Search

Background: Although many options exist for multivessel coronary revascularization, controversy persists over whether multiarterial grafting (MAG) confers a survival advantage over single-arterial grafting (SAG) with saphenous vein in coronary artery bypass grafting (CABG). This study sought to compare longitudinal survival between patients undergoing MAG and those undergoing SAG., Methods: All patients undergoing isolated CABG with ≥2 bypass grafts in The Society of Thoracic Surgeons Adult Cardiac Surgery Database (2008-2019) were linked to the National Death Index. Risk adjustment was performed using inverse probability weighting and multivariable modeling. The primary end point was longitudinal survival. Subpopulation analyses were performed and volume thresholds were analyzed to determine optimal benefit., Results: A total of 1,021,632 patients underwent isolated CABG at 1108 programs (100,419 MAG [9.83%]; 920,943 SAG [90.17%]). Median follow-up was 5.30 years (range, 0-12 years). After risk adjustment, all characteristics were well balanced. At 10 years, MAG was associated with improved unadjusted (hazard ratio, 0.59; 95% CI 0.58-0.61) and adjusted (hazard ratio, 0.86; 95% CI, 0.85-0.88) 10-year survival. Center volume of ≥10 MAG cases/year was associated with benefit. MAG was associated with an overall survival advantage over SAG in all subgroups, including stable coronary disease, acute coronary syndrome, and acute infarction. Survival was equivalent to that with SAG for patients age ≥80 years and those with severe heart failure, renal failure, peripheral vascular disease, or obesity. Only patients with a body mass index ≥40 kg/m 2 had superior survival with SAG., Conclusions: Multiarterial CABG is associated with superior long-term survival and should be the surgical multivessel revascularization strategy of choice for patients with a body mass index of less than 40 kg/m 2 ., (Copyright © 2024. Published by Elsevier Inc.)

Background: There is limited report of outcomes in women undergoing isolated coronary artery bypass grafting (CABG) with left internal thoracic artery and different second conduits (saphenous vein graft [SVG], radial artery [RA], and right internal thoracic artery [RITA])., Methods: The National Adult Cardiac Surgery Audit database was queried for women undergoing isolated CABG with left internal thoracic artery graft in the United Kingdom from 1996 to 2019. Propensity score-based pairwise comparisons were performed between graft types. The primary outcome was in-hospital mortality., Results: The study included 58,063 women (SVG, n = 48,881 [84.2%]; RA, n = 6136 [10.6%]; RITA, n = 2445 [4.2%]). SVG use was stable over the years; RA and RITA use decreased. In-hospital mortality was similar between the RA and RITA grafts (2.3% vs 2.8%; odds ratio [OR], 0.80; 95% CI, 0.53-1.22; P = .39) and between the RA and SVG (2.3% vs 2.0%; OR, 1.20; 95% CI, 0.93-1.55; P = .17) but higher in the RITA group compared with the SVG (2.7% vs 1.4%; OR, 2.04; 95% CI, 1.27-3.36; P = .004). Women receiving the RITA graft were more likely to have sternal wound infection (SWI) compared with the RA (0.6% vs 0.06%; P = .004) and the SVG (0.6% vs 0.2%; P = .032). SWI was consistently associated with higher risk of in-hospital mortality., Conclusions: Conduit selection may affect operative outcomes in women undergoing CABG. The RA shows similar mortality and risk of deep SWI as the SVG., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The benefits of fast-track extubation in the intensive care unit (ICU) after cardiac surgery are well established. Although extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR vs ICU extubation in patients undergoing nonemergency, isolated coronary artery bypass grafting (CABG)., Methods: The Society of Thoracic Surgeons (STS) data for all single-center patients who underwent nonemergency isolated CABG over a 6-year interval were analyzed. Perioperative morbidity and mortality with ICU vs OR extubation were compared., Results: Between January 1, 2017 and December 31, 2022, 1397 patients underwent nonemergency, isolated CABG; 891 (63.8%) of these patients were extubated in the ICU, and 506 (36.2%) were extubated in the OR. Propensity matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the 2 groups in incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure, or 30-day mortality. OR-extubated patients had shorter ICU hours (14 hours vs 20 hours; P < .0001), shorter postoperative hospital length of stay (3 days vs 5 days; P < .0001), a greater likelihood of being discharged directly to home (97.3% vs 89.9%; P < .0001), and a lower 30-day readmission rate (1.7% vs 4.1%; P = .04)., Conclusions: Routine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after nonemergency CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation for nonemergency CABG is indicated., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The decision to perform transfusion is common but varies among centers and surgeons. This study looked at variables associated with red blood cell (RBC) transfusion in a statewide database. The study aimed to understand discrepancies in transfusion rates among hospitals and to establish whether the hospital itself was a significant variable in transfusion, independent of variables known to affect transfusion in patients undergoing cardiac surgical procedures., Methods: The Maryland Cardiac Surgery Quality Initiative is a consortium of centers in the state. Patients undergoing isolated coronary artery bypass grafting from January 2018 to June 2020 from 10 centers in Maryland were included. Multivariable logistic regression was used to determine probability of RBC transfusion with covariates, including age, preoperative hemoglobin value, The Society of Thoracic Surgeons predicted risk of mortality, emergency status, preoperative adenosine diphosphate receptor blocker use, sex, body mass index, and off-pump status., Results: A total of 5343 patients were included and had an overall RBC transfusion rate of 30.3% (range, 11.3%-55.8%). There was significant variability in the incidence of RBC transfusion among hospitals (χ 2  = 604.7; P < .001). After covariate adjustment, a significant effect of hospital on transfusion remained (Wald = 547.3; P < .001). Hospital variation in RBC transfusion was not correlated with hospital variation in median age (P = .467), hemoglobin (P 0 855), The Society of Thoracic Surgeons predicted risk of mortality (P = .855), or sex (P = .726)., Conclusions: In a statewide analysis, wide variability in transfusion rates was observed, with hospital-specific management strongly associated with RBC transfusion. This study suggests that RBC transfusion may be affected by the culture and practices of an institution independent of clinical and demographic variables., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Given the uncertainty of US health care finances, an understanding of reimbursement trends has become increasingly important in the field of cardiac surgery. We aimed to assess Medicare reimbursement trends for common cardiac surgical procedures from 2000 to 2022., Methods: Reimbursement data were extracted from the Centers for Medicare and Medicaid Services Physician Fee Schedule Look-Up Tool during the study period for 6 common cardiac operations: aortic valve replacement, mitral valve repair and replacement, tricuspid valve replacement, Bentall procedure, and coronary artery bypass grafting. Reimbursement rates were adjusted for inflation to 2022 US dollars using the Consumer Price Index. Total percentage change and compound annual growth rate were calculated. A split-time analysis was performed to assess trends before and after 2015. Least squares and linear regressions were performed. The R 2 value was calculated for each procedure, and slope was used to determine change in reimbursements over time., Results: Inflation-adjusted reimbursement decreased by 34.1% during the study period. The overall compound annual growth rate was -1.8%. Reimbursement trends differed by procedure (P < .001), with all reimbursements trending down (R 2 > 0.62), except for mitral valve replacement (P = .21) and tricuspid valve replacement (P = .43). Coronary artery bypass grafting decreased the most (-44.4%), followed by aortic valve replacement (-40.1%), mitral valve repair (-38.5%), mitral valve replacement (-29.8%), Bentall procedure (-28.5%), and tricuspid valve replacement (-25.3%). In split-time analysis, reimbursement rates did not significantly change from 2000 to 2015 (P = .24) but decreased significantly from 2016 to 2022 (P = .001)., Conclusions: Medicare reimbursement significantly decreased for most cardiac surgical procedures. These trends justify further advocacy by The Society of Thoracic Surgeons to maintain access to quality cardiac surgical care., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Postoperative atrial fibrillation (POAF) is a frequent complication of cardiac surgery. However, only a few detailed descriptions of the arrhythmia have been reported. We aim to describe the characteristics, outcomes, and variables associated with POAF and to evaluate how posterior pericardiotomy (PP) affects POAF characteristics., Methods: In this post hoc analysis of the Posterior left pericardiotomy for the prevention of AtriaL fibrillation After Cardiac Surgery (PALACS) trial, we describe POAF characteristics based on continuous in-hospital telemetry data., Results: Of 420 patients, 103 (24.5%) developed POAF. Median time to onset was 50.3 hours; 70.9% of events occurred within 3 days. Hemodynamic instability and rapid ventricular response occurred in 8.7% and 51.5% of cases, respectively. Most POAF patients received antiarrhythmics (97.1%), 22.3% electrical cardioversion, and 40.8% systemic anticoagulation. Median POAF duration was 24.0 hours; 70.9% of cases resolved within 36 hours. Median POAF burden was 15.9%. All patients were in sinus rhythm at follow-up. POAF was associated with longer hospitalization (7 vs 6 days; P < .001), but not increased mortality or morbidity. PP reduced POAF incidence (17.7% vs 31.3%; P = .001), especially after postoperative day 2 (time to POAF onset 41.9 vs 57.1 hours; P = .01). Age was associated with POAF. Female sex, coronary artery bypass grafting, beta blockers, and PP were inversely associated., Conclusions: POAF remains frequent after cardiac surgery. Hemodynamic instability is rare, although rapid ventricular response and need for electrical cardioversion are frequent. POAF burden is significant, and the arrhythmias resolve within 30 days. PP reduces POAF especially after postoperative day 2., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: A post-hoc analysis of the Surgical Treatment for Ischemic Heart Failure (STICH) trial was performed to evaluate the perioperative and long-term outcomes after off-pump vs on-pump coronary artery bypass graft surgery in patients with ischemic cardiomyopathy (coronary artery disease with left ventricular ejection fraction 35% or less)., Methods: Patients who underwent isolated coronary artery bypass graft surgery were enrolled from the STICH trial. Operative details, perioperative outcomes, and long-term outcomes were compared in a 1-to-2 propensity score matching cohort. The primary outcome was death from any cause., Results: Among 768 included patients operated on between July 2002 and May 2007, 152 (19.8%) received off-pump and 616 (80.2%) received on-pump coronary artery bypass graft surgery. In the 1-to-2 matched cohort (152 off pump and 304 on pump), off pump was associated with a higher prevalence of multiple arterial grafting (17.1% vs 8.6%, P = .01) and incomplete revascularization (34.2% vs 17.1%, P < .001). The overall 30-day mortality (3.3% vs 5.3%, P = .34) was comparable between the two groups. After a median follow-up of 8.7 years, off-pump surgery was associated with a similar risk of death from any cause (hazard ratio 0.82; 95% confidence interval, 0.61 to 1.09), with comparable estimated all-cause mortality at 1 year (12.5% vs 11.9%), 5 years (32% vs 32.8%), and 10 years (51.4% vs 62.3%). No significant interaction was detected in the subgroup analyses of incomplete revascularization, multiple arterial grafting, and three-vessel disease., Conclusions: In patients with ischemic cardiomyopathy, off-pump coronary artery bypass graft surgery could be performed with comparable 30-day mortality and similar long-term survival, and appears to have a lower incidence of perioperative morbidities., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to elucidate current national multiarterial coronary bypass grafting practice patterns and assess perioperative outcomes., Methods: Isolated primary nonemergent/nonsalvage coronary artery bypass grafting patients with at least 1 internal thoracic artery and 2 or more grafts in The Society of Thoracic Surgery Adult Cardiac Surgery Database (2018-2019) were divided into 3 cohorts: single-arterial, bilateral internal thoracic artery (BITA), and radial artery multiarterial grafting. Observed-to-expected ratios based on 2017 Society of Thoracic Surgery risk models were derived for 30-day perioperative mortality, composite major morbidity and mortality, and deep sternal wound infections for each grafting group overall and as a function of institutional multiarterial case volumes per study period: low (<10), intermediate (11-30), and high (>30)., Results: A total of 281,515 patients (BITA, 15,663 [5.6%]; radial, 23,905 [8.5%]) at 1013 centers showed distinct geographic grafting patterns: BITA and radial multiarterial grafting rates were lowest in the South (4% and 6%, respectively) and highest in the Northeast (9% and 11%, respectively). The median institutional number of BITA and radial cases per study period was 4 and 7, with only 14% and 21% of institutions performing >30 BITA and radial multiarterial cases per study period, respectively. The observed-to-expected mortality for single-arterial bypass grafting was similar to multiarterial: single-arterial, 1.00 (95% CI, 0.98-1.03); BITA, 0.98 (95% CI, 0.84-1.13; P = .711); and radial, 0.96 (95% CI, 0.86-1.07; P = .818). Observed-to-expected mortality and composite major morbidity and mortality were lower at high vs low multiarterial case-volume centers: 0.91 (95% CI, 0.75-1.08) vs 1.30 (95% CI, 0.89-1.79; P = .048) and 1.06 (95% CI, 0.99-1.13) vs 1.51 (95% CI, 1.32-1.71; P < .001), respectively, for BITA, and 0.82 (95% CI, 0.87-1.30) vs 1.67 (95% CI, 1.21-2.21; P < .001) and 0.91 (95% CI, 0.93-1.08) vs 1.42 (95% CI, 1.24-1.61; P < .001), respectively, for radial., Conclusions: Multiarterial bypass grafting remains underused and limited to select centers. Worse outcomes at low-volume BITA and radial institutions document a case-volume outcomes effect. Additional studies are warranted to improve multiarterial outcomes at low-volume institutions., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Intraoperative transesophageal echocardiography (TEE) is associated with improved outcomes after cardiac surgery, but unexplained practice pattern variation exists. This study aimed to identify and quantify the predictors of intraoperative TEE use among patients undergoing isolated coronary artery bypass graft surgery (CABG) or cardiac valve surgery., Methods: This observational cohort study used The Society of Thoracic Surgeon (STS) Adult Cardiac Surgery Database data to identify and quantify the predictors of intraoperative TEE use among adult patients aged 18 years or more undergoing either isolated CABG or open cardiac valve repair or replacement surgery between January 1, 2011, and December 31, 2019. Generalized linear mixed models were used to measure the relationship between intraoperative TEE and patient characteristics, surgical volume, and geographic location, while accounting for clustering within hospitals (primary analysis) or surgeons (secondary analysis)., Results: Of 1,973,655 patients, 1,365,708 underwent isolated CABG and 607,947 underwent cardiac valve surgery. Overall, intraoperative TEE was used in 62% of surgeries. The primary hospital-level generalized linear mixed models analysis demonstrated that the strongest predictor of intraoperative TEE use was the hospital where the surgery occurred-with a median odds ratio for TEE of 10.13 in isolated CABG and 5.30 in cardiac valve surgery. The secondary surgeon-level generalized linear mixed models analysis demonstrated similar findings., Conclusions: Intraoperative TEE use (vs lack of use) during surgery was more strongly associated with hospital and surgeon practice patterns than with any patient-level factor, surgical volume, or geographic location., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Public interest in stratifying hospital performance has led to the proliferation of commercial, consumer-oriented hospital rankings. In cardiac surgery, little is known about how these rankings correlate with clinical registry quality ratings., Methods: The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried for isolated coronary artery bypass grafting or coronary artery bypass grafting/valve patients at hospitals among the top 100 U.S. News & World Report (USNWR) Cardiology & Heart Surgery rankings from 2016 to 2020. Hospitals were grouped into deciles by risk-adjusted observed/expected (O/E) ratios for morbidity and mortality using the STS 2018 risk models. Agreement between STS Adult Cardiac Surgery Database and USNWR ranked deciles was calculated by Bowker symmetry test. The association between each center's annual change in STS O/E ratio and change in USNWR ranking was modeled in repeated measures regression analysis., Results: Inclusion criteria were met by 524 393 patients from 149 hospitals that ranked in USNWR top 100 at least once during the study period. There was no agreement between USNWR ranking and STS major morbidity and mortality O/E ratio (P > .50 for all years). Analysis of patients undergoing surgery at the 65 hospitals that were consistently ranked in the top 100 during the study period demonstrated no association between annual change in hospital ranking and change in O/E ratio (P all > .3)., Conclusions: There was no agreement between annual USNWR hospital ranking and corresponding risk-adjusted STS morbidity or mortality. Furthermore, annual changes in USNWR rankings could not be accounted for using clinical outcomes. These findings suggest that factors unrelated to key surgical outcomes may be driving consumer-directed rankings., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) estimates mortality risk only for certain common procedures (eg, coronary artery bypass or valve surgery) and is cumbersome, requiring greater than 60 inputs. We hypothesized that deep learning can estimate postoperative mortality risk based on a preoperative chest radiograph for cardiac surgeries in which STS-PROM scores were available (STS index procedures) or unavailable (non-STS index procedures)., Methods: We developed a deep learning model (CXR-CTSurgery) to predict postoperative mortality based on preoperative chest radiographs in 9283 patients at Massachusetts General Hospital (MGH) having cardiac surgery before April 8, 2014. CXR-CTSurgery was tested on 3615 different MGH patients and externally tested on 2840 patients from Brigham and Women's Hospital (BWH) having surgery after April 8, 2014. Discrimination for mortality was compared with the STS-PROM using the C-statistic. Calibration was assessed using the observed-to-expected ratio (O/E ratio)., Results: For STS index procedures, CXR-CTSurgery had a C-statistic similar to STS-PROM at MGH (CXR-CTSurgery: 0.83 vs STS-PROM: 0.88; P = .20) and BWH (0.74 vs 0.80; P = .14) testing cohorts. The CXR-CTSurgery C-statistic for non-STS index procedures was similar to STS index procedures in the MGH (0.87 vs 0.83) and BWH (0.73 vs 0.74) testing cohorts. For STS index procedures, CXR-CTSurgery had better calibration than the STS-PROM in the MGH (O/E ratio: 0.74 vs 0.52) and BWH (O/E ratio: 0.91 vs 0.73) testing cohorts., Conclusions: CXR-CTSurgery predicts postoperative mortality based on a preoperative CXR with similar discrimination and better calibration than the STS-PROM. This may be useful when the STS-PROM cannot be calculated or for non-STS index procedures., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Recent guidelines for the treatment of moderate or severe ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) have changed. This study assessed the real-world impact of changing guidelines on the management of IMR during CABG over time. We hypothesized that the utilization of mitral valve repair for IMR would decrease over time, whereas mitral valve replacement for severe IMR would increase., Methods: Patients undergoing CABG in a statewide collaborative database (2011-2020) were stratified by severity of IMR. Trends in mitral valve repair or replacement were evaluated. To account for differences of the patients, propensity score-matched analyses were used to compare patients with and without mitral intervention., Results: A total of 11,676 patients met inclusion criteria, including 1355 (11.6%) with moderate IMR and 390 (3.3%) with severe IMR. The proportion of patients undergoing mitral intervention for moderate IMR decreased over time (2011, 17.7%; 2020, 7.5%; P trend  = .001), whereas mitral replacement for severe IMR remained stable (2011, 11.1%; 2020, 13.3%; P trend  = .14). Major morbidity was higher for patients with moderate IMR who underwent mitral intervention (29.1% vs 19.9%; P = .005). In a propensity analysis of 249 well-matched pairs, there was no difference in major morbidity (29.3% with mitral intervention vs 23.7% without; P = .16) or operative mortality (1.2% vs 2.4%; P = .5)., Conclusions: Consistent with recent guideline updates, patients with moderate IMR were less likely to undergo mitral repair. However, the rate of replacement for severe IMR did not change. Mitral intervention during CABG did not increase operative mortality or morbidity., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Transfusion in acute aortic syndromes has been studied in a limited fashion. We sought to describe contemporary transfusion practice for root replacement in acute (Stanford) type A aortic dissection., Methods: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was interrogated to identify patients who underwent primary aortic root replacement for acute (Stanford) type A aortic dissection (July 2014 to June 2017). Patients (n = 1558) were stratified by type of root replacement. Multivariate regression was used to determine those variables associated with transfusion and postoperative morbidity., Results: Transfusion was required in 90.5% of cases (n = 1410). Operative mortality for all patients was 17.3% (261 deaths). Intraoperative red blood cell transfusion portended reduced short-term survival (odds ratio [OR] 2.00, P = .025). Massive postoperative transfusion was associated with prolonged ventilation (OR 13.47, P < .001), sepsis (OR 4.13, P < .001), and new dialysis-dependent renal failure (OR 2.43, P < .001). Women were more likely to require transfusion (OR 3.03, P < .001), as were patients who had coronary artery bypass (OR 1.57, P = .009), and those in shock (OR 2.27, P < .001). Valve-sparing aortic root replacement was associated with reduced transfusion requirements vs composite roots. Institutional case volume was not appreciably correlated with transfusion., Conclusions: Most patients undergoing root replacement for aortic dissection require blood products. Composite root replacement is associated with a greater likelihood of transfusion than a valve-sparing operation. Transfusion independently foreshadows greater operative mortality., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), the frequency and outcomes of nonaortic valve cardiac surgery after TAVR are unknown., Methods: Nonaortic valve surgery after TAVR from 2011 to 2019 was queried using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. A total of 666 patients, including 47 (7.1%) unplanned TAVR explants and 3 (0.5%) aborted procedures during nonaortic valve procedures, were identified., Results: These 666 procedures were performed by 459 surgeons (median, 1.0 case per surgeon) from 308 centers (median, 1.0 case per center), representing 29% of STS Database participants. The case number increased over time from 4 in 2011 to 204 in 2019, largely attributable to coronary artery bypass grafting (CABG) (n = 283; 42.5%) and mitral valve (n = 258; 38.7%) procedures. The median age patients of was 75.0 years, and 51.4% had undergone previous cardiac surgical procedures. The 30-day mortality of the entire cohort was 17.0%. Subgroups with particularly high mortality included patients with robot-assisted mitral surgery (n = 5/12; 41.7%), an unplanned TAVR explant (n = 19/47; 40.4%), open atrial transcatheter mitral valve replacement (n = 10/33; 30.3%), and aortic repair (n = 24/79; 29.8%). Among 390 patients with available STS predicted risk of mortality, the 30-day mortality in patients with isolated CABG, patients with isolated mitral repair or replacement, and in the entire group was 8.4% (n = 19/225), 13.5% (n = 21/155), and 10.8% (n = 42/390) with corresponding observed-to-expected mortality (O/E) ratios of 1.8, 1.8, and 1.7, respectively., Conclusions: Nonaortic valve operation after TAVR was associated with a high mortality and O/E ratio. The TAVR team must be mindful of a "lifetime management" strategy, including assessment of concurrent diseases during TAVR candidate selection., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Developing a nomogram to predict improvement in moderate ischemic mitral regurgitation (IMR) after coronary artery bypass grafting (CABG) is in need., Methods: We retrospectively collected data from 112 patients with prior myocardial infarction and moderate IMR undergoing CABG between 2010 and 2018. Patients were divided into 2 groups based on IMR degree 1 year after CABG as follows: Improved Group with no or mild IMR (n = 54) and Failure Group with moderate or severe IMR (n = 58). To determine the predictors of postoperative IMR improvement, preoperative clinical and echocardiographic data were compared, and a nomogram was formulated based on all independent predictors. Discriminative ability, calibration, and clinical usefulness of the prediction model were assessed., Results: Independent predictors of IMR improvement after CABG constructing the nomogram included duration between infarction and operation, posterior-inferior to left ventricular volume ratio, maximum difference of the time to reach minimum systolic volume of 16 segments, P3 leaflet tethering angle, and annular nonplanar angle. The nomogram exhibited well-fitted calibration curves and excellent discriminative ability. The area under the receiver operating characteristic curve was 0.974. Patients with a score >236 demonstrated a high probability of IMR improvement (sensitivity, 90.7%; specificity, 93.1%). Patients in the Improved Group demonstrated greater actuarial survival rates than those in the Failure Group., Conclusions: The nomogram combining 5 preoperative clinical and echocardiographic predictors provides an accurate preoperative estimation of moderate IMR improvement after surgery, with excellent discriminative ability. Based on this nomogram, patients with a higher score have predicted higher probabilities of IMR improvement., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Machine learning may enhance prediction of outcomes after coronary artery bypass grafting (CABG). We sought to develop and validate a dynamic machine learning model to predict CABG outcomes at clinically relevant pre- and postoperative time points., Methods: The Society of Thoracic Surgeons (STS) registry data elements from 2086 isolated CABG patients were divided into training and testing datasets and input into Extreme Gradient Boosting decision-tree machine learning algorithms. Two prediction models were developed based on data from preoperative (80 parameters) and postoperative (125 parameters) phases of care. Outcomes included operative mortality, major morbidity or mortality, high cost, and 30-day readmission. Machine learning and STS model performance were assessed using accuracy and the area under the precision-recall curve (AUC-PR)., Results: Preoperative machine learning models predicted mortality (accuracy, 98%; AUC-PR = 0.16; F1 = 0.24), major morbidity or mortality (accuracy, 75%; AUC-PR = 0.33; F1 = 0.42), high cost (accuracy, 83%; AUC-PR = 0.51; F1 = 0.52), and 30-day readmission (accuracy, 70%; AUC-PR = 0.47; F1 = 0.49) with high accuracy. Preoperative machine learning models performed similarly to the STS for prediction of mortality (STS AUC-PR = 0.11; P = .409) and outperformed STS for prediction of mortality or major morbidity (STS AUC-PR = 0.28; P < .001). Addition of intraoperative parameters further improved machine learning model performance for major morbidity or mortality (AUC-PR = 0.39; P < .01) and high cost (AUC-PR = 0.64; P < .01), with cross-clamp and bypass times emerging as important additive predictive parameters., Conclusions: Machine learning can predict mortality, major morbidity, high cost, and readmission after isolated CABG. Prediction based on the phase of care allows for dynamic risk assessment through the hospital course, which may benefit quality assessment and clinical decision-making., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Cox-Maze procedure (CM) for atrial fibrillation (AF) is associated with a high rate of sinus restoration. This study assessed the safety and efficacy of concomitant CM using an argon-based cryosurgical platform only. Methods: Data were collected prospectively for 250 consecutive patients undergoing concomitant cryosurgical CM. We examined baseline characteristics, perioperative and postoperative outcomes, health-related quality of life (Medical Outcomes Trust SF-12 Health Survey and AF Symptom Checklist) and Kaplan-Meier survival analysis. Results: Mean age was 64.3 ± 12.1 years, AF duration was 35.7 ± 54.2 months, left atrial size was 5.2 cm (range, 3.1 to 11.0 cm; 16.8% > 6 cm), 86% had nonparoxysmal AF, with history of cardioversion in 32% and catheter ablation in 8%. Concomitant procedures were mitral valve operation in 69.6%, coronary artery bypass graft in 29.2%, aortic valve replacement in 22.0%, with 46% multiple concomitant procedures and 16% with a previous cardiac operation. Perioperative outcomes were 5 deaths (2%), 3 strokes (1%), 1 transient ischemic attack (<1%), and 4 pacemakers for sinus node dysfunction (2%). There were no late thromboembolic events (mean follow-up, 28.2 ± 23.7 months), and 11% were taking warfarin for atrial arrhythmia at 1 year. Significant improvement in health-related quality of life (p < 0.001) was noted. At 24 months, 92.4% of patients were in sinus rhythm; with 82.8% in sinus rhythm off antiarrhythmic drugs. Two-year cumulative survival was 91%. Conclusions: The cryosurgical CM procedure can be performed safely and effectively as defined by the low number of postoperative morbidities, high return to sinus rhythm off antiarrhythmic drugs, and low rate of thromboembolic events, with most patients off anticoagulation by 2 years. [ABSTRACT FROM AUTHOR]

Background: The efficacy of antidepressant therapy in patients undergoing coronary artery bypass grafting (CABG) is not clearly established. Methods: This double-blind trial was conducted at University Hospital, Besançon, France. Adult CABG patients were randomized (1:1) to receive escitalopram (10 mg daily) or placebo from 2 to 3 weeks before to 6 months after surgery, including 12 months post-surgery follow-up. The primary composite endpoint was the occurrence of mortality or predefined morbidity events. Secondary endpoints included measures of depression, mental and physical health using Beck Depression Inventory Short Form (BDI), and quality of life 36-Item Short Form (SF-36) self assessments. Results: The treated cohort contained 361 patients with mean age 67 years. At 12 months, the proportions of patients with the composite morbidity and mortality endpoint were not different between escitalopram and placebo (110 of 182 [60.4%] vs 108 of 179 [60.3%], p = 0.984). However, over the 6 months postoperative period, the BDI and SF-36 Mental Component Summary scores were better overall in the escitalopram group than in the placebo group for all patients (p = 0.015 and p = 0.014, respectively) and preoperatively depressed (BDI > 3) patients (p = 0.002 and p = 0.005, respectively). Moreover, the SF-36 Pain score was better overall in the escitalopram group than in the placebo group in the preoperatively-depressed subset (p = 0.026). Conclusions: Antidepressant therapy had no effect on morbidity and mortality events up to 1 year after CABG. However, antidepressant therapy may provide faster improvements to mental health aspects of quality of life and reduce postoperative pain in patients with preoperative depression. Subject to contra-indications, we recommend antidepressant therapy in coronary revascularization patients who are preoperatively depressed. [ABSTRACT FROM AUTHOR]

Background: Prior coronary surgery has been associated with a higher incidence of adverse outcomes after reoperative cardiac surgery compared with previous valve surgery. It is unclear whether this association is primarily due to greater patient comorbidity or the technical challenges posed by mediastinal reentry and operation in the setting of previous bypass grafts. This study was therefore designed to examine whether previous coronary artery bypass grafting (CABG) is a significant risk factor for adverse outcomes after reoperative cardiac surgery. Methods: From a prospective database of 1,093 consecutive adults who underwent reoperative cardiac surgery between 2000 and 2010, 363 patients undergoing isolated reoperative valve surgery were divided according to whether or not the previous surgery included CABG (group I, n = 133) or not (group II, n = 230). Propensity-adjusted multivariate analysis was performed in order to determine independent predictors of any morbidity or mortality, or decreased survival. Results: Patients in group I were more likely to be elderly (p < 0.001), and have greater body mass indexes (p = 0.04), low ejection fractions (p = 0.001), and comorbidities of cerebrovascular disease (p = 0.04), peripheral vascular disease (p = 0.003), and diabetes (p < 0.001) compared with group II. Patent grafts were present in 94% (n = 111). Although group I patients were significantly more likely to experience major postoperative complications and had worse survival, after propensity adjustment no significant difference was observed in either any morbidity or mortality (p = 0.4) or in survival (p = 0.4). Conclusions: A history of CABG does not appear to present a unique risk in reoperative valve surgery. The major determinant of adverse outcomes is morbidity, not prior bypass grafts. [ABSTRACT FROM AUTHOR]

Background: Reports of cardiac surgery in the elderly have focused primarily on septuagenarians and octogenarians. There are very limited data regarding risk-adjusted models in nonagenarians. Methods: From 1983 to 2011, patients with age 90 years or greater at the time of coronary artery bypass grafting (CABG) or valve surgery (aortic or mitral) were retrieved from a prospective institutional database. A Cox proportional hazard model was used to determine significant predictors of 5-year survival. In addition, a 12-month assessment of quality of life was conducted. Results: The CABG-only (n = 46), valve-only (n = 55), or CABG-valve (n = 53) surgery was conducted in 154 patients. Demographic characteristics were similar in all groups except for congestive heart failure, which was more prominent in the valve-only or CABG-valve groups (p < 0.0001). The 30-day mortality was 8.8%, 12.8%, and 18.9% in the CABG-only, valve-only, and CABG-valve groups, respectively, without significant difference among groups (p = 0.35). At 5-years follow-up, the Kaplan-Meier survival curves do not show a difference among groups (p = 0.62). Cox proportional hazard model for 5-year survival identified age (hazard ratio [HR] = 1.25, confidence interval [CI] 1.09 to 1.43, p = 0.001, for 1-year increase), prior surgery (HR = 2.23, CI 1.23 to 4.64, p = 0.007), and prior stroke (HR = 2.39, CI 1.25 to 3.98, p = 0.01), as significant predictors of mortality. The 12-month quality of life questionnaire revealed an improvement in 83% of the patients, whereas only 4% reported a decline in cardiac status. Conclusions: Survival in nonagenarians is comparable after CABG or valve surgery. Redo surgery, stroke, and increasing age are significant hazards for mortality. Nonagenarians can undergo cardiac surgery with acceptable mortality and quality of life. [ABSTRACT FROM AUTHOR]

Background: Left atrial dissection (LatD) is a rare entity most commonly associated with mitral valve surgery. We have reviewed our experience with 4 patients to better define the etiology and the treatment of LatD. Methods: From 1991 to 2012, 4 patients experienced LatD after surgery (1 of 6,302, or 0.02%, of isolated coronary artery bypass grafting patients and 3 of 1,895, or 0.16%, of mitral valve patients). Patient and perioperative data and management were reviewed. Results: Two patients were women, and ages ranged from 49 to 80 years. Three patients underwent mitral procedures (two replacements with coronary artery bypass grafting and one repair) for mitral regurgitation. One patient underwent emergent isolated coronary artery bypass grafting after cardiopulmonary resuscitation for a left main dissection during percutaneous coronary intervention. Three LatDs were found during surgery, and one LatD was found 12 days after mitral repair and was successfully treated nonoperatively. The LatD was located along the posterior atrial wall originating from the atrioventricular junction in all cases and obstructed mitral valve inflow. Operative repair focused on the evacuation of hematoma, obliteration of the false lumen, and repair of the entry injury. No mortality occurred. Conclusions: Left atrial dissection is a rare complication of cardiac surgery, probably related to a contained atrioventricular separation allowing pressurized blood to separate the layers of the posterior left atrium. Prompt intraoperative diagnosis, obliterating the false cavity, and addressing the entry point are essential. In contrast, a nonoperative approach in a stable patient with a delayed LatD suggests healing of the dissection, and atrial remodeling occurs. [ABSTRACT FROM AUTHOR]

Background: Microplegia delivers blood and additives for cardioplegia with minimal crystalloid. We retrospectively compared microplegia with standard 8:1 blood cardioplegia with a propensity-matched analysis in patients undergoing isolated coronary artery bypass graft (CABG) surgery. Methods: Prospectively collected data for 2,630 consecutive patients who underwent isolated CABG surgery (2004 to 2006) with the exclusive use of microplegia was compared with an equivalent 3-year cohort (1998 to 2000) of 5,058 consecutive isolated CABG patients with the exclusive use of 8:1 diluted blood cardioplegia. Propensity score matching identified 1,980 matched pairs (in each group) for analysis. Results: In the matched groups, the hospital mortality was identical (1.2%). The prevalence of low cardiac output syndrome was significantly (p< 0.001) lower in the later period when microplegia was employed (2.7%) compared with the standard cardioplegia group (5.0%). Although these results may also reflect improvements in care with time, a multivariable logistic regression analysis of the entire cohort (not matched) also demonstrated a twofold independent reduction in low cardiac output syndrome in microplegia patients (odds ratio, 1.9; 95% confidence interval 1.4 to 2.5). Conclusions: Compared with 8:1 blood cardioplegia, microplegia during isolated CABG surgery was associated with a lower incidence of postoperative low cardiac output syndrome. Microplegia may reduce postoperative cardiac edema, increase buffering, and permit more rapid recovery of ventricular function. Randomized trials are required to determine whether the relationship between microplegia and reduced low output syndrome is causal or is merely an association. [ABSTRACT FROM AUTHOR]

Background: There have been limited reports on the diagnostic performance and prognostic value of coronary computed tomography angiography (CCTA) for selecting coronary artery bypass graft (CABG) candidates. Methods: There were 1,018 patients with suspected coronary artery disease who underwent 64-slice multidetector CCTA between July 2009 and January 2010. Of them, we excluded 324 patients who denied further treatment (n = 7), who were lost for unidentified reasons (n = 107), or who were transferred to local clinics (n = 210). The total analysis cohort consisted of 694 patients. We established eligible CABG criteria defined as three-vessel disease, left main coronary disease, and left main coronary artery equivalent disease. Diagnostic performance was determined using conventional coronary angiography as the reference standard. For assessment of the prognostic utility of CCTA, electronic medical records were reviewed to screen for the occurrence of a major adverse cardiac event, defined as cardiac death, nonfatal myocardial infarction, or revascularization. Results: The overall sensitivity, specificity, positive predictive value, and negative predictive value of CCTA for the selection of CABG candidates were 83.3%, 96.2%, 90.9%, and 92.7%, respectively. The presence of CABG criteria on CCTA was an independent prognostic factor for predicting a major adverse cardiac event (hazard ratio, 12.508; 95% confidence interval, 7.353 to 21.278; p < 0.0001). Conclusions: We found CCTA had a high diagnostic performance for selecting CABG candidates and predicted major adverse cardiac events in CABG candidates referred for CCTA owing to suspected coronary artery disease. [Copyright &y& Elsevier]