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Background: Aspirin may reduce the risk of vascular graft thrombosis after cardiovascular surgery. We previously reported the 30-day results of a trial evaluating aspirin use before coronary artery surgery. Here we report the 1-year outcomes evaluating late thrombotic events and disability-free survival. Method(s): Using a factorial design, we randomly assigned patients undergoing coronary artery surgery to receive aspirin or placebo and tranexamic acid or placebo. The results of the aspirin comparison are reported here. The primary 1-year outcome was death or severe disability, the latter defined as living with a modified Katz activities of daily living score < 8. Secondary outcomes included a composite of myocardial infarction, stroke and death from any cause through to 1 year after surgery. Result(s): Patients were randomly assigned to aspirin (1059 patients) or placebo (1068 patients). The rate of death or severe disability was 4.1% in the aspirin group and 3.5% in the placebo group (relative risk, 1.17; 95% confidence interval, 0.76-1.81; P =.48). There was no significant difference in the rates of myocardial infarction (P =.11), stroke (P =.086), or death (P =.24), or a composite of these cardiovascular end points (P =.68). With the exception of those with a low European System for Cardiac Operative Risk Evaluation score (P =.03), there were no interaction effects on these outcomes with tranexamic acid (all tests of interaction P >.10). Conclusion(s): In patients undergoing coronary artery surgery, preoperative aspirin did not reduce death or severe disability, or thrombotic events through to 1 year after surgery.Copyright © 2018 The American Association for Thoracic Surgery

Background: Tranexamic acid reduces blood loss and transfusion requirements in cardiac surgery but may increase the risk of coronary graft thrombosis. We previously reported the 30-day results of a trial evaluating tranexamic acid for coronary artery surgery. Here we report the 1-year clinical outcomes. Method(s): Using a factorial design, we randomly assigned patients undergoing coronary artery surgery to receive aspirin or placebo and tranexamic acid or placebo. The results of the tranexamic acid comparison are reported here. The primary 1-year outcome was death or severe disability, the latter defined as living with a modified Katz activities of daily living score of less than 8. Secondary outcomes included a composite of myocardial infarction, stroke, and death from any cause through to 1 year after surgery. Result(s): The rate of death or disability at 1 year was 3.8% in the tranexamic acid group and 4.4% in the placebo group (relative risk, 0.85; 95% confidence interval, 0.64-1.13; P =.27), and this did not significantly differ according to aspirin exposure at the time of surgery (interaction P =.073). The composite rate of myocardial infarction, stroke, and death up to 1 year after surgery was 14.3% in the tranexamic acid group and 16.4% in the placebo group (relative risk, 0.87; 95% CI, 0.76-1.00; P =.053). Conclusion(s): In this trial of patients having coronary artery surgery, tranexamic acid did not affect death or severe disability through to 1 year after surgery. Further work should be done to explore possible beneficial effects on late cardiovascular events.Copyright © 2018 The American Association for Thoracic Surgery

Background: Aspirin may reduce the risk of vascular graft thrombosis after cardiovascular surgery. We previously reported the 30-day results of a trial evaluating aspirin use before coronary artery surgery. Here we report the 1-year outcomes evaluating late thrombotic events and disability-free survival. Method(s): Using a factorial design, we randomly assigned patients undergoing coronary artery surgery to receive aspirin or placebo and tranexamic acid or placebo. The results of the aspirin comparison are reported here. The primary 1-year outcome was death or severe disability, the latter defined as living with a modified Katz activities of daily living score < 8. Secondary outcomes included a composite of myocardial infarction, stroke and death from any cause through to 1 year after surgery. Result(s): Patients were randomly assigned to aspirin (1059 patients) or placebo (1068 patients). The rate of death or severe disability was 4.1% in the aspirin group and 3.5% in the placebo group (relative risk, 1.17; 95% confidence interval, 0.76-1.81; P =.48). There was no significant difference in the rates of myocardial infarction (P =.11), stroke (P =.086), or death (P =.24), or a composite of these cardiovascular end points (P =.68). With the exception of those with a low European System for Cardiac Operative Risk Evaluation score (P =.03), there were no interaction effects on these outcomes with tranexamic acid (all tests of interaction P >.10). Conclusion(s): In patients undergoing coronary artery surgery, preoperative aspirin did not reduce death or severe disability, or thrombotic events through to 1 year after surgery.Copyright © 2018 The American Association for Thoracic Surgery

Background: In 1999, Royse et al. reported on the left internal mammary artery, radial artery, Y-graft technique (LIMA-RA-Y), which achieves total arterial revascularization (TAR). However, the most common coronary reconstruction remains LIMA and supplementary saphenous vein grafts (LIMA + SVG). Objective(s): The goal of this study was to conduct a survival comparison of LIMA-RA-Y versus the conventional LIMA + SVG. Method(s): Of the original 464 LIMA-RA-Y patients reported (1996 to 1998), 346 were from the Royal Melbourne Hospital. Survival at June 2017 was compared with a group of 534 patients from 1996 to 2003 from the same institution who received LIMA + SVG, or 5,800 patients who received TAR with different grafting configurations. Propensity score matching (PSM) was performed with 1:1 matching using 26 variables. Comparisons used Kaplan-Meier (KM) and Cox proportional hazards methods. LIMA-RA-Y was compared with LIMA + SVG in which all non-left anterior descending artery grafts were performed with either composite RA or aorta-coronary SVG with no use of right internal mammary artery. We also conducted a comparison of LIMA-RA-Y versus TAR. Result(s): Baseline characteristics of the LIMA-RA-Y group (n = 346) compared with LIMA + SVG (n = 534) after PSM (n = 232 pairs) did not differ (3.3 +/- 0.8 grafts per patient). Survival was worse for LIMA + SVG in the unmatched groups (KM, p < 0.001) and for PSM groups (KM, p = 0.043; Cox proportional hazards ratio: 1.3; 95% confidence interval: 1.0 to 1.6; p = 0.038). Survival did not differ between LIMA-RA-Y and other TAR (n = 5,800) patients before, or after, PSM (n = 332 pairs). Conclusion(s): Use of LIMA + SVG has worse survival than LIMA-RA-Y in achieving total arterial revascularization.Copyright © 2018 American College of Cardiology Foundation

Background: In 1999, Royse et al. reported on the left internal mammary artery, radial artery, Y-graft technique (LIMA-RA-Y), which achieves total arterial revascularization (TAR). However, the most common coronary reconstruction remains LIMA and supplementary saphenous vein grafts (LIMA + SVG). Objective(s): The goal of this study was to conduct a survival comparison of LIMA-RA-Y versus the conventional LIMA + SVG. Method(s): Of the original 464 LIMA-RA-Y patients reported (1996 to 1998), 346 were from the Royal Melbourne Hospital. Survival at June 2017 was compared with a group of 534 patients from 1996 to 2003 from the same institution who received LIMA + SVG, or 5,800 patients who received TAR with different grafting configurations. Propensity score matching (PSM) was performed with 1:1 matching using 26 variables. Comparisons used Kaplan-Meier (KM) and Cox proportional hazards methods. LIMA-RA-Y was compared with LIMA + SVG in which all non-left anterior descending artery grafts were performed with either composite RA or aorta-coronary SVG with no use of right internal mammary artery. We also conducted a comparison of LIMA-RA-Y versus TAR. Result(s): Baseline characteristics of the LIMA-RA-Y group (n = 346) compared with LIMA + SVG (n = 534) after PSM (n = 232 pairs) did not differ (3.3 +/- 0.8 grafts per patient). Survival was worse for LIMA + SVG in the unmatched groups (KM, p < 0.001) and for PSM groups (KM, p = 0.043; Cox proportional hazards ratio: 1.3; 95% confidence interval: 1.0 to 1.6; p = 0.038). Survival did not differ between LIMA-RA-Y and other TAR (n = 5,800) patients before, or after, PSM (n = 332 pairs). Conclusion(s): Use of LIMA + SVG has worse survival than LIMA-RA-Y in achieving total arterial revascularization.Copyright © 2018 American College of Cardiology Foundation

Objectives This study sought to determine the mechanistic effects of a novel balloon-based lithoplasty system on heavily calcified coronary lesions and subsequent stent placement using optical coherence tomography (OCT). Background The Shockwave Coronary Rx Lithoplasty System (Shockwave Medical, Fremont, California) delivers localized, lithotripsy-enhanced disruption of calcium within the target lesion (i.e., lithoplasty) for vessel preparation before stent implantation. Methods We analyzed OCT findings in 31 patients in whom lithoplasty was used to treat severely calcified stenotic coronary lesions. Results After lithoplasty, intraplaque calcium fracture was identified in 43% of lesions, with circumferential multiple fractures noted in >25%. The frequency of calcium fractures per lesion increased in the most severely calcified plaques (highest tertile vs. lowest tertile; p = 0.009), with a trend toward greater incidence of calcium fracture (77.8% vs. 22.2%; p = 0.057). Post-lithoplasty, mean acute area gain was 2.1 mm2, which further increased with stent implantation, achieving a minimal stent area of 5.94 +/- 1.98 mm2 and mean stent expansion of 112.0 +/- 37.2%. Deep dissections, as part of the angioplasty effect, occurred in 13% of cases and were successfully treated with stent implantation without incidence of acute closure, slow flow/no reflow, or perforation. Conclusions High-resolution imaging by OCT delineated calcium modification with fracture as a major mechanism of action of lithoplasty in vivo and demonstrated efficacy in the achievement of significant acute area gain and favorable stent expansion.Copyright © 2017 American College of Cardiology Foundation

Objectives This study sought to determine the mechanistic effects of a novel balloon-based lithoplasty system on heavily calcified coronary lesions and subsequent stent placement using optical coherence tomography (OCT). Background The Shockwave Coronary Rx Lithoplasty System (Shockwave Medical, Fremont, California) delivers localized, lithotripsy-enhanced disruption of calcium within the target lesion (i.e., lithoplasty) for vessel preparation before stent implantation. Methods We analyzed OCT findings in 31 patients in whom lithoplasty was used to treat severely calcified stenotic coronary lesions. Results After lithoplasty, intraplaque calcium fracture was identified in 43% of lesions, with circumferential multiple fractures noted in >25%. The frequency of calcium fractures per lesion increased in the most severely calcified plaques (highest tertile vs. lowest tertile; p = 0.009), with a trend toward greater incidence of calcium fracture (77.8% vs. 22.2%; p = 0.057). Post-lithoplasty, mean acute area gain was 2.1 mm2, which further increased with stent implantation, achieving a minimal stent area of 5.94 +/- 1.98 mm2 and mean stent expansion of 112.0 +/- 37.2%. Deep dissections, as part of the angioplasty effect, occurred in 13% of cases and were successfully treated with stent implantation without incidence of acute closure, slow flow/no reflow, or perforation. Conclusions High-resolution imaging by OCT delineated calcium modification with fracture as a major mechanism of action of lithoplasty in vivo and demonstrated efficacy in the achievement of significant acute area gain and favorable stent expansion.Copyright © 2017 American College of Cardiology Foundation

Background Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart defect with limited data on long-term outcomes after surgical intervention. Methods We conducted a retrospective review of all children (N = 42) who underwent surgical repair of ALCAPA between 1980 and 2014 at the Royal Children's Hospital, Melbourne. Results Twenty-nine (69% [29 of 42]) patients underwent coronary reimplantation, 12 (29% [12 of 42]) had intrapulmonary baffle (Takeuchi) repair, and 1 (2% [1 of 42]) patient had ligation of the anomalous coronary artery. Nine (21%, 9 of 42) patients had concomitant mitral valve (MV) repair at the time of ALCAPA repair. A left ventricular assist device (LVAD) was used in 36% (15 of 42) of patients. Early mortality was 2.4% (1 of 42 patients). Median follow-up was 14 years (mean, 13 years; range, 4 months-31 years). There were no late deaths. Survival was 98% at 20 years. Freedom from reoperation was 81%, 81%, and 76% at 5, 10, and 20 years after operation, respectively. Eight patients underwent late MV repair or replacement at a median of 3 years (mean, 8 years; range, 2 months-25 years) after operation. Freedom from late MV repair or replacement was 86% at 5 and 10 years and 81% at 20 years after operation. Eleven (26% [11 of 42]) patients had severe mitral regurgitation (MR) preoperatively. Of those 11 patients, 5 (45% [5 of 11]) had concomitant MV repair at the time of ALCAPA repair, 3 (27% [3 of 11]) had late MV repair or replacement, and the remaining 3 (27% [3 of 11]) patients had mild MR at last follow-up. Thirty-six (90% [36 of 41]) patients had normal left ventricular function and 4 (10% [4 of 41]) patients had mildly reduced left ventricular (LV) function at last follow-up. Conclusions ALCAPA can be operated on with good outcomes. Persistent MR and a moderate rate of late MV repair warrants close follow-up.Copyright © 2016 The Society of Thoracic Surgeons.

Background Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital heart defect with limited data on long-term outcomes after surgical intervention. Methods We conducted a retrospective review of all children (N = 42) who underwent surgical repair of ALCAPA between 1980 and 2014 at the Royal Children's Hospital, Melbourne. Results Twenty-nine (69% [29 of 42]) patients underwent coronary reimplantation, 12 (29% [12 of 42]) had intrapulmonary baffle (Takeuchi) repair, and 1 (2% [1 of 42]) patient had ligation of the anomalous coronary artery. Nine (21%, 9 of 42) patients had concomitant mitral valve (MV) repair at the time of ALCAPA repair. A left ventricular assist device (LVAD) was used in 36% (15 of 42) of patients. Early mortality was 2.4% (1 of 42 patients). Median follow-up was 14 years (mean, 13 years; range, 4 months-31 years). There were no late deaths. Survival was 98% at 20 years. Freedom from reoperation was 81%, 81%, and 76% at 5, 10, and 20 years after operation, respectively. Eight patients underwent late MV repair or replacement at a median of 3 years (mean, 8 years; range, 2 months-25 years) after operation. Freedom from late MV repair or replacement was 86% at 5 and 10 years and 81% at 20 years after operation. Eleven (26% [11 of 42]) patients had severe mitral regurgitation (MR) preoperatively. Of those 11 patients, 5 (45% [5 of 11]) had concomitant MV repair at the time of ALCAPA repair, 3 (27% [3 of 11]) had late MV repair or replacement, and the remaining 3 (27% [3 of 11]) patients had mild MR at last follow-up. Thirty-six (90% [36 of 41]) patients had normal left ventricular function and 4 (10% [4 of 41]) patients had mildly reduced left ventricular (LV) function at last follow-up. Conclusions ALCAPA can be operated on with good outcomes. Persistent MR and a moderate rate of late MV repair warrants close follow-up.Copyright © 2016 The Society of Thoracic Surgeons.

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We sought to determine the anatomic characteristics of coronary arteries arising from an anomalous location (CAAL) detected on coronary computed tomography angiography (CTA) and assess the impact of high-risk anatomic characteristics on patient management and outcomes. We reviewed 9,774 consecutive CTA studies performed in adults between 2008-2013 and identified 114 with CAAL. CTA examinations were analysed to determine CAAL type, CAAL course (pre-pulmonary, interarterial, septal or retroaortic) and whether additional high-risk anatomic characteristics were present (luminal compression, intramural course, slit-like ostium and acute takeoff angle). Patients were contacted at mean 27.1-months to determine safety outcomes. The prevalence of CAAL was 1.14 % (114 of 9,974), with 36 (32 %) having anomalous right coronary artery from left coronary sinus, 71 (62 %) having anomalous left coronary artery from right coronary sinus and 7 (6 %) having a coronary artery arising outside coronary sinuses. Fifty-six patients (49 %) had >=1 high-risk anatomic characteristic on CTA. Ten patients (9 %) underwent surgical intervention. Patients with high-risk anatomic features more frequently underwent functional testing (46 vs. 12 %, P = 0.01) and surgical intervention (14 vs. 3 %; P = 0.04) compared to patients without high-risk features. Patients undergoing surgery were more likely to have obstructive coronary disease on CTA than patients managed conservatively (50 vs. 13 %, P = 0.01). There was no cardiac death or ACS at follow-up (100 % complete). High-risk anatomic features on CTA in patients with CAAL more frequently lead to surgical management. Regardless of CAAL type, presence of high-risk anatomic characteristics or management strategy, the medium-term outcome of adults with CAAL is excellent.Copyright © 2014, Springer Science+Business Media Dordrecht.

We sought to determine the anatomic characteristics of coronary arteries arising from an anomalous location (CAAL) detected on coronary computed tomography angiography (CTA) and assess the impact of high-risk anatomic characteristics on patient management and outcomes. We reviewed 9,774 consecutive CTA studies performed in adults between 2008-2013 and identified 114 with CAAL. CTA examinations were analysed to determine CAAL type, CAAL course (pre-pulmonary, interarterial, septal or retroaortic) and whether additional high-risk anatomic characteristics were present (luminal compression, intramural course, slit-like ostium and acute takeoff angle). Patients were contacted at mean 27.1-months to determine safety outcomes. The prevalence of CAAL was 1.14 % (114 of 9,974), with 36 (32 %) having anomalous right coronary artery from left coronary sinus, 71 (62 %) having anomalous left coronary artery from right coronary sinus and 7 (6 %) having a coronary artery arising outside coronary sinuses. Fifty-six patients (49 %) had >=1 high-risk anatomic characteristic on CTA. Ten patients (9 %) underwent surgical intervention. Patients with high-risk anatomic features more frequently underwent functional testing (46 vs. 12 %, P = 0.01) and surgical intervention (14 vs. 3 %; P = 0.04) compared to patients without high-risk features. Patients undergoing surgery were more likely to have obstructive coronary disease on CTA than patients managed conservatively (50 vs. 13 %, P = 0.01). There was no cardiac death or ACS at follow-up (100 % complete). High-risk anatomic features on CTA in patients with CAAL more frequently lead to surgical management. Regardless of CAAL type, presence of high-risk anatomic characteristics or management strategy, the medium-term outcome of adults with CAAL is excellent.Copyright © 2014, Springer Science+Business Media Dordrecht.

Background: Despite some concern that recent aspirin ingestion increases blood loss after coronary artery surgery, there is some evidence that this may reduce thrombotic complications. In contrast, antifibrinolytic drugs can reduce blood loss in this setting, but there is concern that they may increase thrombotic complications. Published guidelines are limited by a lack of large randomized trials addressing the risks and benefits of each of these commonly used therapies in cardiac surgery. The ATACAS Trial is a study comparing aspirin, tranexamic acid, or both, with placebo in patients undergoing on-pump or off-pump coronary artery surgery. Method(s): We discuss the rationale for conducting ATACAS, a 4600-patient, multicenter randomized trial in at-risk coronary artery surgery, and the features of the ATACAS study design (objectives, end points, target population, allocation, treatments, patient follow-up, and analysis). Conclusion(s): The ATACAS Trial will be the largest study yet conducted to ascertain the benefits and risks of aspirin and antifibrinolytic therapy in coronary artery surgery. Results of the trial will guide the routine clinical care of patients in this setting. © 2008 Mosby, Inc. All rights reserved.

Objective: Mitral valve surgery may be regarded as less favourable for training, due to greater mortality risk, technical complexity, and difficulty for the supervisor to observe. We examined this perception by reviewing a multicentre experience. Method(s): We analysed a multicentre database over a 7-year period containing 2216 isolated and combined mitral procedures. Of these, 2048 were performed by consultants and 168 by trainees (92% vs 8%) of varying seniority. Preoperative characteristics, early postoperative outcomes and 6-year survival were compared between groups. Propensity-score matching was performed to correct for group differences. Result(s): Trainees were less likely to operate on patients, who had previously undergone coronary surgery (consultant 4.3% vs trainee 1.2%, p=0.043) and those with moderate to severe mitral regurgitation (86% vs 81%, p=0.012). There were no other statistically significant differences in preoperative variables, such as urgency, endocarditis and left-ventricular dysfunction. There were similar rates of mitral valve repair (48% vs 51%, p=0.48). Trainees were more likely to operate on rheumatic valve pathology (20% vs 28%, p=0.012). Intra-operatively, trainees had longer aortic cross-clamp times (119 +/- 52 vs 136 +/- 50. min, p=0.0001). At 30 days, mortality was comparable (4.5% vs 3.6%, p=0.56) with a trend towards higher any mortality/morbidity in consultant procedures (33% vs 26%, p=0.059). At 6 years, survival was similar (79 +/- 1.4% vs 78 +/- 4.0%, p=0.73). After derivation of 142 propensity-score-matched patient pairs, trainees cases still experienced longer cross-clamp times (121 +/- 58 vs 137 +/- 52. min, p=0.023), but there was similar 30-day mortality (4.2% vs 3.5%, p>0.99) and any mortality/morbidity (28% vs 24%, p=0.52). Six-year survival between matched pairs was also similar (74 +/- 7.2% vs 80 +/- 4.4%, p=0.64). Trainee status did not predict early or late adverse events after multivariate Cox regression with and

Objective: The effect of training on outcomes in cardiac surgery is poorly studied. We aimed to study the results of coronary artery bypass grafting procedures performed by surgeons in training across our state with respect to short- and midterm postoperative outcomes. Method(s): All coronary artery bypass grafting surgeries performed by trainee surgeons between July 2001 and December 2006 were compared with those performed by consultant surgeons using mandatory prospectively collected statewide data. Early mortality; prolonged ventilation or intensive care unit stay; return to operating theater for bleeding, stroke, myocardial infarction, or renal failure; and 5-year survival were compared using propensity score analysis. Result(s): A total of 7745 surgeries were included in this study. Trainees performed 983 (13%) surgeries. Trainee surgeries had longer perfusion and crossclamp times. Crude early postoperative outcomes were similar between trainee and consultant surgeries. After propensity score adjustment, early outcomes remained similar, with the exception of myocardial infarction (0.8% in trainee surgeries vs 0.4% in consultant surgeries, P = .046). Adjusted 1-, 3-, and 5-year survivals were similar between trainee and consultant surgeries: 95.3% versus 95.5%, 90.8% versus 92.0%, and 86.3% versus 87.1%, respectively. Conclusion(s): Coronary artery bypass grafting performed by trainee surgeons within a supervised program is safe with acceptable short- and midterm outcomes. © 2009 The American Association for Thoracic Surgery.

Objectives: The use of the radial artery as a second arterial graft during coronary surgery has become popular due to high patency and low harvest site complication rates. We sought to assess whether higher-risk patients derive such benefits. Method(s): From 2001 to 2009, 11 388 patients underwent isolated primary multivessel coronary surgery. We identified a higher risk subgroup (n=2581) according to urgency status, coronary instability, low ejection fraction and/ or aortic counterpulsation. Among these, 1832 (71%) received at least one radial artery graft in addition to a left internal thoracic artery (LITA). The remaining 749 (29%) received LITA and veins only. Result(s): Patients not receiving a radial artery were more likely to be elderly, female, have poor left ventricular function or be of emergency status. These patients experienced higher unadjusted 30-day mortality (radial 2% vs vein 8%, P<0.0001) with lower unadjusted 7-year survival (80+/-1.3% vs 67+/-2.4%, P<0.0001). Subsequently, 515 patients in the radial group were propensitymatched to 515 receiving only veins (mean logistic EuroSCORE, radial 19+/-14% vs vein 19+/-13%, P=0.87). At 30 days, there were comparable rates of mortality (radial 4% vs vein 3%, P>0.99), stroke (1% vs 1%, P>0.99), myocardial infarction (1% vs 2%, P=0.79), and any morbidity/mortality (34% vs 35%, P=0.95). At seven years, survival of radial and vein groups was similar (radial 75+/-2.6% vs vein 74+/-2.9%, P=0.65). Conclusion(s): Patients with the greatest coronary instability, urgency of surgery, or impairment of ventricular function are not disadvantaged in early outcomes or mid-term survival by use of only a single arterial graft.

Background: Despite some concern that recent aspirin ingestion increases blood loss after coronary artery surgery, there is some evidence that this may reduce thrombotic complications. In contrast, antifibrinolytic drugs can reduce blood loss in this setting, but there is concern that they may increase thrombotic complications. Published guidelines are limited by a lack of large randomized trials addressing the risks and benefits of each of these commonly used therapies in cardiac surgery. The ATACAS Trial is a study comparing aspirin, tranexamic acid, or both, with placebo in patients undergoing on-pump or off-pump coronary artery surgery. Method(s): We discuss the rationale for conducting ATACAS, a 4600-patient, multicenter randomized trial in at-risk coronary artery surgery, and the features of the ATACAS study design (objectives, end points, target population, allocation, treatments, patient follow-up, and analysis). Conclusion(s): The ATACAS Trial will be the largest study yet conducted to ascertain the benefits and risks of aspirin and antifibrinolytic therapy in coronary artery surgery. Results of the trial will guide the routine clinical care of patients in this setting. © 2008 Mosby, Inc. All rights reserved.

Objective: Mitral valve surgery may be regarded as less favourable for training, due to greater mortality risk, technical complexity, and difficulty for the supervisor to observe. We examined this perception by reviewing a multicentre experience. Method(s): We analysed a multicentre database over a 7-year period containing 2216 isolated and combined mitral procedures. Of these, 2048 were performed by consultants and 168 by trainees (92% vs 8%) of varying seniority. Preoperative characteristics, early postoperative outcomes and 6-year survival were compared between groups. Propensity-score matching was performed to correct for group differences. Result(s): Trainees were less likely to operate on patients, who had previously undergone coronary surgery (consultant 4.3% vs trainee 1.2%, p=0.043) and those with moderate to severe mitral regurgitation (86% vs 81%, p=0.012). There were no other statistically significant differences in preoperative variables, such as urgency, endocarditis and left-ventricular dysfunction. There were similar rates of mitral valve repair (48% vs 51%, p=0.48). Trainees were more likely to operate on rheumatic valve pathology (20% vs 28%, p=0.012). Intra-operatively, trainees had longer aortic cross-clamp times (119 +/- 52 vs 136 +/- 50. min, p=0.0001). At 30 days, mortality was comparable (4.5% vs 3.6%, p=0.56) with a trend towards higher any mortality/morbidity in consultant procedures (33% vs 26%, p=0.059). At 6 years, survival was similar (79 +/- 1.4% vs 78 +/- 4.0%, p=0.73). After derivation of 142 propensity-score-matched patient pairs, trainees cases still experienced longer cross-clamp times (121 +/- 58 vs 137 +/- 52. min, p=0.023), but there was similar 30-day mortality (4.2% vs 3.5%, p>0.99) and any mortality/morbidity (28% vs 24%, p=0.52). Six-year survival between matched pairs was also similar (74 +/- 7.2% vs 80 +/- 4.4%, p=0.64). Trainee status did not predict early or late adverse events after multivariate Cox regression with and

Objective: The effect of training on outcomes in cardiac surgery is poorly studied. We aimed to study the results of coronary artery bypass grafting procedures performed by surgeons in training across our state with respect to short- and midterm postoperative outcomes. Method(s): All coronary artery bypass grafting surgeries performed by trainee surgeons between July 2001 and December 2006 were compared with those performed by consultant surgeons using mandatory prospectively collected statewide data. Early mortality; prolonged ventilation or intensive care unit stay; return to operating theater for bleeding, stroke, myocardial infarction, or renal failure; and 5-year survival were compared using propensity score analysis. Result(s): A total of 7745 surgeries were included in this study. Trainees performed 983 (13%) surgeries. Trainee surgeries had longer perfusion and crossclamp times. Crude early postoperative outcomes were similar between trainee and consultant surgeries. After propensity score adjustment, early outcomes remained similar, with the exception of myocardial infarction (0.8% in trainee surgeries vs 0.4% in consultant surgeries, P = .046). Adjusted 1-, 3-, and 5-year survivals were similar between trainee and consultant surgeries: 95.3% versus 95.5%, 90.8% versus 92.0%, and 86.3% versus 87.1%, respectively. Conclusion(s): Coronary artery bypass grafting performed by trainee surgeons within a supervised program is safe with acceptable short- and midterm outcomes. © 2009 The American Association for Thoracic Surgery.

Objectives: The use of the radial artery as a second arterial graft during coronary surgery has become popular due to high patency and low harvest site complication rates. We sought to assess whether higher-risk patients derive such benefits. Method(s): From 2001 to 2009, 11 388 patients underwent isolated primary multivessel coronary surgery. We identified a higher risk subgroup (n=2581) according to urgency status, coronary instability, low ejection fraction and/ or aortic counterpulsation. Among these, 1832 (71%) received at least one radial artery graft in addition to a left internal thoracic artery (LITA). The remaining 749 (29%) received LITA and veins only. Result(s): Patients not receiving a radial artery were more likely to be elderly, female, have poor left ventricular function or be of emergency status. These patients experienced higher unadjusted 30-day mortality (radial 2% vs vein 8%, P<0.0001) with lower unadjusted 7-year survival (80+/-1.3% vs 67+/-2.4%, P<0.0001). Subsequently, 515 patients in the radial group were propensitymatched to 515 receiving only veins (mean logistic EuroSCORE, radial 19+/-14% vs vein 19+/-13%, P=0.87). At 30 days, there were comparable rates of mortality (radial 4% vs vein 3%, P>0.99), stroke (1% vs 1%, P>0.99), myocardial infarction (1% vs 2%, P=0.79), and any morbidity/mortality (34% vs 35%, P=0.95). At seven years, survival of radial and vein groups was similar (radial 75+/-2.6% vs vein 74+/-2.9%, P=0.65). Conclusion(s): Patients with the greatest coronary instability, urgency of surgery, or impairment of ventricular function are not disadvantaged in early outcomes or mid-term survival by use of only a single arterial graft.

The aim of this study was to establish whether removal of breathing exercises from a regimen including early mobilisation changes the incidence of post-operative pulmonary complications for patients after cardiac surgery. Two hundred and thirty patients undergoing open heart surgery at Monash Medical Centre, Melbourne, were enrolled in this randomised controlled trial. All patients received physiotherapy treatment pre-operatively and post-operatively for three days. Patients were mobilised as soon as possible after surgery. Breathing group (control) patients performed a set routine of deep breathing exercises at each physiotherapy visit while those in the intervention group did not perform this routine. Other than the breathing exercises, patient management was similar between groups in terms of assessment, positioning and mobility. The incidence of post-operative pulmonary complications, post-operative length of stay, oxyhaemoglobin saturation and pulmonary function were measured pre-operatively and post-operatively. Intention-to-treat analysis was performed for post-operative pulmonary complications and length of stay. Other data were analysed using Mests, chi square and repeated measures analysis of variance. There were no significant differences between the groups in the primary dependent variables. It is concluded that removal of breathing exercises from the routine physiotherapy management of open heart surgery patients does not significantly alter patient outcome.

Introduction: The use of the radial artery as a second arterial graft during coronary surgery has become popular due to high patency, encouraging clinical outcomes and low harvest site complication rates. However it is not clear whether higher risk patients derive such benefits. We sought to assess this by examining outcomes in higher risk subgroups. Method(s): A multicentre database was analysed. From 2001 to 2009, 11 388 patients underwent isolated multivessel coronary surgery. We identified a higher risk subgroup (n=3149) according to emergent status, coronary instability, low ejection fraction, aortic counterpulsation or anticoagulant status. Among these, 2231 (71%) received at least 1 radial artery graft in addition to a left internal thoracic artery (LITA). The remaining 918 (29%) received LITA and veins only. Propensity-score matching and adjustment was performed to correct for group differences. Result(s): Patients who did not receive a radial artery were more likely to be older (mean age, radial: 66+/-10 years vs vein: 71+/-10, p<0.0001) female (22% vs 27%, p=0.002), have poor left ventricular function (16% vs 23%, p<0.0001), left main stenosis (35% vs 41%, p=0.002) or be of emergent status (11% vs 24%, p<0.0001). These patients experienced higher unadjusted 30-day mortality (2.2% vs 7.1%, p<0.0001) and poorer 7-year survival (p<0.0001). Furthermore, 548 patients in the radial group were propensity-score matched to 548 receiving LITA and veins.At 30 days, there were comparable rates of mortality (radial: 2% vs vein: 3%, p=0.19), stroke (1% vs 1%, p=0.51), myocardial infarction (1% vs 1%, p=0.77), major adverse cardiac or cerebrovascular events (MACCE) (2% vs 4%, p=0.12), return to theatre (5% vs 7%, p=0.19), hospital readmissions (12% vs 12%, p>0.99) and combined any mortality/morbidity (30% vs 32%, p=0.33). At 7 years, survival between radial and vein groups was similar (79+/-2.5% vs 80+/-2.5%, p=0.74). Propensity-adjusted multivariable regression did not

Introduction: The use of the radial artery as a second arterial graft during coronary surgery has become popular due to high patency, encouraging clinical outcomes and low harvest site complication rates. However it is not clear whether higher risk patients derive such benefits. We sought to assess this by examining outcomes in higher risk subgroups. Method(s): A multicentre database was analysed. From 2001 to 2009, 11 388 patients underwent isolated multivessel coronary surgery. We identified a higher risk subgroup (n=3149) according to emergent status, coronary instability, low ejection fraction, aortic counterpulsation or anticoagulant status. Among these, 2231 (71%) received at least 1 radial artery graft in addition to a left internal thoracic artery (LITA). The remaining 918 (29%) received LITA and veins only. Propensity-score matching and adjustment was performed to correct for group differences. Result(s): Patients who did not receive a radial artery were more likely to be older (mean age, radial: 66+/-10 years vs vein: 71+/-10, p<0.0001) female (22% vs 27%, p=0.002), have poor left ventricular function (16% vs 23%, p<0.0001), left main stenosis (35% vs 41%, p=0.002) or be of emergent status (11% vs 24%, p<0.0001). These patients experienced higher unadjusted 30-day mortality (2.2% vs 7.1%, p<0.0001) and poorer 7-year survival (p<0.0001). Furthermore, 548 patients in the radial group were propensity-score matched to 548 receiving LITA and veins.At 30 days, there were comparable rates of mortality (radial: 2% vs vein: 3%, p=0.19), stroke (1% vs 1%, p=0.51), myocardial infarction (1% vs 1%, p=0.77), major adverse cardiac or cerebrovascular events (MACCE) (2% vs 4%, p=0.12), return to theatre (5% vs 7%, p=0.19), hospital readmissions (12% vs 12%, p>0.99) and combined any mortality/morbidity (30% vs 32%, p=0.33). At 7 years, survival between radial and vein groups was similar (79+/-2.5% vs 80+/-2.5%, p=0.74). Propensity-adjusted multivariable regression did not

Although most cardiac surgeons perform coronary surgery on microscopic structures, not often any sort of direct quality control method to test patency of the constructed anastomoses is applied. In most cases, simple evaluation of the immediate perioperative hemodynamic performance is considered as an acceptable marker of operative success. In this regard, it is very provocative that in surgical myocardial revascularization, electrocardiographic and hemodynamic parameters may remain postoperatively unchanged, even with a malfunctioning coronary graft.

Background - On-pump coronary artery bypass graft (CABG) surgery triggers an inflammatory response (IR) which may impair revascularization. The study aimed at (1) characterizing the temporal profile of the IR by assaying appropriate markers in both systemic and coronary blood, and (2) determining whether (and which doses of) cardiovascular drugs known to have antiinflammatory properties, namely statins and ACE-inhibitors (ACEI), inhibit the response. Methods and Results - Patients scheduled for CABG (n = 22) were randomized to statin/ACEI combination treatment at standard doses (STD, ramipril 2.5/simvastatin 20 mg, or atorvastatin 10 mg), or at high doses (HiDo, ramipril 10 mg, or enalapril 20 mg/simvastatin 80 mg, or atorvastatin 40 mg). Plasma levels of interleukin 6, tumor necrosis factor alpha, E-selectin, von Willebrand factor (vWF), and sVCAM-1 were serially assayed (ELISA) before, during, and after CABG. Blood was drawn from an artery, a systemic vein, and the coronary sinus. Myocardial perfusion scans were obtained before and 2 months after surgery in 19 out of 22 subjects. In the STD group both IL-6 and TNF displayed striking increases which were similar at all sites and peaked 10 to 60 minutes after aortic declamping. Such increases were drastically attenuated in the HiDo group. Instead, only modest increases in venous E-selectin, vWF, and sVCAM-1 were observed. Scintigraphic ischemia scores were entirely normalized after versus before CABG in the HiDo but not in the STD treatment group. Conclusions - On-pump CABG surgery is associated with an intense systemic inflammatory response, which can be almost completely prevented by early treatment with high (but not standard) doses of ACE-inhibitors and statins.

OBJECTIVE: The conventional surgical treatment of isolated critical stenosis of the left main coronary artery (LMCA) leads to the definitive occlusion of LMCA, restores only a retrograde perfusion to a rather extensive myocardial area and consumes bypass material. Direct surgical angioplasty avoids these inconveniences. METHODS: Between June 1985 and August 1996, 49 surgical angioplasties have been performed in 47 patients. LMCA was approached posteriorly in the first 11 procedures, and an anterior approach was preferred in the last 38 because of better exposure. The onlay patch consisted of saphenous vein in 37 cases; pericardium was used in 12 cases, and only for ostial stenosis. RESULTS: No technical failure occurred in the last 28 cases. 44 procedures, (90%), succeeded, but 1 patient (2.3%) died later of a massive air embolism, and 2 patients needed conventional CABG after 3 and 5 months, respectively. The 35 survivors still benefiting from a successful LMCA angioplasty on the long term are free of ischemia after a mean follow-up of 75 months (2-136). Angiographic restudy was obtained in 30 patients (70%) at an average of 38 months and revealed an excellent result in 26 (87%). In 10 patients, a late angiographic restudy at an average of 71 months (32-119) still revealed a perfect result. CONCLUSION: Provided that well-defined contra-indications (involvement of the distal bifurcation, heavy calcification) are respected, LMCA surgical angioplasty deserves a place in the array of surgical strategies.