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To identify to what extent distinguishing patient and procedural characteristics can explain center-level transfusion variation during coronary artery bypass grafting surgery.Observational cohort study using the Perfusion Measures and Outcomes Registry from 43 adult cardiac surgical programs from July 1, 2011, to July 1, 2017. Iterative multilevel logistic regression models were constructed using patient demographic characteristics, preoperative risk factors, and intraoperative conservation strategies to progressively explain center-level transfusion variation.Of the 22,272 adult patients undergoing isolated coronary artery bypass surgery using cardiopulmonary bypass, 7241 (32.5%) received at least 1 U allogeneic red blood cells (range, 10.9%-59.9%). When compared with patients who were not transfused, patients who received at least 1 U red blood cells were older (68 vs 64 years; P .001), were women (41.5% vs 15.9%; P .001), and had a lower body surface area (1.93 mThe results suggest that variation in center-level red blood cells transfusion cannot be explained by patient and procedural factors alone. Investigating organizational culture and programmatic infrastructure may be necessary to better understand variation in transfusion practices.

OBJECTIVE: Durability of transcatheter aortic valves (TAV) remains their greatest disadvantage given that fixed tissue leaflets are not immune to structural degeneration from calcification and thrombosis. Therefore, a second intervention is necessary especially that TAV in low-risk patients showed non-inferior outcomes compared with surgery. This study aims at assessing hemodynamic and turbulent properties of the flow downstream different TAV-in-TAV configurations to offer basic hemodynamic guidance for future interventions when currently implanted valves structurally degrade. METHODS: Six TAV-in-TAV configurations were chosen: (1)23mm Evolut in 26mm Evolut; (2)23mm Evolut in 23mm SAPIEN3; (3)26mm Evolut in 26mm Evolut; (4)26mm Evolut in 23mm SAPIEN3; (5)23mm SAPIEN3 in 26mm Evolut and (6)23mm SAPIEN3 in 23mm SAPIEN3. Their hemodynamic performance was assessed in a pulse duplicator for 100 cycles. High-speed imaging and particle image velocimetry were performed to assess turbulence. Effective orifice areas (EOA), pinwheeling indices (PI) and Reynolds Shear Stresses (RSS)were evaluated. RESULTS: The largest EOA was obtained with 23mm SAPIEN in 26mm Evolut (2.07±0.06cm(2)) and the smallest with 23mm Evolut in 23mm SAPIEN (1.50±0.04cm(2))(p

Findings from a large multicenter experience showed that sex influenced the relationship between low nadir hematocrit and increased risk of acute kidney injury after cardiac surgery. We explored whether sex-related differences persisted among patients undergoing isolated coronary artery bypass grafting.We undertook a prospective, observational study of 17,363 patients without dialysis (13,137 male: 75.7%; 4226 female: 24.3%) undergoing isolated coronary artery bypass grafting between 2011 and 2016 across 41 institutions in the Perfusion Measures and Outcomes registry. Odds ratios between nadir hematocrit and stage 2 or 3 acute kidney injury were calculated, and the interaction of sex with nadir hematocrit was tested. The multivariable, generalized, linear mixed-effect model adjusted for preoperative and intraoperative factors and institution.Median nadir hematocrit was 22% among women and 27% among men (P .001). Women were administered a greater median net prime volume indexed to body surface area (407 vs 363 mL/mWe found no sex-related differences in the effect of nadir hematocrit on acute kidney injury after isolated coronary artery bypass grafting. However, the strong inverse relationship between anemia and acute kidney injury across sexes suggests the importance of reducing exposure to low nadir hematocrit.

ObjectivePerioperative red blood cell transfusion is associated with increased morbidity and mortality after coronary artery bypass grafting (CABG). Whether transfusion is a cause of these outcomes or serves as a surrogate for a high-risk patient population remains uncertain. This retrospective study tested the hypothesis that increased preoperative risk profile of patients receiving transfusion would explain the relationship between red blood cell transfusion and operative mortality in isolated CABG.MethodsA total of 31,818 patients undergoing isolated CABG were entered into a statewide collaborative database between January 2006 and June 2010. With the Society of Thoracic Surgeons risk calculator, patient cohorts were stratified into 4 groups by predicted risk of mortality (PROM) of less than 2%, 2% to 5%, more than 5% to 10% and more than 10%. The association between blood transfusion and mortality was tested at each stratum with a χ2 test. A Breslow-Day test for homogeneity of odds ratios was used to test whether the 4 odds ratios of the strata were similar, and a Cochran-Mantel-Haenszel test was used to test the association between blood transfusion and mortality while controlling for predicted risk mortality strata.ResultsIn all, 17,720 (55.7%) of all patients were transfused during the hospitalization. Incidence of transfusion increased stepwise with risk level; 93.3% of patients with PROM greater than 10% received blood. Operative mortality was 2.1% overall, 0.6% among the 44.3% of patients who were not transfused, and 3.3% in the transfused group (odds ratio, 6.19; P

Although there is convincing evidence that prophylactic administration of high doses of the monoclonal antibody OKT3 predisposes patients to an increased prevalence of early posttransplantation malignancy, particularly posttransplantation lymphoproliferative disease, it is indeterminate whether polyclonal antilymphocyte globulin poses a similar hazard. We reviewed the outcome of 112 consecutive cardiac transplant recipients who received uniform immunosuppression, including induction therapy with antilymphocyte globulin, and were prospectively followed-up for a median duration of 41.5 months (range 1 to 81 months). No patients had posttransplantation lymphoproliferative disease. Nine malignant neoplasms (8%) were detected from 6 to 70 months after transplantation. Four patients with cutaneous neoplasms were alive and well at the time this article was written. Three patients died of disseminated adenocarcinoma 6 months, 17 months, and 60 months after transplantation. One patient was undergoing treatment of Kaposi’s sarcoma at the time this article was written, and another was undergoing treatment of transitional bladder cell carcinoma. Actuarial survival for all patients was 88% at 1 year and 79% at 5 years. Moderate doses of induction antilymphocyte globulin may facilitate rapid reduction of maintenance cyclosporine and steroid doses, thereby decreasing the duration of intense immunosuppression and lowering the risk of posttransplantation lymphoproliferative disease. Testing this hypothesis would require the development of reliable and reproducible in vivo assays to prospectively assess immune status. ( J Thorac Cardiovasc Surg 1993;106:1202-7)

Anomalous origin of the left coronary artery from the pulmonary artery To the Editor: In a recent article in this JOURNAL, Tashiro and colleagues I reported their use of a new technique to restore a dual coronary system for repair of anomalous origin of the left coronary artery from the pulmonary artery in two adult patients. The repair entails transection and reanastomosis of the pulmonary trunk, as well as creation of a new left main coronary artery with anastomosis to the aorta, and mandates aortic crossclamping and cardioplegic arrest. Although we agree that teleologic supposition would favor restoration of a two coronary system in this setting, we nonetheless submit that this technique, although innovative, may be unnecessarily complex. We believe comparable results can be effected by conventional revascularization techniques. A 66-year-old man was admitted to an outside hospital with the recent onset of exertional dyspnea. Workup at that institution revealed evidence of a sinus arrhythmia for which the patient underwent insertion of a permanent transvenous VVI pacemaker. Over the subsequent 2 years, the patient continued to have worsening dyspnea and was transferred to our institution after requiring hospitalization for an exacerbation of congestive heart failure. Cardiac catheterization demonstrated an anomalous origin of the left coronary artery from the pulmonary artery with collateral flow from a massively dilated right coronary artery. At operation, the proximal 3 em of the right coronary artery was severely calcified and the left anterior descending artery measured approximately 8 mm in its mid portion. Repair included two-layer closure of a 12 mm fistulous opening from within the pulmonary artery and bypass grafting of the mid portion of the left anterior descending artery with the pedicled left internal thoracic artery. This repair was easily accomplished in a moderately hypothermic fibrillating heart vented through the open pulmonary artery, with a brief period of local occlusion for the arterial anastomosis. The postoperative course was uneventful and the patient remains well 16 months later. The technique proposed by the authors may, indeed, be advantageous in infants and small children, in whom size constraints may preclude effective internal thoracic artery grafting. However, for the rare patient in whom this anomaly becomes manifest in adult life, closure of the fistula with arterial grafting of the left anterior descending artery would seem to be considerably less complicated. As described here, we purposely wanted the aorta unclamped while closing the fistula to ensure complete obliteration and to avoid maldistribution of antegrade infusion of cardioplegic solution into the aortic root. Alternatively, cardioplegic solution could have been given retrograde or after fistula closure. Regardless of the myocardial protective strategy, we maintained the advantage of a two coronary system without need for prosthetic material or concern over the longevity of saphenous vein bypass grafting.

ObjectiveA number of established regional quality improvement collaboratives have partnered to assess and improve care across their regions under the umbrella of the Cardiac Surgery Quality Improvement (IMPROVE) Network. The first effort of the IMPROVE Network has been to assess regional differences in potentially discretionary transfusions (