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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: Despite supportive evidence and guidelines, the use of multiple arterial grafts (MAGs) in coronary artery bypass grafting remains low. We sought to determine surgeon perception of personal MAG use and compare this with actual MAG use., Methods: We conducted a statewide surgeon survey of MAG use, presence of a hospital MAG protocol, and barriers for MAG use, with a response rate of 78% (n = 25). Surgeon survey responses were compared with actual Society of Thoracic Surgeons patient data from January 1, 2017, to December 31, 2020 using χ 2 or Fisher's exact tests., Results: Of 5299 patients who had first-time, nonemergent, isolated coronary artery bypass grafting (≥2 grafts) by responding surgeons, 16% received MAG (n = 825). MAG use in patients whose surgeons self-designated as "routine" MAG users was 21% vs 7% for "nonroutine" users. Surgeons with a hospital protocol for MAG use utilized MAG more often (18% vs 14%, P = .001). Surgeons who were unconvinced by the data on the benefits of MAGs used MAGs in 11% vs 22% in surgeons who were convinced. MAG use increased over time, particularly from before to after the survey (13.1% vs 30.5%, P < .001)., Conclusions: Although MAG use increased over time, barriers to routine use remain. In surgeons who reported routine use, only 21% of their patients received MAGs. Hospital protocols, education, and increased awareness may reduce barriers to use and encourage evidence-based clinical practice., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Implantation of an appropriately sized donor heart is critical for optimal outcomes after heart transplantation. Although predicted heart mass has recently gained consideration, there remains a need for improved granularity in size matching, particularly among small donor hearts. We sought to determine if indexed donor cardiac output is a sensitive metric to assess the adequacy of a donor heart for a given recipient., Methods: A retrospective analysis was performed (2003-2021) in isolated orthotopic heart transplant recipients from the United Network for Organ Sharing database. Donor cardiac output was divided by recipient body surface area to compute cardiac index (donor cardiac index). Predicted heart mass ratio was computed as donor/recipient predicted heart mass. The primary outcome was mortality 1 year after transplant., Results: Among transplant recipients, median donor cardiac output was 7.3 (5.8-9.0) liters per minute and donor cardiac index was 3.7 (3.0-4.6) liters per minute/m 2 . Predicted heart mass ratio was 1.01 (0.91-1.13). After multivariable adjustment, higher donor cardiac index was associated with lower 1-year mortality risk (odds ratio, 0.92, P  = .042). Recipients with predicted heart mass ratio less than 0.80 (n = 255) had a lower median donor cardiac index than those with a predicted heart mass ratio of 0.80 or greater (3.2 vs 3.7, P  < .001). As predicted, heart mass ratio became smaller and the association between donor cardiac index and 1-year mortality became progressively stronger., Conclusions: Higher donor cardiac index was associated with a lower probability of 1-year mortality among patients undergoing heart transplantation and served to further quantify mortality risk among those with a small predicted heart mass ratio. Donor cardiac index appears to be an effective tool for size matching and may serve as an adjunctive strategy among small donor hearts with a low predicted heart mass ratio., (© 2023 The Authors.)

Objective: Coronary artery bypass grafting is associated with significant interhospital variability in charges. Drivers of hospital charge variability remain elusive. We identified modifiable factors associated with statewide interhospital variability in hospital charges for coronary artery bypass grafting., Methods: Charge data were used as a surrogate for cost. Society of Thoracic Surgeons data from Maryland institutions and charge data from the Maryland Health Care Commission were linked to characterize interhospital charge variability for coronary artery bypass grafting. Multivariable linear regression was used to identify perioperative factors independently related to coronary artery bypass grafting charges. Of the factors independently associated with charges, we analyzed which factors varied between hospitals., Results: A total of 10,337 patients underwent isolated coronary artery bypass grafting at 9 Maryland hospitals from 2012 to 2016, of whom 7532 patients were available for analyses. Mean normalized charges for isolated coronary artery bypass grafting varied significantly among hospitals, ranging from $30,000 to $57,000 (P < .001). Longer preoperative length of stay, operating room time, and major postoperative morbidity including stroke, renal failure, prolonged ventilation, reoperation, and deep sternal wound infection were associated with greater hospital charges. Incidence of major postoperative events, except stroke and deep sternal wound infection, was variable between hospitals. In a univariate linear regression model, patient risk profile only accounted for approximately 10% of statistical variance in charges., Conclusions: There is significant charge variability for coronary artery bypass grafting among hospitals within the same state. By targeting variation in preoperative length of stay, operating room time, postoperative renal failure, prolonged ventilation, and reoperation, cardiac surgery programs can realize cost savings while improving quality of care for this resource-intense patient population., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure in the world and up to one-third of patients are transfused red blood cells (RBCs). RBC transfusion may increase the risk for health care-associated infection (HAI) after CABG, but previous studies have shown conflicting results and many did not establish exposure temporality. Our objective was to explore whether intraoperative RBC transfusion is associated with increased odds of postoperative HAI. We hypothesized that intraoperative RBC transfusion would be associated with increased odds of postoperative HAI., Methods: We performed an observational cohort study of isolated CABG patients in the Society of Thoracic Surgeons adult cardiac surgery database from July 1, 2017, to June 30, 2019. The exposure was intraoperative RBC transfusion modeled as 0, 1, 2, 3, or 4+ units. The authors focused on intraoperative RBC transfusion as a risk factor, because it has a definite temporal relationship before postoperative HAI. The study's primary outcome was a composite HAI variable that included sepsis, pneumonia, and surgical site infection (both deep and superficial). Mixed-effects modeling, which controlled for hospital as a clustering variable, was used to explore the relationship between intraoperative RBC transfusion and postoperative HAI., Results: Among 362,954 CABG patients from 1076 hospitals included in our analysis, 59,578 patients (16.4%) received intraoperative RBCs and 116,186 (32.0%) received either intraoperative or postoperative RBCs. Risk-adjusted odds ratios for HAI in patients who received 1, 2, 3, and 4+ intraoperative RBCs were 1.11 (95% confidence interval [CI], 1.03-1.20; P = .005), 1.13 (95% CI, 1.05-1.21; P = .001), 1.15 (95% CI, 1.04-1.27; P = .008), and 1.14 (95% CI, 1.02-1.27; P = .02) compared to patients who received no RBCs., Conclusions: Intraoperative RBC transfusion is associated with a small increase in odds of HAI in CABG patients. Future studies should explore whether reductions in RBC transfusion can also reduce HAIs., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 International Anesthesia Research Society.)

Background: Patients presenting with acute coronary syndrome are administered a P2Y 12 inhibitor and aspirin before coronary catheterization to prevent further myocardial injury from thrombosis. Guidelines recommend a standard waiting period between the time patients are administered dual antiplatelet therapy (DAPT) and elective cardiac surgery. Since 25% to 30% of the population may be considered nonresponders to clopidogrel, platelet function testing can be utilized for timing of surgery and to assess bleeding risks. The extent to which a standard waiting period or platelet function testing is used across centers is not established, representing an important opportunity to standardize practice., Methods: We conducted a retrospective cohort study from 2011 to 2020 using data from the Maryland Cardiac Surgical Quality Initiative, a consortium of all 10 hospitals in the state performing cardiac surgery. The proportion of patients administered DAPT within 5 days of surgery was examined by hospital over the time period. Mixed-effects multivariable logistic regressions were used to examine the association of preoperative DAPT with ischemic and bleeding outcomes. Centers were surveyed on use or nonuse of preoperative platelet function testing, and bleeding outcomes were compared., Results: There was significant heterogeneity of preoperative DAPT usage across centers ranging from 2% to 54% ( P < .001). DAPT within 5 days of isolated coronary artery bypass grafting (CABG) was associated with higher odds of reoperation for bleeding (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.19-2.01; P = .001), >2 units of red blood cells (RBCs) transfused (OR, 1.62; 95% CI, 1.44-1.81; P < .001), and >2 units of non-RBCs transfused (OR, 1.79; 95% CI, 1.60-2.00; P < .001). In the 5 hospitals using preoperative platelet function testing to guide timing of surgery, there were greater odds for DAPT within 5 days (OR, 1.33; 95% CI, 1.22-1.45; P < .001), fewer RBCs >2 units transfusions (22% vs 33%; P < .001), and non-RBCs >2 units (17% vs 28%; P < .001) transfusions within DAPT patients., Conclusions: There is significant variability in DAPT usage within 5 days of CABG between hospital centers. Preoperative platelet function testing may allow for earlier timing of surgery for those on DAPT without increased bleeding risks., Competing Interests: Conflicts of Interest: See Disclosures at the end of article., (Copyright © 2022 International Anesthesia Research Society.)

Background: There is an established relationship between the degree of mitral regurgitation (MR) and prognosis. Quantitation of MR severity guides therapeutic approaches. Inconsistent definitions and categorization of MR severity in clinical studies limit meaningful comparisons among trials and compromise development of an effective evidence base. The purpose of this study was to quantify heterogeneity in grading systems for MR severity in the contemporary literature., Methods: This was a systematic review of randomized controlled trials and propensity score-adjusted clinical studies of mitral valve interventions (surgical or percutaneous). A total of 35 articles from 2015 to 2020 were included (15 randomized controlled trials and 20 propensity score-adjusted clinical studies)., Results: There were 22 studies that reported MR severity in numeric categories, either values from the historical "plus" system or numeric MR grades, whereas 9 studies reported MR severity using text-only descriptive categories. Among the studies that used numeric categories, 2+ MR was defined as moderate in 64% of studies, mild in 27%, and mild-moderate in 9%, and 3+ MR was defined as moderate in 14%, moderate-severe in 52%, and severe in 14%., Conclusions: There was substantial variability in MR severity definition and reporting in contemporary clinical studies of mitral valve interventions. We recommend that the historical plus numeric grading system be abandoned and that inclusion and outcome criteria in MR clinical trials be based on US and European guideline-recommended categories as none or trace, mild, moderate, and severe. Adoption of these simple recommendations will improve the consistency and quality of MR clinical trial design and reporting., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to present a rigorous method to analyse the intraoperative echocardiographic images from the novel mitral translocation procedure, which assesses the changes in mitral structure and function and compares this data to a control group of patients who have no mitral regurgitation (MR)., Methods: Transoesophageal echocardiography was post-processed using dedicated 3D software. Ten patients with normal mitral valves (MV) undergoing non-mitral cardiac surgery served as controls. Mitral coaptation area, mid-leaflet coaptation length and mitral annular circumference were measured in 3D., Results: Twenty-three consecutive patients with severe secondary MR underwent MV translocation. All patients had none/trace MR post-translocation. The mean coaptation surface area increased from 63 to 427 mm2 (P < 0.001) and coaptation length increased from 1.0 to 10.5 mm (P < 0.001). The control group coaptation surface area (136 mm2) and length (2.5 mm) were greater than pre-translocation (P = 0.019; P < 0.001) and less than post-translocation (P < 0.001; P < 0.001). 3D mitral annular circumference in the translocation group decreased 15% (130-110 mm) (P < 0.001). Post-translocation, the mean gradient was 2(2-3) mmHg with the diastolic mitral orifice area of 3.4 ± 0.3 cm2 by planimetry and 3.5 ± 0.3 cm2 by pressure half-time. The coaptation to septum distance remained unchanged (P = 0.305) without systolic anterior leaflet motion., Conclusions: This echocardiographic analysis method demonstrates that MV translocation abolishes secondary MR, increases coaptation area and length and produces acceptable diastolic function. This method of analysis should allow precise structural and quantitative assessment of the durability of the repair in future long-term follow-up., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Enhanced Recovery After Surgery (ERAS) programs have demonstrated improved outcomes in noncardiac surgery. More recently, ERAS has been applied to cardiac surgery with promising results. We have implemented cardiac ERAS at our community-based program, aiming to improve all phases of care, and now report our early results., Methods: We retrospectively analyzed 73 consecutive patients treated with ERAS care compared with 74 patients treated before implementing ERAS. Our ERAS program consisted of 6 perioperative care bundles including enhanced patient education, shortened preoperative fasting period and oral carbohydrate load, postoperative nausea prophylaxis, multimodal opioid-sparing analgesia, early extubation, and early mobilization., Results: ERAS patients required significantly less opioids captured as total morphine milligram equivalents (MME) (median 35.0 vs 75.3; P < .001), less nausea as determined by fewer total ondansetron rescue doses (median 0 vs 0.5; P = .011), and less lightheadedness (P = .028) compared with pre-ERAS patients. Postoperative mobility was significantly better (postoperative day 4: 95% vs 81%; P = .013) and postoperative length of stay was lower for ERAS care but did not reach statistical significance (median 4 days vs 5 days; P = .06). There was no difference in pain or glucose control or in early extubation., Conclusions: Cardiac ERAS significantly decreased opioid use, nausea, and lightheadedness and improved functional outcome for cardiac surgical patients in a community hospital., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Theoretical studies demonstrate that controlled addition of noise can enhance the amount of information transmitted by a cochlear implant (CI). The present study is a proof-of-principle for whether stochastic facilitation can improve the ability of CI users to categorize speech sounds. Analogue vowels were presented to CI users through a single electrode with independent noise on multiple electrodes. Noise improved vowel categorization, particularly in terms of an increase in information conveyed by the first and second formant. Noise, however, did not significantly improve vowel recognition: the miscategorizations were just more consistent, giving the potential to improve with experience.

Background: The association between blood transfusion and adverse outcome is documented in cardiac surgery. However, the incremental significance of each unit transfused, whether red blood cell (RBC) or non-RBC, is uncertain. This study examined the relationship of patient outcomes with the type and number of blood product units transfused., Methods: Statewide data from 24 082 adult cardiac surgery patients were included. The relationship with blood transfusion was assessed for morbidity and 30-day mortality using total number of RBC and non-RBC units transfused, specific type of non-RBC units, and different combinations of transfusion (only RBC, only non-RBC, RBC + non-RBC). Multivariable logistic regressions examined these associations., Results: Median age was 66 years (30% female patients), and 51% of patients received a transfusion (31%-66% across hospitals). Risk-adjusted analyses found each blood product unit was associated with 9%, 7%, and 4% greater odds for 30-day mortality, major morbidity, and minor morbidity, respectively (all P < .001). Odds for 30-day mortality were 13% greater with each RBC unit (P < .001) and 6% greater for each non-RBC unit (P < .001). Each unit of fresh frozen plasma (P < .001) and platelets (P < .001) increased the odds for 30-day mortality, but no effect was found for cryoprecipitate (P = .725). Odds for 30-day mortality were lower for non-RBC-only (odds ratio, 0.52; P = .030) and greater for RBC + non-RBC (odds ratio, 2.98; P < .001) compared with RBC-only transfusion., Conclusions: Independent of center variability on transfusion methods, each additional unit transfused was associated with increased odds for complications, with RBC transfusion carrying greater risk compared with non-RBC. Comprehensive evidence-based clinical approaches and coordination are needed to guide each blood transfusion event after cardiac surgery., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Functional (secondary) mitral regurgitation (FMR) results from altered geometry of the mitral valve apparatus. Repair with restrictive mitral annuloplasty is associated with high rates of recurrent mitral regurgitation (MR). We developed a novel operative repair for FMR that translocates the intact mitral valve towards the apex., Methods: The mitral valve was detached circumferentially and translocated into the ventricle with a frustum-shaped glutaraldehyde-treated autologous pericardial patch. Clinical and echocardiographic follow-up was performed., Results: Fifteen consecutive patients with FMR (mean age, 59 years; 67% female) had mitral valve translocation between 2018 and 2020. Preoperative mean ejection fraction, left ventricular end-diastolic dimension, and systolic pulmonary artery pressure were 40% ± 11%, 59 ± 8 mm, and 49 ± 21 mm Hg, respectively; 33% had atrial fibrillation. Cardiomyopathy was ischemic in 4 and nonischemic in 11. Concomitant procedures included tricuspid valve operation (n = 8), coronary artery bypass grafting (n = 4), and atrial fibrillation ablation (n = 5). Post bypass transesophageal echocardiogram demonstrated none/trace MR in all patients and mean gradient of 3 mm Hg (interquartile range, 2-4 mm Hg). Mean leaflet extent of coaptation was 14 ± 2 mm (range, 11-17 mm). There was no postoperative mortality, stroke, or renal failure. Predismissal echocardiography showed none/trace MR in 14 patients and mild MR in 1. One patient underwent successful late rerepair of a suture line leak. Twelve patients were alive at latest follow-up and MR at 1 and 6 months was mild or less in all patients with mean leaflet extent of coaptation of 14 ± 2 mm (range, 12-16 mm) at 6 months., Conclusions: Mitral valve translocation creates a large surface of coaptation and effectively corrects FMR. Further study is needed to demonstrate the long-term durability and clinical utility of this operation., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether the changing cardiac landscape has affected traditional cardiothoracic surgery (CTS) resident case volume, particularly cardiac case volume., Methods: The Accreditation Council for Graduate Medical Education (ACGME) case logs for traditional CTS residents from 2016 to 2019 were reviewed. Using linear and nonlinear regression, trends in the annual volume and proportion of CTS operations were examined., Results: Overall, the average number of total and category-specific CTS resident cases have increased from 2016 to 2019. However, in general, the proportion of thoracic surgery cases has been increasing, and the proportion of cardiac surgery cases has been decreasing. In particular, the proportion of coronary atherosclerosis (-0.2546 per 100 cases/year; P < .001) and valvular heart disease (-0.319 per 100 cases/year; P < .001) procedures demonstrated the greatest downward trends. The average operative experience for residents has increased (28.8 cases/resident/year; P < .001), but cardiac track residents (22.24 cases/resident/year; P < .001) have had a smaller increase than thoracic track residents (35.04 cases/resident/year; P < .001). Nevertheless, cardiac track residents experienced an increase in their average proportion of cardiac cases (0.176 per 100 cases/year; P < .001) compared with average (-0.263 per 100 cases/year; P < .001) and thoracic track (-0.978 per 100 cases/year; P < .001) CTS residents, indicating specialization of the tracks., Conclusions: The overall CTS resident operative experience has increased over the last several years, with cardiac cases increasing more slowly than thoracic cases. The analysis reveals that cardiac operative volume has been asymmetrically allocated to cardiac track residents, indicating a greater specialization of the tracks. Annual evaluation of CTS resident case volume will provide essential insight into the field., (Copyright © 2020 The American Association for Thoracic Surgery. All rights reserved.)

Background: Several studies have established morbidity associated with bleeding after cardiac surgery. Although reoperation has been implicated as the marker for this morbidity, there remains limited understanding regarding relative morbidities of reoperation and substantial transfusion., Methods: The Society of Thoracic Surgeons (STS) Maryland Adult Cardiac Surgery Database (July 2011-September 2018) was reviewed (N = 23,240). Substantial transfusion was defined as requiring greater than the reoperation group median red blood cells (5 units) and non-red blood cells (4 units). Patients were stratified into 4 subgroups: group 1, no reoperation without substantial transfusion (n = 22,365); group 2, reoperation without substantial transfusion (n = 351); group 3, no reoperation with substantial transfusion (n = 350); and group 4, reoperation with substantial transfusion (n = 167). Operative morbidity and mortality were compared., Results: Reoperation patients were older with a higher STS predicted risk of mortality (1.8% vs 1.2%, P < .001). Multivariable analysis demonstrated that group 4 increased the odds of renal failure (odds ratio [OR] 7.36, P < .001), stroke (OR 3.24, P = .002), and operative mortality (OR 8.68, P < .001) compared with group 1. Both group 2 and group 3 increased the odds of mortality and renal failure compared with group 1. However, group 3 had greater risk for renal failure (OR 3.48, P < .001) and mortality (OR 2.91, P < .001) than group 2., Conclusions: Although reoperation for bleeding is associated with morbidity after cardiac surgery, substantial transfusion without reoperation appears to increase morbidity compared with a limited-transfusion reoperative approach. Better timing for reoperation and guided transfusion approaches may mitigate morbidity compared with substantial transfusion alone., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Racial disparities persist in health care. Our study objective was to evaluate racial disparity in cardiac surgery in Maryland., Methods: A statewide database was used to identify patients. Demographics, comorbidities, and predicted risk of death were compared between races. Crude mortality and incidence of complications were compared between groups, as were risk-adjusted odds for mortality and major morbidity or mortality., Results: The study included 23,094 patients. Most patients were white (75.8%), followed by African American (16.3%), Asian (3.8%), and other races (4.1%). African Americans had a higher preoperative risk for mortality based on The Society of Thoracic Surgeons predictive models compared with white patients (3.0% vs 2.3%, P < .001). African Americans also had higher prevalence of diabetes mellitus, hypertension, peripheral vascular disease, and cerebral vascular disease than white patients. After adjustment for preoperative risk, there was no difference in 30-day mortality between African Americans (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.99-1.59), Asians (OR, 1.22; 95% CI, 0.75-1.97), and other races (OR, 1.18; 95% CI, 0.74-1.89) compared with whites. African Americans had lower risk-adjusted odds of major morbidity or mortality compared with whites (OR, 0.83; 95% CI, 0.75-0.93)., Conclusions: African American cardiac surgical patients have the highest preoperative risk in Maryland. Patients appeared to receive excellent cardiac surgical care, regardless of race, as risk-adjusted mortality did not differ between groups, and African American patients had lower risk-adjusted odds of major morbidity or mortality than white patients. Future interventions in Maryland should be aimed at reducing preoperative risk disparity in cardiac surgical patients., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In 2014 Maryland began a global budget revenue (GBR) program where hospitals were assigned a global budget for each year. We hypothesized that this program would be associated with changes in coronary artery bypass grafting (CABG) patient risk profile, reductions in potentially preventable complications (PPCs) and 30-day hospital readmissions, and low annual per patient charge growth., Methods: Patients having isolated CABG surgery in Maryland between fiscal years 2013 and 2017 were included. Patient characteristics, admission all-payer refined severity of illness, PPCs, 30-day hospital readmissions, and per patient hospital charges were compared between years. The impact of Maryland's GBR program on PPCs and 30-day hospital readmissions was evaluated using interrupted time series analysis., Results: During the study period 11,070 patients had CABG surgery. The percentage of patients with major or extreme severity of illness at admission differed significantly between years (34.6% in 2013 vs 46.1% in 2017, P < .001). There was a significant reduction in mean PPC incidence of -22.8% (95% confidence interval, -29.8% to -15.8%) after GBR implementation but no significant reduction in 30-day hospital readmissions (-2.7%; 95% confidence interval, -6.0% to 0.6%). Without adjusting for inflation the annual per patient charge growth remained between -1.4% and 2.6% from 2013 to 2017., Conclusions: Maryland's GBR program was associated with significant PPC reductions, minimal charge growth, and no significant change in 30-day hospital readmissions during its first 14 fiscal quarters. These findings suggest that Maryland's GBR program achieved some but not all of its predefined goals in CABG patients., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Resectional and artificial cordal repair techniques are effective strategies for degenerative mitral valve (MV) repair. However, resectional repair requires a tailored approach using various techniques, whereas cordal repair offers a simpler, easily reproducible repair. The approach described in this study approach has evolved from resectional to cordal over time, and outcomes are compared between the eras., Methods: Clinical and echocardiographic outcomes of all patients undergoing MV repair for degenerative mitral regurgitation (MR) from January 2004 to September 2017 were reviewed. Patients were stratified by era: from January 2004 to June 2011 (era 1; n = 405), resectional techniques were used in 62% and artificial cordal techniques were used in 38%. From July 2011 to September 2017 (era 2; n = 438), artificial cordal repair was used in 98% of patients. The primary outcome was repair failure, defined as greater than moderate MR or MV reoperation., Results: Of 847 patients with degenerative MR, successful repair was achieved in 843 patients (99.5% repair rate). Leaflet prolapse was posterior in 66%, anterior in 8%, and bileaflet in 26%. Cardiopulmonary bypass time and cross-clamp times were shorter in era 2 (CPB: 109 [IQR, 92-128] minutes vs 97 [IQR, 76-121] minutes; P < .001; cross-clamp: 88 [IQR, 73-106] minutes vs. 79 [IQR, 61-99] minutes; P < .001). Predismissal echocardiography demonstrated no MR or trace MR in 95%, mild MR in 4.7%, and moderate MR in 0.3% of patients. Operative mortality was similar in the eras (0.5% vs 0.5%; P > .999). The rates of 5-year freedom from repair failure (95.1% vs 95.5%; P = .707), stroke (96.8% vs 95.3%; P = .538), and endocarditis (99.3% vs 99.7%; P = .604) were similar between the eras., Conclusions: Artificial cordal repair for all patients with degenerative MR simplifies MV repair and yields equivalent, excellent outcomes compared with a tailored resectional approach., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database was used to examine the incidence and factors associated with acute stroke following type A repair., Methods: Acute type A aortic dissection repairs performed from 2014 to 2017 were identified from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. The effect of cannulation strategy (eg, axillary, femoral, direct, or innominate), lowest temperature, cerebral protection techniques (antegrade cerebral profusion, retrograde cerebral perfusion, both, or none), repair technique, and institutional volume on postoperative stroke was investigated., Results: Acute type A repair was performed on 8937 patients at 772 centers, of which 7353 met inclusion criteria. Operative mortality was 17% and incidence of postoperative stroke was 13%. Axillary cannulation was associated with lower risk of stroke versus femoral (odds ratio, 0.60; P < .001). Retrograde cerebral perfusion was associated with reduced risk for stroke compared with no cerebral perfusion (odds ratio, 0.75; P = .008) or antegrade cerebral perfusion (odds ratio, 0.75; P = .007). Total arch replacement was associated with greater risk for stroke versus hemiarch technique (odds ratio, 1.30; P = .013). Longer circulatory arrest time, cerebral perfusion time, and cardiopulmonary bypass time were all related to higher risk of postoperative stroke., Conclusions: Stroke is a common complication after type A repair. Axillary cannulation was associated with lower incidence of stroke, whereas femoral cannulation significantly increased the risk of stroke regardless of the cerebral perfusion strategy or the degree of hypothermia. Retrograde cerebral profusion was found to have reduced risk for postoperative stroke. Degree of hypothermia and center volume were not related to stroke incidence., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical treatment of symptomatic atrial fibrillation has been performed for 3 decades. We reviewed trends and outcomes of surgical ablation (SA) for stand-alone atrial fibrillation using The Society of Thoracic Surgeons Adult Cardiac Surgical Database (STS-ACSD)., Methods: The STS-ACSD was reviewed from 2011 to 2017 (N = 7187) for trends. Contemporary data from 2014 to 2017 (n = 3893) were used to compare three subgroups: off pump (n = 3252), on pump (n = 491), and patients with incision conversion or conversion from off pump to on pump (n = 150). Propensity score matching was conducted to balance groups., Results: Annual growth of stand-alone SA was 7%. Median age of patients was 64 years (interquartile range, 57 to 70), and 30% were female. Overall 30-day mortality was 0.8% and perioperative stroke incidence was 0.8%. Most SA procedures were off pump (84%), with 12% greater odds for off pump per year (odds ratio [OR] 1.12, P < .001). The off-pump group had fewer biatrial SA (21% vs 71%, P < .001) and left atrial appendage obliterations (53% vs 95%, P < .001) compared with the on-pump group. After matching, uneventful off-pump SA had similar mortality (0.4% vs 0.9%, P = .292) vs on-pump SA, but reduced incidence of renal failure (0.9% vs 2%, P = .033). After risk adjustment, the conversion group had worse perioperative outcomes vs the off-pump group, including greater incidence of stroke (OR 5.37, P < .001) and operative mortality (OR 9.98, P < .001). Mortality (OR 4.69, P = .011) was also greater for conversion vs on pump., Conclusions: Steady growth of stand-alone SA operations was noted. Procedures performed either on pump or off pump were relatively safe. However, intraoperative conversion was associated with significantly higher morbidity and mortality. Patient selection, improvement of surgical techniques, and long-term follow-up should be emphasized to improve decision making and outcome., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

This study evaluated the impact of Medicaid eligibility expansion (ME) on lung transplant (LT) listings and Medicaid coverage. Data on LT candidates aged 18-64 were obtained from the Scientific Registry of Transplant Recipients (N = 9153). The impact of ME was evaluated by comparing LT listings in 2011-2013 with listings in 2014-2016, as well as comparing states that had and had not adopted ME in 2014. LT listings increased by 7.7% nationally post-ME. In ME states, LT listings increased by 15.2%, whereas nonexpansion states decreased by 1.5%. LT candidates with Medicaid increased after ME nationally (8.3% vs. 9.9%, P = 0.006) and in ME states (9.7% vs. 11.5%, P = 0.036), but not in nonexpansion states (6.6% vs. 7.7%, P = 0.170). Following multivariable adjustment, LT listings in ME states had 58% greater odds for Medicaid compared to nonexpansion states (P < 0.001). Expansion of Medicaid provided greater healthcare access and increased LT listings, but only within states that adopted eligibility expansion., (© 2019 Steunstichting ESOT.)

Objective: Newly published guidelines made the highest level recommendation for surgical treatment for atrial fibrillation. However, the number of patients without a mitral valve procedure with atrial fibrillation who are treated with concomitant surgical ablation is still low (15%-25%), because surgeons are reluctant to perform procedures in patients who would not otherwise require left atriotomy. The purpose of this study was to compare the outcomes of concomitant Cox maze with and without mitral valve procedures., Methods: Patients who underwent concomitant Cox maze procedures were prospectively followed since September 2005. Of the 711 patients, 238 did not receive mitral valve surgery. Propensity score matching was conducted to balance preoperative characteristics between patients with and without mitral valve procedures (164/group after matching)., Results: Before matching, patients in the mitral valve group were younger (65 vs 67 years, P = .047) and had higher euroSCORE II (European System for Cardiac Operative Risk Evaluation; 3.2% vs 2.6%, P = .002), larger mean left atrial size (5.3 vs 4.8 cm, P < .001), and shorter median atrial fibrillation duration (19 vs 25 months, P = .064). Early outcomes were similar for the matched groups. Cumulative 5-year freedom from stroke did not differ between matched mitral valve and non-mitral valve groups (96.1% vs 96.6%, P = .667). At each time point, the proportion in sinus rhythm off antiarrhythmic medications was similar for the matched groups, including 5 years after surgery (68% vs 63%, P = .492)., Conclusions: The Cox maze procedure is safe and effective with comparable outcomes when performed concomitant to mitral valve or non-mitral valve surgery. Surgeons should base the decision to perform surgical ablation procedures on atrial fibrillation pathophysiology and the benefit to patients, not on the type of concomitant procedure., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have demonstrated significant effects on low-density lipoprotein (LDL) cholesterol and nonhigh density lipoprotein (HDL) cholesterol. To date, there have been limited reports on the effect of PCSK9 inhibitors on remnant cholesterol., Objectives: Assess the effect of PCSK9 inhibitors on nonfasting remnant cholesterol in a real world population. Identify whether pretreatment triglyceride levels are associated with PCSK9 inhibition success as indicated by changes in remnant cholesterol levels., Methods: Patients in our adult lipid clinic ( n = 109) receiving PCSK9 inhibition for atherosclerotic cardiovascular disease or familial hypercholesterolemia who had available pre- and post-PCSK9 inhibition standard nonfasting lipid data were, retrospectively, selected for data analysis. Remnant cholesterol was the difference between non-HDL and LDL cholesterol. LDL cholesterol was measured directly and calculated from Friedewald and Martin/Hopkins methods. Data were analyzed using repeated measures ANOVA and multivariable linear regression for differential effects on remnant and LDL cholesterol based upon pretreatment nonfasting triglyceride levels., Results: Remnant cholesterol as well as total, LDL, non-HDL cholesterol, and triglycerides decreased significantly ( P <0.001) after PCSK9 inhibition. Patients with higher pretreatment triglyceride levels showed greater decrease in remnant cholesterol after PCSK9 inhibition ( P <0.001) than those with lower pretreatment triglycerides., Conclusions: In patients receiving PCSK9 inhibitors, remnant cholesterol as determined from nonfasting blood was reduced in proportion to pretreatment triglycerides.

Background: An important challenge in surgical ablation for atrial fibrillation (AF) is the scarcity of publications on credible predictors of long-term success in procedures performed with ablation tools that produce consistently reliable transmural lesions. We examined factors associated with 1-year success and no atrial arrhythmia (AA) recurrence during 1 to 5 years after surgical ablation for AF., Methods: The study prospectively monitored 743 surgical ablation patients with complete rhythm follow-up at 12 months after the operation. No detected AA was defined as no known recurrence of AA, no cardioversions, and no catheter ablations at all available follow-up assessments., Results: Patients were a mean age of 64.7 years, and 32% were women. Patients with no detected AA during the first year after surgical ablation were more likely to maintain sinus rhythm without recurrence during 1 to 5 years (74% vs 28%, p < 0.001) and to be in sinus rhythm off medication at 5 years (80% vs 53%, p < 0.001). Mixed-model logistic regression revealed that lower risk for AA recurrence during 1 to 5 years was associated with no detected AA during the first 12 months (odds ratio [OR], 0.11; p < 0.001) and surgeon experience with 50 or more cases (OR, 0.63; p = 0.043), whereas older age (OR, 1.03; p < 0.001) and longer preoperative AF duration (OR, 1.04; p = 0.043) were associated with greater risk for AA recurrence., Conclusions: Most patients with no detected AA throughout the first 12 months after surgical ablation continued to be recurrence free for 5 years. Younger age, shorter preoperative AF duration, and greater surgeon experience may be associated with more persistent surgical correction of AF., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Atrial fibrillation (AF) is associated with increased early and long-term morbidity/mortality following valve surgery. This study examined long-term influence of concomitant full Cox maze (CM) and mitral valve procedures on freedom from atrial arrhythmia and stroke., Methods: This sample comprised patients who underwent CM with a mitral valve procedure (N = 473). Data on rhythm, medication status, and clinical events captured according to Heart Rhythm Society guidelines at 6, 9, 12, 18, and 24 months and yearly thereafter up to 7 years., Results: Mean age was 65 years, mean left atrium size was 5.3 cm, and 15% had paroxysmal AF. Perioperative stroke occurred in 2 patients (0.4%) and operative mortality was 2.7% (n = 13). Return to sinus rhythm regardless of antiarrhythmic drugs at 1, 5, and 7 years was 90%, 80%, and 66%. Sinus rhythm off antiarrhythmic drugs at 1, 5, and 7 years was 83%, 69%, and 55%. Freedom from embolic stroke at 7 years was 96.6% (0.4 strokes per 100 patient-years) with a majority of patients off anticoagulation medication. Greater odds of atrial arrhythmia recurrence during 7 years was associated with longer AF duration (odds ratio [OR], 1.07; P = .001), whereas lower odds were associated with cryothermal energy only (OR, 0.64; P = .045) and greater surgeon experience (OR, 0.98; P = .025)., Conclusions: This study suggests that the addition of CM to mitral valve procedures, even with a high degree of complexity, did not increase operative risk. In long-term follow-up, the CM procedure demonstrated acceptable rhythm success, reduced AF burden, and remarkably low stroke rate. Individual surgeon experience and training may notably influence long-term surgical ablation for AF success., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The del Nido cardioplegia solution has been used extensively in congenital heart surgery for more than 20 years and more recently for adults. This randomized controlled trial examined whether expanding this technique to adult cardiac surgery confers benefits in surgical workflow and clinical outcome compared with blood-based cardioplegia., Methods: Adult first-time coronary artery bypass grafting (CABG), valve, or CABG/valve surgery patients requiring cardiopulmonary bypass (CPB) were randomized to del Nido cardioplegia (n = 48) or whole blood cardioplegia (n = 41). Primary outcomes assessed myocardial preservation. Troponin I was measured at baseline, 2 hours after CPB termination, 12 and 24 hours after cardiovascular intensive care unit admission. Alpha was set at P < .001., Results: Preoperative characteristics were similar between groups, including age, Society of Thoracic Surgeons risk score, CABG, and valve procedures. There was no significant difference on CPB time (97 vs 103 minutes; P = .288) or crossclamp time (70 vs 83 minutes; P = .018). The del Nido group showed higher return to spontaneous rhythm (97.7% vs 81.6%; P = .023) and fewer patients required inotropic support (65.1% vs 84.2%; P = .050), but did not reach statistical significance. Incidence of Society of Thoracic Surgeons-defined morbidity was low, with no strokes, myocardial infarctions, renal failure, or operative deaths. For del Nido group patients, troponin levels did not increase as much as for control patients (P = .040), but statistical significance was not reached., Conclusions: Evidence from this study suggests del Nido cardioplegia use in routine adult cases may be safe, result in comparable clinical outcomes, and streamline surgical workflow. The trend for troponin should be investigated further because it may suggest superior myocardial protection with the del Nido solution., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Alzheimer's disease (AD) research progress is impeded due to participant recruitment challenges. This study seeks to better understand, from the perspective of individuals engaged in clinical trials (CTs), research motivations., Methods: Participants, or their caregivers, from AD treatment and prevention CTs were surveyed about research motivators., Results: The 87 respondents had a mean age of 72.2, were predominantly Caucasian, 55.2% were male, and 56.3% had cognitive impairment. An overwhelming majority rated the potential to help themselves or a loved one and the potential to help others in the future as important motivators. Relatively few respondents were motivated by free healthcare, monetary rewards, or to make others happy., Conclusions: Recruitment efforts should focus on the potential benefit for the individual, their loved ones, and others in the future rather than free healthcare or monetary rewards.

Background: Rhythm control is challenging in patients with extended atrial fibrillation (AF) duration and persistent/long-standing persistent AF. Among surgical approaches to treat AF, the Cox maze procedure performed using alternative energy sources remains superior to other beating heart techniques. We examined permanence of safety and success for the on-pump, minimally invasive, stand-alone Cox maze procedure 5 years after surgery., Methods and Results: Stand-alone, right 5 cm minithoracotomy, Cox maze III/IV procedure for nonparoxysmal AF was conducted in 133 patients (mean follow-up=65±34 months). Data collected prospectively at 3, 6, 9, 12, 18, 24 months and yearly thereafter and reported per Heart Rhythm Society Guidelines. Paired-samples t tests evaluated quality of life changes. Mean age was 57.3±9.2 years, mean LA size was 4.9±1.1 cm, median AF duration was 51 months, and 78% had long-standing persistent AF. All procedures performed with no conversion to midsternotomy, no renal failure, strokes, or operative mortality (<30 days), transient ischemic attack in 1 patient, reoperation for bleeding in 2 patients, and median length of stay was 4 days [3-5.5 days]. At 5 years, 73% were in sinus rhythm off antiarrhythmic medications after single intervention, 1 stroke (718 patient-years) with 81% off anticoagulation, catheter ablation reinterventions in 13 patients for atrial arrhythmia, and cardioversions in 15 patients. Quality of life scores improved significantly by 12 months after surgery., Conclusions: Successful ablation for nonparoxysmal AF is challenging. Therefore, periprocedural safety and long-term efficacy of minimally invasive Cox maze procedures should be noted. Continued refinement of decision-making techniques is warranted to improve patient selection for the appropriate intervention to treat AF., (© 2017 American Heart Association, Inc.)

Background: The Cox maze (CM) procedure is routinely performed using surgical ablation technology. Reports are scarce on long-term outcomes of CM, especially for a large series of patients. This study examined the potential impact of surgical ablation energy source on safety and long-term efficacy of concomitant CM procedures., Methods: The study sample consisted of 709 concomitant CM-treated patients operated on with cryothermal energy only (group 1; n = 386) or combination of cryothermal and bipolar radiofrequency (group 2; n = 323). Data were collected prospectively on perioperative outcomes, rhythm status, survival, and clinical events. Propensity score matching conducted by energy source resulted in 298 patients per group., Results: Perioperative outcomes included stroke (n = 4), reoperation for bleeding (n = 23), renal failure requiring temporary dialysis (n = 18), readmissions before 30 days (n = 86), and operative death before 30 days (n = 16; ratio of observed to expected mortality [O/E ratio], 0.50). Independent predictors for 1-year and 5-year rhythm success were a shorter history of atrial fibrillation (1-year odds ratio [OR], 0.93, p = 0.001; 5-year OR, 0.93, p = 0.042) and cryothermia alone (1-year OR=1.77, p = 0.020; 5-year OR = 2.29, p = 0.009). After matching, group 1 had significantly higher sinus rhythm without antiarrhythmic drugs at 6 months (79% vs 70%; p = 0.016), 36 months (81% vs 69%; p = 0.010), and 60 months (75% vs 57%; p = 0.008). Stroke incidence was lower for group 1 (0.7% vs 3%; p = 0.033), with no difference in major bleeding (10% vs 11%; p = 0.597). Groups had similar survival rates (log rank, 0.6; p = 0.452)., Conclusions: Concomitant CM procedures performed with cryothermal energy alone or combined with bipolar radiofrequency ablation are safe and exceedingly effective. The association of cryothermal energy alone with higher rates of sinus rhythm and stroke reduction should be investigated further., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The Cox maze procedure (CM) is safe and effective for all atrial fibrillation (AF) types. A recent randomized trial found alarming rates of pacemaker implantation (PMI) during hospitalization after CM. The purpose of this study was to assess the rate of PMI and its impact on outcomes after CM., Methods: Incidence of PMI was captured for all CM patients (2005-2015; N = 739). Data were collected prospectively. Multivariable logistic regression was conducted to determine risk factors for PMI. Propensity score matching was conducted between concomitant CM patients and patients without surgical ablation since 2011., Results: Fifty-two patients (7.0%) had in-hospital PMI after CM. Most common primary indication for PMI was sick sinus syndrome (67%), followed by complete heart block (23%) and sinus bradycardia (10%). The only risk factor for in-hospital PMI was type of procedure (P = .020). Patients with multiple valve procedures were at greatest risk (P = .004-.035). STS-defined perioperative outcomes were similar for patients with and without in-hospital PMI. Sinus rhythm off antiarrhythmic drugs were similar by PMI. After propensity score matching (n = 180 per group), in-hospital PMI was similar in CM patients and those without surgical ablation (5% vs 4%, P = .609)., Conclusions: This study demonstrated lower incidence of PMI after CM procedures than recently reported. When indicated, PMI was not associated with increased short- or long-term morbidity or inferior freedom from atrial arrhythmia. Efforts to increase surgeon training with the CM procedure and postoperative management awareness are warranted to improve rhythm outcome and minimize adverse events and PMI., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Although associations between transfusion and inferior outcomes have been documented, there is a lack of blood transfusion standardization in cardiac surgery. At the Inova Heart and Vascular Institute, a multidisciplinary, criterion-driven algorithm for transfusion management was implemented. We examined the effect of our blood conservation protocol on transfusion rates and outcomes after cardiac surgery and on stability of transfusion over time., Methods: Patients undergoing first-time cardiac surgery from 2006 (full year before protocol) were compared with those in 2009 (after protocol) and propensity score matched to improve balance. Data were prospectively collected. Stability of transfusion incidence also was compared (2005-2006 vs 2008-2014)., Results: After matching, 890 patients from each year were included. Use of blood products decreased from 54% in 2006 to 25% in 2009 (P < .001). Patients in 2009 had a lower incidence of postoperative renal failure (2.6% vs 4%, P = .04), reoperations for bleeding (2% vs 4%, P = .004), and readmissions at less than 30 days (6% vs 12%, P < .001). No differences were found for operative mortality, deep sternal wound infection, or permanent strokes. Patients in 2009 had greater improvement in physical (P = .001) and mental (P = .02) quality of life than patients in 2006. Reduction of blood products led to significant cost savings for packed erythrocytes (P < .001) and platelets (P < .001). After protocol implementation, transfusion incidence remained 30% or less, with less than 28% in most years., Conclusions: A multidisciplinary blood conservation program can significantly control blood transfusion rates, improve outcomes, and be sustained over time. Efforts are needed to implement evidence-based protocols to standardize and decrease blood use in cardiac surgery to improve outcomes and reduce cost., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Growing evidence indicates the effectiveness of surgical ablation confined to the left atrium, especially with short duration of atrial fibrillation (AF) and smaller left atrial (LA) size. This study examined rhythm status and predictors of failure in this group of patients., Methods: Of 800 patients who underwent concomitant surgical ablation (2005 to 2015), 110 had LA-only ablation. Rhythm status was defined according to Heart Rhythm Society guidelines: sinus rhythm (SR) without class I/III antiarrhythmic drugs (AADs). Multivariate analyses examined predictors for SR without AADs. Predictors of failure were also stratified as age 75 years or older, LA size 5 cm or larger, AF duration 5 years or more, and nonparoxysmal AF type for secondary analyses., Results: Mean age was 70.7 ± 9.4 years, mean EuroSCORE II (European System for Cardiac Operative Risk Evaluation) was 4.7 ± 4.3%, mean LA size was 4.4 ± 0.8 cm, median (interquartile range) AF duration was 3.5 months (range, 0.4 to 21 months), 26% of patients were female, 59% had coronary artery bypass graft procedures, 36% had aortic valve procedures, and 25% had mitral valve procedures. SR without AADs at 6, 12, and 24 months was 82% (79 of 96), 87% (78 of 90), and 79% (61 of 77), respectively. The only independent predictor of SR without AADs at 6 months was smaller LA size (odds ratio, 0.35; p = 0.014). Return to SR without AADs at 6, 12, and 24 months was as follows: 92%, 93%, and 91%, respectively, for patients with no traditional predictors of failure (n = 32); 88%, 90%, and 77%, respectively, for one predictor (n = 47); and 66%, 76%, and 70% for two or more predictors (n = 31)., Conclusions: LA-only ablation yielded acceptable success rates, primarily in patients with shorter AF duration and smaller LA. However, success was reduced in patients with traditional predictors of failure. Well-designed studies with standardized lesion sets and ablation tools are required to determine whether full Cox maze yields better outcomes in patients with more advanced AF., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was developed to reflect a more current dataset and evidence-based improvements in cardiac surgery. In the United States, The Society of Thoracic Surgeons (STS) risk score is more accepted owing to relatively high predictive value despite less user friendliness and inapplicability to some cardiac surgeries. We compared the precision of EuroSCORE II with EuroSCORE I and the STS risk score for operative mortality., Methods: Data were collected prospectively for all cardiac surgery patients at a single center since 2001 (N = 11,788). A secondary analysis for patients with cardiac surgery not accommodated by the STS model compared only EuroSCORE II and I (N = 5,880). Receiver-operating characteristic analyses were performed for operative mortality to determine the discriminative ability for each score., Results: Observed operative mortality was 1.8%. Mean predicted mortality for STS risk score, EuroSCORE II, and EuroSCORE I was 2.7%, 3.3%, and 7.8%, respectively. The discriminative ability for operative mortality by area under the curve for EuroSCORE II, EuroSCORE I, and STS risk score was 0.844, 0.819, and 0.846, respectively. In secondary analyses comparing EuroSCORE II with EuroSCORE I, risk scores were correlated (rs = 0.83, p < 0.001). However, for operative mortality (observed, 4%), EuroSCORE II had better absolute prediction and discriminative ability (expected, 5.8%; area under the curve 0.754) than EuroSCORE I (expected, 12.5%; area under the curve 0.688)., Conclusions: EuroSCORE II had better predictive discrimination for operative mortality than EuroSCORE I, which greatly overestimated this risk. EuroSCORE II fared well compared with the STS risk score. The inclusive nature of EuroSCORE II for numerous procedures provides more flexibility than the STS score for complex procedures. EuroSCORE II should be considered for calculating risk score for complex cardiac surgical patients., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Prophylactic antiarrhythmic drug (AAD) treatment is a well-established practice after catheter ablation for atrial fibrillation (AF), but it is controversial after surgical ablation. This prospective randomized controlled trial examined whether amiodarone after surgical ablation reduced atrial arrhythmia recurrence within the first 3 months after surgery., Methods: Ninety patients were randomized to receive (n = 45) or not receive (n = 45) amiodarone after surgical ablation. Rhythm status was ascertained via clinical follow-up and 72-hour continuous monitoring at 6 and 12 weeks, using Heart Rhythm Society guidelines. Primary outcome was defined as atrial arrhythmia recurrence, cardioversion, ablation, or crossover from no-amiodarone to amiodarone as a result of atrial arrhythmia during follow-up. An intention-to-treat approach was used., Results: The 2 study groups were similar in traditional predictors for failure, including left atrium size (5.0 vs 5.1 cm, P = .734), median AF duration (23 vs 20 months, P = .513), and long-standing persistent AF (44% vs 33%, P = .280). The primary outcome occurred in 52% of the no-amiodarone group (23 of 44) and 19% of the amiodarone group (8 of 43; P = .001). Cumulative freedom from primary outcome was greater in the amiodarone group (81.4% vs 47.7%, P < .001). Amiodarone was discontinued in 18 patients randomized to amiodarone for side effects, bradycardia, or noncompliance., Conclusions: Prophylactic amiodarone reduced early atrial arrhythmia recurrence. These results are consistent with catheter AF ablation findings and should inform recommendations for prophylactic class I/III AAD after surgical AF ablation, regardless of discharge rhythm status. As previously recommended, monitoring for side effects and amiodarone discontinuation by 3 months, for patients in sinus rhythm, is warranted., Clinical Trial Registration: NCT01416935., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Recent financial challenges highlight the importance of accurate prediction of length of hospital stay (LOS). We assessed reliability of The Society of Thoracic Surgeons (STS) risk prediction for extended and shorter LOS and examined whether modifiable clinical variables are associated with LOS in first-time cardiac surgery patients., Methods: Isolated aortic valve, mitral valve, and coronary artery bypass graft surgery patients since 2008 were included (n = 3,472). Multivariate regression was used to evaluate nonmodifiable and potentially modifiable (preoperative hematocrit, hemoglobin A1c, body mass index, current smoker, major perioperative morbidity, and blood product transfusion) predictors of LOS in days., Results: Mean age was 63.9 ± 11.2 years, 76% were males, and mean STS mortality risk was 1.9% ± 3.2%. Median (interquartile range) LOS was 4 (3 to 6) days. Predicted STS risk was 6.2% ± 7.1% for extended LOS (>14 days) and 48.3% ± 20.2% for short LOS (<6 days). Extended LOS was observed in 5.2% of patients (observed versus expected, 0.84; p = 0.019). Observed short LOS was better than predicted (67.8%; observed versus expected, 1.40; p < 0.001). Inclusion of modifiable variables in the LOS prediction model was significant (p < 0.001). Significant modifiable predictors were lower hematocrit, higher hemoglobin A1c, major morbidity, and transfusion. Longer predicted LOS from the model correlated with longer actual LOS (rs = 0.63; p < 0.001). Applying the prediction equation from the model to a hypothetical average patient, predicted LOS was 4.6 days., Conclusions: The STS risk model was reliably predictive of short and extended LOS but did not allow prediction of exact LOS in days. Accounting for potentially modifiable clinical variables, such as low hematocrit and blood transfusion, especially in elective patients, should lead to shorter LOS, higher satisfaction, and reduced financial burden., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Open-heart surgery with fibrillatory arrest has been reported to be associated with an increased risk of stroke. We examined whether minimally invasive mitral valve surgery with fibrillatory arrest conferred a higher risk of stroke/transient ischaemic attack (TIA) and other major complications compared with median sternotomy and cardioplegic arrest., Methods: Data were collected prospectively for 387 patients who had mitral valve surgery; 239 had a minimally invasive surgical approach and 148 had median sternotomy. All minimally invasive surgeries were performed by surgeons who were experienced in minimally invasive techniques. The effect of operative approach on risk of stroke/TIA and major morbidity was examined. After propensity score matching (PSM) was conducted between the two groups, 76 patients remained in each group., Results: Before matching, the incidence of stroke/TIA did not differ between patients who had minimally invasive surgery (0.5%, n = 1) and those who had median sternotomy (1.4%, n = 2; P = 0.56). Patients who had minimally invasive surgery had a lower incidence of other major morbidity (0.8%, n = 2) than patients who had median sternotomy (6.1%, n = 9; P = 0.004). After adjustment for age and Society of Thoracic Surgeons predicted risk, there was no effect of operative approach on the odds for stroke/TIA (odds ratio [OR] = 0.41, P = 0.49) or other major morbidity (OR = 0.40, P = 0.31). After PSM, patients were balanced on preoperative characteristics. No patient in either matched group experienced permanent stroke/TIA, and major morbidity did not differ between the two groups (minimally invasive, 1.3%, n = 1; median sternotomy, 1.3%, n = 1; P > 0.99)., Conclusions: A minimally invasive approach for mitral valve surgery on a fibrillating heart was not associated with a greater incidence of stroke/TIA than was median sternotomy. When performed by highly experienced surgeons, the minimally invasive approach with fibrillatory arrest did not increase the risk of perioperative stroke., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Atrial fibrillation (AF) duration is one of the most consistent predictors of Cox maze (CM) procedure failure. We examined the impact of AF duration on CM success in patients having first-time concomitant surgery., Methods: First-time concomitant CM was performed in 505 patients. Freedom from atrial arrhythmia (AA) and class I/III antiarrhythmic drug (AAD) data were collected prospectively. Patients with longer AF duration (≥ 5 years; n = 113) were compared with shorter duration (<5 years; n = 392) in primary analyses. The AF duration was examined as a continuous variable in regression analyses., Results: Patients with longer AF duration were older (68.4 vs 65.1 years, p = 0.002) and in long-standing persistent AF (80% vs 36%, p < 0.001). Freedom from AA and AA off AAD was lower in longer duration patients at 1 year (80% vs 94%, p < 0.001; 74 vs 87%, p = 0.005) and 2 years (69 vs 90%, p < 0.001; 61 vs 81%, p = 0.001). Freedom from stroke or transient ischemic attack (TIA) was similar (96.1% vs 95.4%, p = 0.65). Adjusting for clinical and AF-associated factors, each 1-year increase in AF duration had 13% greater odds for failure at 1 year (odds ratio [OR], 1.13, p = 0.004) and 20% greater odds at 2 years (OR, 1.20, p < 0.001). Cryothermia as sole energy source attenuated the negative impact of AF duration on 1-year success., Conclusions: Longer AF duration significantly impacted CM success and may result from extensive tissue remodeling. Patients with longer AF duration can expect reasonable success rates, especially when on AAD, and low stroke rates during follow-up. Cryoablation may reduce AF duration impact on success compared with combined bipolar radiofrequency and cryothermia., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Blood transfusion in cardiac surgery patients is associated with increased morbidity and cost. The decision to transfuse patients after surgery varies but is often based on low hemoglobin (Hgb) levels, regardless of symptom status. This study examined whether asymptomatic patients discharged with lower Hgb levels had increased risk for perioperative complications and 1-year mortality., Methods: Between 2008 and mid-2014, a total of 1107 valve-only procedures were performed. Patients discharged alive with complete data (N = 1044) were divided into 2 groups with discharge Hgb levels of ≤8 g/dL (n = 153) or >8 g/dL (n = 891). Propensity score matching was conducted between Hgb groups, resulting in 152 patient pairs., Results: In multivariate analyses, discharge Hgb level did not predict 30-day mortality (odds ratio [OR] = 1.01, P = .991), 1-year survival (hazard ratio [HR] = 0.87, P = .34), or readmission <30 days (OR = 0.92, P = .31). Furthermore, after propensity score matching, no differences were found between groups with Hgb levels ≤8 versus >8 g/dL in 30-day mortality (0% vs 0.7%, P > .99) or readmissions (14% vs 16%, P = .52). Cumulative 1-year survival was similar between matched groups with discharge Hgb level of ≤8 versus >8 g/dL (89.3% vs 91.4%, P = .67). Matched groups with Hgb level ≤8 versus >8 g/dL had similar physical (28% vs 18% increase; P = .27) and mental (7% vs 6% increase; P = .94) health-related quality of life (HRQL) improvements at 6 months., Conclusions: Asymptomatic patients discharged with lower Hgb levels did not manifest inferior outcomes, including perioperative morbidity/mortality, readmission <30 days, HRQL, and 1-year survival. The practice of blood transfusion to correct lower Hgb levels in asymptomatic patients should be eliminated, as it may be associated with increased morbidity without apparent clinical benefits after valve surgery., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Blood product transfusion after cardiac surgery is associated with increased morbidity and mortality. Transfusion thresholds are often lower for the elderly, despite the lack of clinical evidence for this practice. This study examined the role of age as a predictor for blood transfusion., Methods: A total of 1898 patients were identified who had nonemergent cardiac surgery, between January 2007 and August 2013, without intra-aortic balloon pumps or reoperations, and with short (<24 hours) intensive care unit stays (age ≥75 years; n = 239). Patients age ≥75 years were propensity-score matched to those age <75 years to balance covariates, resulting in 222 patients per group. Analyses of the matched sample examined age as a continuous variable, scaled in 5-year increments., Results: After matching, covariates were balanced between older and younger patients. Older age significantly predicted postoperative (odds ratio = 1.39, P = .028), but not intraoperative (odds ratio = 0.96, P = .559), blood transfusion. Older age predicted longer length of stay (B = 0.21, P < .001), even after adjustment for blood product transfusion (B = 0.20, P < .001). As expected, older age was a significant predictor for poorer survival, even with multivariate adjustment (hazard ratio = 1.34, P = .042)., Conclusions: In patients with a routine postoperative course, older age was associated with more postoperative blood transfusion. Older age was also predictive of longer length of stay and poorer survival, even after accounting for clinical factors. Continued study into effects of transfusion, particularly in the elderly, should be directed toward hospital transfusion protocols to optimize perioperative care., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Targeted blood glucose (BG) levels following cardiac surgery continues to be debated. According to the Society of Thoracic Surgeons (STS) guidelines, BG should be kept <180 mg/dl following cardiac surgery. However, our practice and others shifted to a stricter BG control (90-110 mg/dl) based on data suggesting an association with improved outcome. Recently, we conducted a randomized control study that demonstrated no added value to stricter control over liberal control (120-180 mg/dl). As a result, we shifted our management accordingly. The purpose of this study was to evaluate the impact that this change to a more liberal BG management (BGM) had on patient outcomes at our centre., Methods: BGM was changed in June 2011 from strict (90-110 mg/dl) to liberal (120-180 mg/dl). Insulin drips, managed through a computerized algorithm, controlled BG for the first 72 h post surgery. Consecutive cardiac surgery patients operated on throughout 1 year prior to BGM change (n = 934) were propensity score matched to patients operated on throughout 1 year after the change (n = 927)., Results: After matching, there were 846 patient pairs. There was no difference between cohorts for length of stay and perioperative complications, and both cohorts achieved acceptable outcomes. Incidence of perioperative renal failure (P = 0.02) and renal failure requiring dialysis (P = 0.004) were better for the cohort with liberal BGM. One-year cumulative survival did not differ between cohorts (log-rank = 0.70, P = 0.40)., Conclusions: Implementation of glycaemic control of 120-180 mg/dl into clinical practice was not associated with increased morbidity. The present results confirm our prior findings that a more liberal glycaemic control strategy to maintain BG is equal to a stricter target range. These findings are important for patient care and demonstrate the safety and efficacy of practice change for all patients following a successful randomized controlled trial., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Reporting methods for surgical ablation (SA) of atrial fibrillation (AF) were standardized by the Heart Rhythm Society Guidelines, stating that results should be reported only for the first 2 years following SA. The purpose of this study was to assess the outcome of SA over 5 years and determine predictors for success over that period., Methods: Data were collected prospectively for all SA (n=787). Rhythm was verified by electrocardiogram and Holter monitoring at 3, 6, 9, 12, 18 and 24 months and yearly thereafter. Patients with rhythm status available at 2 and 5 years were included in the main analyses (n=137). Multivariate logistic regression was used for predictors of normal sinus rhythm (NSR). Receiver operating curves compared 2- and 5-year predicted probability against observed rhythm status by year., Results: Return to NSR at 2 years was 88% (80% off antiarrhythmic drugs) and at 5 years was 85% (71% off antiarrhythmic drugs). The majority of patients (64%) had stable NSR over 5 years. The only predictor for 2-year NSR was smaller left atrial size (odds ratio [OR]=0.40, P=0.044). Predictors for 5-year NSR were smaller left atrial size (OR=0.28, P=0.002), age (OR=0.91, P=0.031) and length of hospital stay (OR=0.85, P=0.026)., Conclusions: This study demonstrated stable results of SA for AF over time with somewhat different predictors for 2- and 5-year NSR in a group of patients with complete follow-up at both time points. Accurate models to determine predictors for success of SA more than 2 years after surgery are essential to better understand long-term outcome for patients with AF., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Cardiac surgery patients with atrial fibrillation face increased risks for perioperative morbidity and decreased survival, yet only 39% of patients presenting with atrial fibrillation undergo concomitant surgical ablation. This low percentage may relate to the perception of lower yield for surgical ablation, especially in patients with complex clinical presentations. In this study, we compared outcomes after a concomitant Cox maze III/IV procedure in patients with high, intermediate, and low predicted operative risk., Methods: Outcome data were prospectively captured after surgery. The additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) was greater than 6 for high-risk patients (n = 145), 3 or less for low-risk patients (n = 76), and greater than 3 and 6 or less for intermediate-risk patients (n = 149)., Results: No differences were found for perioperative morbidities, including operative mortality (high vs low risk, 2% vs 1%, P = 1.00; high vs intermediate risk, 2% vs 0.7%, P = .37). Median length of stay was longer in high-risk patients versus low-risk patients (8 vs 5 days, P < .001) and intermediate-risk patients (8 vs 6 days, P < .001). Return to sinus rhythm was comparable for high-risk versus low- and intermediate-risk patients at 6, 12, and 24 months. Physical health-related quality of life scores improved similarly for all groups at 12 months. No difference in long-term survival was found (log rank = 0.40; P = .82)., Conclusions: The Cox maze III/IV procedure can be performed safely and effectively in patients with higher operative risk, who fare well when compared with lower-risk patients. The Cox maze III/IV procedure should be considered carefully in patients with a significant history of atrial fibrillation., (Copyright © 2014. Published by Elsevier Inc.)

Background: Glycemic control in the perioperative period decreases mortality and morbidity, but data are scarce with regard to the effects of glucose control approaches on survival. We assessed long-term survival in patients treated with 2 strategies of glucose control after first-time isolated coronary artery bypass graft., Methods: In a previously published trial, patients were prospectively randomized to strict (90-120 mg/dL) or liberal (121-180 mg/dL) glucose control protocols. The aim of this study was to assess long-term data on survival and health-related quality of life based on the original prospective randomized study population., Results: No differences were found in cumulative survival between the strict (95.5%) and liberal (93.5%) target range groups (log-rank = 0.32, p = 0.57) over a mean follow-up of 40.0 ± 4.4 months. Physical health-related quality of life significantly improved in all patients from baseline to 6 months after surgery (F = 17.73, p < 0.001), and there were no differences in improvement of health-related quality of life between the 2 target range groups (F = 0.15, p = 0.70)., Conclusions: These results support our previous findings and indicate that a liberal glycemic control strategy after coronary artery bypass leads to survival rates and improvements in health-related quality of life that are similar to those achieved with a strict target range. In addition, the liberal strategy is superior in glucose control and target range management., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Long-term management of oral anticoagulation (OAC) after ablation for atrial fibrillation (AF) is an ongoing challenge. Heart Rhythm Society (HRS) guidelines provide no specific recommendations for OAC after surgical ablation. The purpose of this study was to determine the necessity of OAC protocols after surgical ablation., Methods: Patients (N = 691) who underwent the Cox-Maze procedure with left atrial appendage (LAA) management were followed prospectively. All patients were discharged on OAC unless contraindicated. Cardiac rhythm, bleeding, and embolic stroke or transient ischemic attack (TIA), or both, were verified during follow-up., Results: Over a mean follow-up of 47.3 ± 30.3 months, stroke/TIA was reported in 14 patients (5.1 cases per 1,000 person-years) and major bleeding events were found in 46 patients (16.9 cases per 1,000 person-years). Patients with major bleeding events had higher median CHADS2 (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) scores (2 [range, 1-3] versus 1 [range, 1-2]; p = 0.012), but no association was found between incidence of stroke/TIA and median CHADS2 score (1 [range, 0-2.25] versus 1 [range, 1-2]; p = 0.377). Patients with CHADS2 scores of 2 or greater had the same rates of stroke/TIA (p = 0.787) but a higher incidence of major bleeding (p = 0.009) as did patients with CHADS2 scores less than 2. Adjusting for OAC discontinuation and stable sinus rhythm, patients with CHADS2 scores of 2 or greater did not have higher stroke/TIA risk (hazard ratio [HR], 0.84; p = 0.759)., Conclusions: Our results indicate that the decision to discontinue OAC after the Cox-Maze procedure should not be based solely on CHADS2 scores; rather, rhythm status, echocardiographic findings, and patient risk for bleeding should be considered. These findings underscore the need for an OAC protocol for patients who have undergone the Cox-Maze procedure with appropriate LAA management., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: One of the challenges that exists when discussing the Cox maze procedure for atrial fibrillation (AF) with patients is predicting the success for a given patient. The purpose of the present study was to develop a scoring system using well-established clinical factors to predict the probability of sinus rhythm (SR) after surgery., Methods: The data from patients 1 and 2 years postoperatively were analyzed using logistic regression to predict SR, including the most accepted variables associated with failure (age, left atrium size, AF duration, AF type). Regression models were applied using hypothetical patients to examine the predicted probability of SR., Results: The predictors of 1-year SR were a shorter AF duration and greater surgeon experience performing surgical ablation. The predictors at 2 years were a shorter AF duration and smaller left atrium. The 1-year prediction model applied to hypothetical data found a 1-cm increase in left atrial size associated with a 0.4% reduction in SR probability, a 5-year increase in AF duration associated with a 0.8% reduction, and a reduction by 50 cases of surgeon experience associated with a 1.0% reduction. The 2-year model found a 1-cm increase in left atrial size associated with a 1.0% reduction in SR probability, a 5-year increase in AF duration associated with a 0.8% reduction, and a reduction by 50 cases of experience associated with a 0.2% reduction., Conclusions: Our findings are the first step in establishing a risk scoring system to better predict the outcomes after surgical ablation for AF and improve the ability to discuss the risk and benefits with patients., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)