AA/D164. ACT indicates activated clotting time; SCA, Society of Cardiovascular Anesthesiologists.

Ample evidence supports the negative impact of allogenic blood products transfusion on postoperative outcomes in cardiac surgical patients. Despite a notable trend toward decreasing the frequency of blood transfusions, the proportion of patients who receive a transfusion is still significant (~30% in the lowest-risk procedures and ~80% for highest-risk categories).24 Limiting blood transfusions requires a multifaceted approach that includes reducing blood loss, minimizing hemodilution, and optimizing targeted coagulopathy management. A cornerstone of such an approach is the use of antifibrinolytic agents to decrease blood loss and transfusion requirements.

A recent prospective, randomized, and placebo-controlled trial showed that tranexamic acid significantly decreased blood loss, red blood cell volume transfused, and proportion of patients receiving a transfusion, with no significant negative impact on outcomes.25 Similarly, ε-aminocaproic acid effectively decreases postoperative bleeding and blood products transfusion, but studies reporting the comparative effectiveness of ε-aminocaproic acid and tranexamic acid have shown conflicting results. Most studies report slightly higher effectiveness with tranexamic acid with a comparable safety profile.26 A recent single-center prospective trial suggested comparable effectiveness between tranexamic acid and ε-aminocaproic acid, with a minimal advantage to tranexamic acid, reducing more transfusions specifically in CABG surgery.27 Regardless of the agent chosen, antifibrinolytic agents are considered helpful to minimize blood loss during cardiac operations with CPB.

Hemodilution is associated not only with intraoperative and postoperative anemia and consequent transfusion but also (in the case of significant hemodilution) with negative outcomes, including increased risk of cardiac surgery-associated acute kidney injury.28 Processes aimed at reducing hemodilution incorporate several clinical perfusion practices during CPB, including using miniaturized CPB circuits, retrograde autologous priming, ultrafiltration, and cell salvage. In a recent prospective analysis, the use of a standardized set of autologous priming techniques effectively decreased hemodilution and was associated with reduced postoperative transfusion rates.29 A prospective randomized trial30 and a meta-analysis31 both suggest that ultrafiltration reduces blood transfusions and possibly decreases specific organ injury in cardiac surgical patients, but a recent retrospective analysis of a large cohort of such patients from 195 hospitals did not find a statistically significant effect on postoperative transfusion according to ultrafiltrate volume, calling into question existing information.32

Despite the effect of ultrafiltration limiting hemodilution and decreasing the odds of transfusion, some studies suggest an association between increased ultrafiltration volume and increased risk of acute kidney injury.33 The effect of ultrafiltration on cardiac surgical outcomes requires further study. Research results regarding cell salvage use are more consistent, showing it reduces blood products transfusion when used during the entire operative course.34,35

Finally, the use of blood transfusion algorithms that incorporate point-of-care coagulation testing has been the subject of recent studies. A large, prospective, randomized controlled trial demonstrated the use of one such algorithm resulted in reduced frequency of red blood cells and platelets transfusion in addition to lowering major bleeding.36

In collaboration with other stakeholders, SCA recently developed guidelines based on expert opinion including (1) a Clinical Practice Improvement Advisory for management of perioperative bleeding and hemostasis in cardiac surgical patients,37 and (2) practice guidelines on anticoagulation management during CPB.38 Use of large-scale data from the STS ACSD and the Adult Cardiac Anesthesiology Section will be useful to define the best perioperative blood management practices to improve outcomes for specific populations or in patients with different risk profiles.

Pain Management

Perioperative pain assessment and control outcome measures are represented in the Adult Cardiac Anesthesiology Section of the STS ACSD by data elements provided in Supplemental Digital Content, Table 5, https://links.lww.com/AA/D164. The frequency and distribution of preoperative and postoperative pain scores are shown in Figure 5. Most patients present no pain preoperatively. However, only 20.8% of patients are pain-free on postoperative day 3 and 43.2% at discharge. In addition, a proportion of patients (4.5%–7.5%) reported pain scores of 5 to 8 at discharge.

Figure 5.
Figure 5.:
Frequency and distribution of preoperative and postoperative pain scores are shown based on the visual analog scale (from 0 to 10) and the frequency of patients without a recorded pain score (11), comparing baseline (preoperative), on postoperative day 3 and at discharge from all patients reported between 2015 and 2018. The frequencies reported here were based on data available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons’ Adult Cardiac Surgery Database.

Interest in alternative, opioid-sparing multimodal pain management protocols is increasing.39 For decades, the mainstay of pain management in cardiac surgical patients has been primarily opioid-based regimens. However, opioids have been implicated as potential contributors to the development of postoperative hyperalgesia and chronic pain. In addition, the incidence of a wide spectrum of opioid-induced adverse effects and complications may be underestimated, and the cardiac surgical population is particularly vulnerable.40 A recent prospective, randomized controlled study found that compared with fentanyl, intraoperative use of remifentanil during cardiac operations was associated with increased postoperative pain and analgesic requirements until 3 months after surgery but did not affect chronic postoperative pain at 1 year.41 Multimodal analgesia techniques may provide synergistic effects with fewer adverse events; for example, intraoperative and postoperative administration of intravenous acetaminophen has been shown to reduce postoperative pain in cardiac surgical patients.42

Other research questions included the extent of persistent postoperative pain and the development of chronic pain after cardiac surgical procedures or thoracotomy. Multimodal protocols based on regional analgesia techniques are being actively tested to not only evaluate their comparative effectiveness but also to determine potential benefits for persistent postoperative and chronic pain.43 A prospective, randomized clinical trial and 2 systematic reviews found consistent decreases in pain scores and opioid requirements with novel regional block techniques. More studies are required to establish the safety profile and impact of these techniques on patient outcomes.44–46 Enhanced recovery after cardiac surgery (ERACS) pathways seek to optimize pain control while minimizing opioid requirements and adverse effects to expedite recovery.47 Lastly, effective pain management and minimal adverse effects are major determinants of patient satisfaction, a main goal of ERACS and opioid-sparing protocols.

Further analysis of pain frequency and persistence would define the future roles of multimodal analgesia and ERACS protocols. Data from the STS ACSD and the Adult Cardiac Anesthesiology Section will be useful to define the best perioperative pain management practices for cardiac surgical patients.

Temperature Management

Measures assessing temperature management and, in particular, avoidance of hyperthermia for cerebral protection are captured by several fields of the Adult Cardiac Anesthesiology Section of the STS ACSD, as provided in Supplemental Digital Content, Table 5, https://links.lww.com/AA/D164. Figure 6 and Supplemental Digital Content, Table 6, https://links.lww.com/AA/D164, represent the distribution of use rates for different surrogate sources of intraoperative temperature measurement and compliance with temperature measurement taken upon intensive care unit entry between 2015 and 2018. These data indicate that over the years, the frequency of nasopharyngeal core temperature measurement increased, whereas the frequency of bladder core temperature measurement decreased. The reasons for and possible influence of such changing practice patterns on patient outcomes are not clear, highlighting this area as a potential field of future research.

Figure 6.
Figure 6.:
Frequency distribution of core temperature source and compliance with temperature measurement upon intensive care unit (ICU) entry between 2015 and 2018. The comparative use of different surrogate sites for core temperature measurement and the comparative annual rate of compliance with temperature measurement upon ICU entry are both shown. The frequencies reported here were based on data available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons’ Adult Cardiac Surgery Database. For more details see Supplemental Digital Content, Table 6, https://links.lww.com/AA/D164.

Intraoperative and postoperative temperature both have a significant influence on several major outcomes after cardiac surgery, including increased death rate. Hyperthermia is associated with postoperative cognitive dysfunction,48 infection,49 and acute kidney injury.50 Postoperative hypothermia is common and also has been associated with increased morbi-mortality.51 There are particular associations between hypothermia and increased hospitalization,52 postoperative bleeding,53 and surgical site infections52 in different patient populations. A large retrospective cohort study, however, suggested that correcting hypothermia within the first 24 hours postoperatively may improve outcomes.51 Therefore, avoidance of hyperthermia and active management of hypothermia are both measures included as part of recent consensus guidelines for postoperative care of cardiac surgical patients54 and of ERACS consensus recommendations.55

Although prior studies link temperature to outcome, the impact of temperature management on different subpopulations and organ systems remains inadequately defined. Of particular importance, temperature management is a shared responsibility between clinical perfusion and anesthesiology teams working in conjunction with the surgical team. Data from the STS ACSD and the Adult Cardiac Anesthesiology Section will be useful to define optimal perioperative temperature management practices.

Anesthetic Agents and Outcomes in Cardiac Surgery

The use of specific anesthetic agents and their possible combinations are represented by multiple data fields, as described in Supplemental Digital Content, Table 5, https://links.lww.com/AA/D164. The frequencies of anesthetic and sedative agents used are presented in Figure 7 and Supplemental Digital Content, Table 6, https://links.lww.com/AA/D164. There is an increasing trend for intraoperative and postoperative propofol and dexmedetomidine administration compared with inhalational anesthetics. A better understanding of how these trends in administration of anesthetic medications may impact postoperative outcomes warrants future investigations.

Figure 7.
Figure 7.:
Frequency distribution of anesthetic medications use between 2015 and 2018. The Figure depicts a comparison of intraoperative and postoperative use of propofol and dexmedetomidine and use of inhaled anesthetic agents. The frequencies reported here were based on data available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons’ Adult Cardiac Surgery Database. For more details see Supplemental Digital Content, Table 6, https://links.lww.com/AA/D164.

The effects of different anesthetic regimens on diverse clinical events and postoperative outcomes in adult cardiac surgical patients are not well understood. For more than a decade, several clinical studies and systematic reviews comparing inhaled agents vs propofol (or other intravenous anesthetics) for maintenance of general anesthesia have provided contradictory results. The most recently published systematic review showed that volatile anesthetics used in a variety of cardiac surgical procedures with CPB were associated with lower 1-year mortality and lower indicators of myocardial injury compared with propofol.56 Nonetheless, a 2019 systematic review and meta-analysis that included only patients undergoing cardiac valvular procedures demonstrated similar survival and major complications with use of volatile vs intravenous anesthetics.57

A better understanding of how classes of anesthetic medications may impact postoperative outcomes is necessary. Studies using data from the Adult Cardiac Anesthesiology Section and the STS ACSD to address this question in subpopulations of patients with specific risk factors (eg, frailty, very elderly, chronic kidney disease, cerebrovascular disease) could probably yield more consistent results.

Postoperative Delirium

Use of the Adult Cardiac Anesthesiology Section and STS ACSD data is ideal for large-scale studies to better define which anesthetic techniques, agents, and interventions may prevent or minimize delirium and other neurologic outcomes. The occurrence of postoperative delirium is captured in the Adult Cardiac Anesthesiology Section of the STS ACSD (Supplemental Digital Content, Table 5, https://links.lww.com/AA/D164). The frequency of postoperative delirium reported from 2015 to 2018 was approximately 2% to 10% (Figure 8).

Figure 8.
Figure 8.:
Major adverse events and mortality between 2015 and 2018 according to types of surgical procedures. A, Shows the comparative annual incidence of postoperative delirium between types of procedures. B, The comparative annual observed-to-expected ratio of permanent stroke (panel A), and mortality (panel B). C, The comparative annual observed-to-expected ratio of prolonged ventilation (panel A), and renal failure (panel B) is demonstrated. The frequencies reported here were based on data available in the Adult Cardiac Anesthesiology Section of The Society of Thoracic Surgeons’ Adult Cardiac Surgery Database. For more details see Supplemental Digital Content, Table 7, https://links.lww.com/AA/D164. AVR indicates aortic valve replacement; CABG, coronary artery bypass grafting surgery; MV, mitral valve; MVR, mitral valve replacement.

Patients undergoing cardiac operations are at high risk of developing postoperative delirium and cognitive dysfunction. Postoperative delirium increases intensive care and hospital lengths of stay and has been associated with increased long-term morbidity and mortality rates. Similarly, early postoperative cognitive dysfunction is associated with short- and long-term cognitive deficits.58,59 A recent prospective cohort study found that compared with nondelirious patients, those cardiac surgical patients with postoperative delirium had a larger decline in composite cognitive measures at 1 month. At 1 year, a larger decline, specifically in processing speed, was evident in delirious patients.60

More evidence is required to clarify the relationship between anesthetic management and postoperative delirium and cognitive dysfunction in cardiac surgical patients. Studies comparing inhaled anesthetics with intravenous agents have yielded conflicting results.61 Several studies found that dexmedetomidine sedation compared with propofol was associated with a decreased risk for postoperative delirium.62,63 A recent systematic review of randomized trials focusing on prevention and treatment of delirium after cardiac operations indicated that dexmedetomidine administration was most likely to reduce the occurrence of delirium compared with the administration of ketamine, antipsychotics, glucocorticoids, propofol, opioids, volatile anesthetics, local anesthetics, and remote ischemic preconditioning.64 Recent results from a multicenter randomized trial suggest that perioperative administration of dexmedetomidine could delay onset or shorten duration of postoperative delirium, or both, in cardiac surgical patients.65 In addition, a prospective, randomized placebo-controlled study in a cohort of elderly cardiac surgical patients showed that scheduled postoperative administration of intravenous acetaminophen in combination with dexmedetomidine or propofol reduced the incidence of in-hospital delirium.66

Major Adverse Events

Several critical postoperative patient outcomes that may be related to anesthetic management in cardiac surgical procedures are captured by both the Adult Cardiac Anesthesiology Section and the STS ACSD (Supplemental Digital Content, Tables 5 and 7, https://links.lww.com/AA/D164). The incidence of mortality and other major postoperative complications, such as stroke, prolonged postoperative mechanical ventilation, and renal failure, and their respective observed-to-expected ratios by type of surgical interventions reported between 2015 and 2018, are illustrated in Figure 8 and reported in Supplemental Digital Content, Table 7, https://links.lww.com/AA/D164. There were some notable trends by type of surgical interventions suggesting the need for further study of patient- and procedure-related factors that may have played a significant role in reported outcomes.

A study of CABG patients from the STS ACSD found that at least 1 significant complication (eg, new-onset atrial fibrillation, prolonged ventilation, renal failure, reoperation, stroke, or sternal wound infection) developed in 41% of patients. All complications were associated with an increased risk of early (90 days) and late (up to 7 years) mortality and rehospitalization.67

Examples of clinically significant adverse outcomes that may be influenced by anesthetic management include:

  • Postoperative stroke significantly increases morbidity and mortality rates and is associated with poor functional outcomes. A large database analysis showed that carotid stenosis, prior stroke, and age 80 years or older are independent predictors of stroke-related fatalities after cardiac operations.68 Aortic cannulation and manipulation and CPB use are considered determinant factors. A recent study suggests that patients with prior neurologic events are at higher risk of postoperative stroke and may benefit from off-pump CABG given a lower incidence of postoperative stroke and other neurologic outcomes.69 Development of preventive strategies and management tailored to patients at high risk could reduce the increased morbidity and death rate associated with postoperative stroke in cardiac surgical patients.
  • Prolonged postoperative ventilatory support is an outcome associated with increased risk of death, incidence of morbidity, and hospital and intensive care lengths of stay.70 Retrospective cohort analyses found postoperative hypoxemia and anemia are independently associated with the need for prolonged ventilation,70 and patients who need prolonged ventilation have a 5-fold associated increase in operative mortality.71 Identification of predisposing risk factors would facilitate development of preventive strategies.
  • Renal failure after cardiac surgical procedures is a common and widely studied complication given its negative impact on short- and long-term outcomes. More importantly, its multifactorial nature and complex mechanisms involved have hindered implementation of effective therapeutic and preventive interventions. The use of novel pharmacologic and other interventions in subgroups at the highest risk of postoperative renal failure is being investigated.72,73

Challenges and Future Directions

Increasing awareness of the Adult Cardiac Anesthesiology Section of the STS ACSD and participation among cardiac anesthesiologists will be critically important to allow rapid accumulation of multiinstitutional data in cardiac surgical patients. Currently, only 70 of the 1088 cardiac surgery groups in the US participate in the optional STS/SCA Adult Cardiac Anesthesiology Section of the STS ACSD. Furthermore, the present review does not contain information about the proportional contribution of each participating center to the absolute volume of cardiac surgical procedures reported. Thus, an evaluation of the effect of institutional volume on the measures and outcomes described is not possible. Finally, given the amount and specificity of data required, individual and institutional incentives for participating in the STS ACSD should include improvements that streamline the data acquisition process to reduce collection burden and encourage robust participation and compliance with accurate and complete data entry.

Future developments to ensure valid and thorough data collection by enhancing the data-collection experience will likely include user-friendly interfaces and logic algorithms as well as availability of immediate user feedback to inform and define important research questions and allow development of quality improvement programs in individual institutions. Another expected benefit will be to have the ability to demonstrate the value of specific anesthesiology practices for provision of cost-efficient, safe care and improved outcomes in cardiac surgical patients.

ACKNOWLEDGMENTS

Society of Cardiovascular Anesthesiologists/Society of Thoracic Surgeons Database Sub-Committee Former Members: S. Aronson, A. T. Cheung, M. L. Fontes, A. Mahajan, J. P. Mathew, J. P. Miller, J. Raphael, S. Reeves, D. L. Reich, D. Settles, S. K. Shernan, L. Shore-Lesserson, and C. A. Troianos. The authors wish to thank Carole Krohn, BSN, RN (National Database Manager–Adult Cardiac Surgery Database, Society of Thoracic Surgeons, Chicago, IL) and Donna McDonald, RN, MPH (Director of Quality, Society of Thoracic Surgeons, Chicago, IL) for their help in reviewing the article and providing constructive suggestions, and would also like to thank Yvonne Poindexter, MA (Editor, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN), for her editorial contributions to the report.

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