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Purpose: Continuous annual reporting on coronary artery bypass grafting (CABG) surgical practice is key for quality control and improvement of clinical results. In this report, Japanese nationwide features and trends in the extent of coronary artery disease and the characteristics of those undergoing CABG procedures in 2019 are presented. Clinical results of related ischemic heart disease are also presented., Methods and Results: The Japanese Cardiovascular Surgery Database (JCVSD) is a nationwide surgical case registry system. Data regarding CABG cases in the year 2019 (1 January-31 December) were captured with questionnaires regularly administered by the Japanese Association for Coronary Artery Surgery (JACAS). We analyzed trends in the number and types of grafts selected according to the number of diseased vessels in patients undergoing CABG. We also analyzed descriptive clinical results of those undergoing surgery for acute myocardial infarction or ischemic mitral regurgitation., Conclusions: This is the second publication summarizing the results following the JACAS annual report based on JCVSD Registry data from the year 2019. Clinical outcomes and surgical strategy trends were relatively stable. Further accumulation of information with a similar data collection system is expected.

Purpose: The principal of this analysis was to understand global feature of the number and type of grafts and number of diseased vessels of those undergoing coronary artery bypass grafting (CABG) and their short-term clinical results., Methods and Results: This report presents annual report on the collective data of CABG in the year 2018 (1 January-31 December). Data were collected based on the series of questionnaire which has been performed by The Japanese Association for Coronary Artery Surgery (JACAS), capturing the corresponding data from the Japan Adult Cardiovascular Surgery Database (JCVSD). We also analyzed descriptive clinical results of those undergoing surgeries for acute myocardial infarction and ischemic mitral regurgitation., Conclusion: This is the first article summarizing the results from annually performed questionnaires by JACAS based on JCVSD, on the trend of CABG procedures and clinical results in Japan as a scientific manuscript.

Intraoperative conversion to cardiopulmonary bypass with its subsequent high mortality is a major concern associated with off-pump coronary artery bypass grafting (OPCAB). The impact of procedure volume on the incidence of intraoperative conversion, however, is poorly defined. This study therefore evaluated the effect of procedure volume on the incidence of conversion in OPCAB using nationwide data. We analyzed 31,361 patients who underwent primary, nonemergent, isolated OPCAB during 2013-2016 reported in the Japan Cardiovascular Surgery Database. Hospitals (n = 548) and surgeons (n = 1315) were divided into tertile categories (low-, medium-, and high volumes) based on the total number of isolated coronary artery bypass grafting (CABG). Hierarchical logistic regression analysis, including 22 preoperative factors and hospital and surgeon CABG volumes, was used to assess the relation between procedure volume and the risk of conversion due to bleeding/hemodynamic instability. There were 797 (2.5%) intraoperative conversions due to bleeding/hemodynamic instability. Risk-adjusted odds ratios for conversion were significantly lower in some combined hospital/surgeon CABG volume categories than in the reference category. Hospital/surgeon volumes and their odds ratio (95% confidence interval) were as follows: low/low 1.00 (reference); medium/low 0.62 (0.39-0.96); high/low 0.47 (0.27-0.81); high/high 0.58 (0.38-0.89). There was a lower risk of conversion in medium- and high-volume than low-volume hospitals, especially among low-volume surgeons. Procedure volume is associated with the incidence of conversion during OPCAB. Among low-volume surgeons, hospital CABG volume significantly reduces conversion in a volume-dependent manner. These findings will be useful for safety training of OPCAB surgeons., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To investigate the relationship between body mass index (BMI) and early outcomes, and specific types of morbidities associated with low and high BMI, in patients undergoing coronary artery bypass grafting., Methods: This was a retrospective study on isolated coronary artery bypass grafting patients (aged ≥60 years) between 2008 and 2017 in the Japan Cardiovascular Surgery Database. The primary end point was defined as operative mortality. The secondary end point was combined morbidity (ie, operative mortality, reoperation for bleeding, stroke, new onset of hemodialysis, mediastinitis, and prolonged ventilation). Patient characteristics and outcomes were compared among BMI groups. Spline curves were fit between BMI and outcomes. Multivariable logistic regression models with categorized BMI and generalized additive models with spline-transformed BMI were used to estimate and visualize the effect of BMI adjusted for other covariates., Results: A total of 96,058 patients were included in the analysis. Low (<18.5) and high (≥30) BMI were both associated with a higher risk of mortality (low: adjusted odds ratio, 1.34; 95% confidence interval, 1.16-1.54; P < .0001, and high: adjusted odds ratio, 2.10; 95% confidence interval, 1.70-2.59; P < .0001) and combined morbidity (low: adjusted odds ratio, 1.18; 95% confidence interval, 1.08-1.29; P = .0002 and high: adjusted odds ratio, 1.82; 95% confidence interval, 1.63-2.03; P < .0001). Low and high BMI were associated with different types of morbidities. In models using spline transformation, the deviation of BMI from a proximately 21 to 23 was proportionally associated with increased risk., Conclusions: In patients undergoing coronary artery bypass grafting, low and high BMI were risk factors of mortality associated with different types of morbidities, which may warrant tailored preventive approaches., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: International collaboration has an interest in health care quality evaluation. We compared characteristics and surgical outcomes between Asian patients in the United States and Japanese patients who undergo adult cardiac surgery., Methods: Using the Japan Adult Cardiovascular Surgery Database (JCVSD) and The Society of Thoracic Surgeons (STS) National Database, we compared Asian patients undergoing isolated coronary artery bypass graft surgery between 2013 and 2016 in Japan and the United States. The STS had 16,903 Asian patients among 573,823 patients of all races undergoing isolated coronary artery bypass graft surgery (2.95%); the JCVSD had 55,570 patients, almost all of whom are Japanese. Descriptive statistics were analyzed independently, then the data were aggregated for comparison., Results: The JCVSD patients were older (69 vs 65 years) with a smaller body surface area (1.65 m 2 vs 1.81 m 2 ) and body mass index (24 kg/m 2 vs 26 kg/m 2 ). The proportion of males (79% vs 78%), prevalence of chronic lung disease (82% vs 86%), and diabetes mellitus (54% vs 60%) were similar. The JCVSD had higher prevalence of renal disease requiring dialysis (11% vs 6%). The numbers of anastomoses were similar (3.1 vs 3.3); off-pump procedures and the usage of right internal mammary artery were more prevalent (60% vs 15% and 38% vs 7%, respectively) in the JCVSD. The unadjusted operative mortality was 2.7% in the JCVSD and 2.1% in the STS database., Conclusions: Comparisons of coronary artery bypass graft surgery characteristics and outcomes were conducted between the STS National Database and the JCVSD to illustrate the value of international collaboration on adult cardiac surgery databases., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The outcome of cardiovascular surgery has been improving over time, but the treatment of postoperative complications such as deep sternal wound infection (DSWI) still needs critical attention. A nationwide surgical registry was analyzed for procedural details and hospital factors related to DSWI., Methods: The study used the Japan Adult Cardiovascular Surgery Database, which captured data from 82% of all the hospitals performing cardiac surgery in Japan. A total of 109,717 surgical cases (34,980 coronary artery bypass grafting, 43,602 valve operations, 31,135 thoracic aortic operations) were included in the study., Results: The overall incidence of DSWI was 1738 (1.6%). The 30-day mortality and operative mortality were 3311 (3.0%) and 5155 (4.7%), respectively. Across the 3 procedures, thoracic aortic operation showed the highest odds ratio (2.61; 95% confidence interval [CI], 2.32 to 2.94) for operative mortality but the lowest (0.91; 95% CI:,0.73 to 1.13) for DSWI incidence. Conversely, coronary artery bypass grafting showed the lowest odds ratio (1.36; 95% CI, 1.24 to 1.49) for operative mortality but the highest (1.52; 95% CI, 1.32 to 1.76) for DSWI. There was also hospital-level variation: Correlation was statistically significant between the observed-to-expected ratio of DSWI incidence and the observed-to-expected mortality ratio of cardiovascular procedures across the hospitals, but the coefficient was small (r = .24, P < .001)., Conclusions: Hospitals that have a lower risk-adjusted mortality rate of cardiovascular procedures do not always have a lower risk-adjusted DSWI occurrence rate. In addition, the incidence of DSWI varies across hospitals. We need to consider DSWI independently of surgical mortality, whereas for treatment we should consider both the specific hospital environment and the multidisciplinary care., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Data on isolated coronary artery bypass grafting (CABG) performed in 2015 and 2016, and registered in the Japan Cardiovascular Surgery Database were reviewed for preoperative characteristics, postoperative outcomes, and choice of graft material for the left anterior descending artery (LAD). Isolated CABG was performed off-pump in 55.0% (n = 16,173) of all CABG cases (n = 29,392), and graft material for the LAD was positioned at the internal thoracic artery in 72.1% and at the right internal thoracic artery in 17.4% of patients. Operative mortality was 1.7% in elective cases, 8.8% in emergency cases, and 3.0% overall, which was similar to our previous report. In elective cases, operative mortality was 1.1% for off-pump CABG compared with 2.5% for on-pump CABG, and all morbidities except for "readmission < 30 days" were significantly better in OPCAB cases.

Background: Coronary artery disease (CAD) is associated with increased morbidity and mortality after open repair of thoracic aorta. Nevertheless, the efficacy of preoperative coronary angiography (CAG) and revascularization is controversial. The aim of this study was to clarify the effect of preoperative CAD on surgical outcome by reviewing the Japan Adult Cardiovascular Database. Methods and Results: This study involved 4,596 patients who underwent open surgery for true thoracic aortic aneurysm between 2004 and 2009. After excluding patients with concomitant cardiac operation, except coronary artery bypass grafting (CABG), the remaining 1,904 patients with coronary artery stenosis included 995 cases of simultaneous CABG. The prevalence of CAD was significantly higher in patients with diabetes, renal dysfunction, hyperlipidemia, cerebrovascular disorders, peripheral artery lesions, old myocardial infarction (MI), and coronary intervention. Patients with simultaneous CABG had severe CAD compared with those without, with no other major differences in patient background noted. Thirty-day postoperative and in-hospital mortalities were higher in CAD patients. Incidence of perioperative MI was higher in patients who underwent open aortic repair with simultaneous CABG, but simultaneous CABG did not affect operative mortality., Conclusions: In patients with surgically treated true aortic aneurysm, CAD was frequently observed, suggesting that aggressive preoperative coronary evaluation is needed.

Objectives: Despite its survival benefits, bilateral internal thoracic artery (BITA) grafting is not commonly utilized due to concerns over deep sternal wound infection (DSWI). The present study investigated the early outcome of BITA grafting and analyzed the risk of DSWI using a Japanese national database (the Japan Adult Cardiovascular Surgery Database)., Methods: Data from 560 hospitals were used. Between April 2012 and December 2015, BITA was harvested in 14,249 patients, corresponding to 32.6% of isolated coronary artery bypass cases. DSWI was defined as a wound infection requiring surgical intervention and/or the administration of antibiotics. Multiple logistic regression analysis was employed to model the risk of DSWI., Results: The mean age was 67.1 years. The prevalence of diabetes, renal failure, hemodialysis, and liver dysfunction was 51.8%, 21.2%, 7.8%, and 1.2%, respectively. The incidence of DSWI and operative mortality was 1.6 (234 patients) and 1.6% (226 patients), respectively. The operative mortality rate in patients with DSWI was 13.7% (32 patients). The off-pump technique was used in 72.8%, with a conversion rate of 2.5%. Female sex, diabetes mellitus, chronic lung disease, renal failure, liver dysfunction, ejection fraction ≤60%, shock status, reoperation, preoperative intra-aortic balloon pump use, and an increased operative time were independent risk factors for DSWI after BITA grafting. The off-pump technique did not reduce the risk of DSWI., Conclusions: The present study showed that early outcomes of BITA grafting were satisfactory regarding DSWI and operative mortality. The current data are informative to predict the risk of DSWI when performing BITA grafting., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective and Methods: Data on isolated coronary artery bypass grafting (CABG) performed in 2013 and 2014, and registered in the Japan Cardiovascular Surgery Database were reviewed for preoperative characteristics, postoperative outcomes, and choice of graft material for the left anterior descending artery (LAD)., Results: Isolated CABG was performed off-pump in 54.7% of cases, and graft material for the LAD was left internal thoracic artery in 74.3% and right internal thoracic artery in 15.6%. Operative mortality was 2.0% in elective cases, 8.2% in emergency cases, and 3.0% overall. In elective cases, operative mortality was 1.1% for off-pump CABG compared with 3.0% for on-pump CABG., Conclusions: Clinical results of our isolated CABG were reasonable and acceptable.

Background: The present study aimed to clarify the current use and outcomes of coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS) based on the Japan Adult Cardiovascular Surgery Database (JACVSD) in stratified risk categories, and also to provide guidance on selection of optimal surgical strategies for ACS.Methods and Results:From January 2008 through December 2012, 7,867 isolated CABG procedures for ACS were identifiedfrom the JACVSD. Patients were stratified into 3 subgroups (<2%, 2-9.9%, ≥10%) according to preoperative risk estimations based on this database. Off- and on-pump CABG surgical outcomes were evaluated in each subgroup. Off-pump CABG (OPCAB) was the predominant surgical strategy in all subgroups. The proportion of on-pump beating CABG increased in the higher-risk groups. Although average observed mortality rates were compatible with preoperative estimated risk in all subgroups, those after OPCAB were significantly lower in the medium (2-9.9%) risk group with lower incidence of major complications. In the low (<2%) and high (≥10%) risk groups, observed mortality rates did not show statistically significant differences between off- and on-pump CABG., Conclusions: In this study in Japan, OPCAB was mainly performed in patients with ACS, particularly those with estimated risk <10%, with lower mortality rates, whereas on-pump beating CABG was selected for higher-risk patients with ACS, with reasonable mortality rates.

Background: Adverse effects of previous percutaneous coronary intervention (PCI) on clinical outcomes after coronary artery bypass grafting (CABG) are unclear. This study aimed to evaluate the effect of previous PCI on early outcomes after subsequent CABG by using data from the Japanese national database., Methods: This study analyzed data from 48,051 consecutive patients that were retrieved from the Japan Adult Cardiovascular Surgery Database. These patients underwent primary, isolated, elective CABG between January 2008 and December 2013. Early mortality and morbidity rates in patients with previous PCI (n = 12,457, 25.9%) were compared with those in patients with no PCI (n = 35,594, 74.1%) by using multivariate logistic regression analysis and propensity score analysis., Results: Operative mortality rates (no PCI, 1.2%; previous PCI, 1.2%; P = 0.970) and morbidity rates (no PCI, 7.4%; previous PCI, 7.2%; p = 0.436) were similar between the two groups. In risk-adjusted multivariate logistic-regression analysis, previous PCI (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.82 to 1.22; p = 0.995) and morbidity (OR, 0.97; 95% CI, 0.89 to 1.05; p = 0.391) were not significant risk factors of operative mortality. Inverse probability of treatment weighting using the propensity score confirmed these results., Conclusions: This study shows that a previous PCI procedure does not increase postoperative adverse events after subsequent CABG. In the setting of repeat coronary revascularization, the most appropriate method of revascularization should be selected by the heart team, without being affected by a history of a previous PCI procedure., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Using data from the Japan Adult Cardiovascular Surgery Database, we evaluated the prognostic influence of off-pump technique in patients with low ejection fraction who underwent coronary artery bypass grafting., Methods: We analyzed 2187 patients with an ejection fraction <0.30 who underwent primary, nonemergency, isolated coronary artery bypass grafting between 2008 and 2012, as reported in the Japan Adult Cardiovascular Surgery Database. Patients were divided into on-pump (n = 1134; 51.1%) and off-pump (n = 1053; 48.9%) coronary artery bypass grafting groups. Propensity-score matching for 20 preoperative variables was performed, and early mortality and morbidity were compared between matched groups., Results: Propensity-score matching created 918 pairs. Of the 918 patients in the off-pump group, conversion to an on-pump procedure occurred in 56 (6.1%). Compared with on-pump, off-pump technique was associated with significantly lower incidences of 30-day death (1.7% vs 3.7%; P = .01), operative death (3.3% vs 6.1%; P = .006), mediastinitis (1.9% vs 3.4%; P = .041), reoperation for bleeding (0.9% vs 3.5%; P < .001), and prolonged ventilation (8.2% vs 13.4%; P < .001). Comparison of patients undergoing off-pump versus on-pump procedures demonstrated no significant differences in the incidence of stroke (1.5% vs 2.1%; P = .38), renal failure (6.1% vs 7.4%; P = .26), and postoperative dialysis (3.1% vs 4.4%; P = .14). Institutional volume-adjusted analysis confirmed most of these results., Conclusions: Off-pump coronary artery bypass grafting is associated with significantly reduced early mortality and morbidity in patients with an ejection fraction <0.30., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The authors evaluated the effect of preoperative β-blocker use on early outcomes in patients undergoing coronary artery bypass grafting (CABG) in Japan., Methods: The authors analyzed 34,980 cases of isolated CABGs, performed between 2008 and 2011, at the 333 sites recorded in the Japanese Cardiovascular Surgical Database. In addition to the use of multivariate models, a one-to-one matched analysis, based on estimated propensity scores for patients with or without preoperative β-blocker use, was performed., Results: The study population (mean age, 68 yr) comprised 20% women, and β-blockers were used in 10,496 patients (30%), who were more likely to have risk factors and comorbidities than patients in whom β-blockers were not used. In the β-blocker and non-β-blocker groups, the crude in-hospital mortality rate was 1.7 versus 2.5%, whereas the composite complication rate was 9.7 versus 11.6%, respectively. However, after adjustment, preoperative β-blocker use was not a predictor of in-hospital mortality (odds ratio, 1.00; 95% CI, 0.82 to 1.21) or complications (odds ratio, 0.99; 95% CI, 0.91 to 1.08). When the outcomes of the two propensity-matched patient groups were compared, differences were not seen in the 30-day operative mortality (1.6 vs. 1.5%, respectively; P = 0.49) or postoperative complication (9.8 vs. 9.7%; P = 1.00) rates. The main findings were broadly consistent in a subgroup analysis of low-risk and high-risk groups., Conclusion: In this nationwide registry, the use of preoperative β-blockers did not affect short-term mortality or morbidity in patients undergoing CABG.

Objectives: To evaluate early outcomes of bilateral internal mammary artery (BIMA) compared with single IMA (SIMA) in patients who underwent isolated coronary artery bypass grafting (CABG)., Methods: Patients who received isolated CABG with SIMA or BIMA were retrospectively reviewed using the Japan Adult Cardiovascular Surgery Database from 210 institutions for 2008 and 2009. We performed a one-to-one matched analysis on the basis of estimated propensity scores for patients receiving either SIMA or BIMA and obtained two cohorts with 3851 patients in each group balanced for baseline characteristics out of 8136 SIMA and 4093 BIMA patients. We compared procedures actually performed, early outcomes including 30-day operative mortality and details of postoperative complications between the groups using Pearson's chi-square test, with P < 0.05 being statistically significant., Results: Preoperative profiles in both groups included 20% females and 50% diabetes mellitus patients with a mean age of 67 years. Off-pump CABG was similar in both groups, being performed 75% of the time, with the mean number of anastomosis being 3.1 and 3.4 in the SIMA and BIMA groups, respectively (P < 0.0001). Thirty-day operative mortality was 1.2% in both groups, and the overall incidence of postoperative complications also was similar, although deep sternal infection was more frequent with BIMA (1.3 of SIMA and 2.3% of BIMA patients; P = 0.0001), while prolonged ventilation and renal failure were more frequent with SIMA (P < 0.05)., Conclusions: The use of BIMA did not affect either short-term survival as postoperative mortality was low in both groups, or overall morbidity despite higher incidence of deep sternal infection.

Objective: The Japan Cardiovascular Surgery Database (JCVSD) was established in 2000 and initiated a benchmarking project to improve the quality of cardiovascular surgery. Although the importance of quality improvement initiatives has been emphasized, few studies have reported the effects on outcomes., Methods: To examine the time-trend effects in initial JCVSD participants (n = 44), we identified 8224 isolated coronary artery bypass graft (CABG) procedures performed between 2004 and 2007. The impact of surgery year was examined using a multiple logistic regression model that set previously identified clinical risk factors and surgery year as fixed effects. To examine the difference in outcomes between initial participants (n = 44) and halfway participants (n = 55), we identified 3882 isolated CABG procedures performed in 2007. The differences between the 2 hospital groups were examined using a multiple logistic regression model that set clinical risk factors, hospital procedure volume, and hospital groups as fixed effects., Results: For operative mortality, the odds ratio of surgery year was 0.88 (P = .083). Observed/expected (OE) ratios for operative mortality were 0.71 in 2004, 0.73 in 2005, 0.63 in 2006, and 0.54 in 2007. As for composite mortality and major morbidities (reoperation, stroke, dialysis, infection, and prolonged ventilation), odds ratio of surgery year was 0.97 (P = .361). OE ratios for composite mortality and morbidities were 1.01 in 2004, 1.04 in 2005, 1.04 in 2006, and 0.94 in 2007. Compared with halfway participants, initial participants had a significantly lower rate of operative mortality (odds ratio = 0.527; P = .008) and composite mortality and major morbidities (odds ratio 0.820; P = .047)., Conclusions: This study demonstrated that a quality improvement initiative for cardiovascular surgery has positive impacts on risk-adjusted outcomes. Although the primary target of benchmarking was 30-day mortality in Japan, major morbidities were less affected by those activities., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Perioperative risk during coronary artery bypass grafting (CABG) is reportedly high in patients with chronic renal disease. We aimed to determine postoperative mortality and morbidity and identify the perioperative risk factors of mortality during CABG in hemodialysis (HD)-dependent patients., Methods and Results: From the Japan Adult Cardiovascular Surgery Database, we compared 1,300 HD-dependent chronic renal failure patients with 18,387 non-HD patients who all underwent isolated CABG between January 2005 and December 2008. The operative mortality and mortality, including major morbidity, was 4.8% vs. 1.4% and 23.1% vs. 13.7% in the HD and non-HD groups, respectively. Preoperative predictors of operative mortality included age, chronic obstructive pulmonary disease, peripheral arterial disease, congestive heart failure, arrhythmia, preoperative inotropic agent requirement, New York Heart Association class IV, urgent or emergency operation, poor left ventricular function, aortic valve regurgitation (>2), and mitral valve regurgitation (>3). Postoperative predictors of operative mortality included stroke, infection, prolonged ventilation, pneumonia, heart block, and gastrointestinal complications., Conclusions: Compared with non-HD patients, CABG in HD patients was associated with high mortality and morbidity rates. An appropriate surgical strategy and careful perioperative assessment and management for prevention of respiratory and gastrointestinal complications might contribute to improved clinical outcomes after CABG in these patients.

'Age' is a major risk factor in cardiac surgery, however, the precise risks accompanying 'age' have not been fully analyzed. This study aimed to clarify the age-specific risks affecting the short-term outcome after isolated coronary artery bypass grafting (CABG). Data of 13488 procedures were obtained from the Japan Adult Cardiovascular Surgery Database, and the patients were divided into three groups; under 65 years of age ('Young', n=4420), 65-75 ('Middle', n=5485), and over 75 years of age ('Old', n=3583). As a preoperative profile, 'Old' tended to have extracardiac arteriopathy, left main stenosis, and emergency operation, whereas, 'Young' had more coronary risk factors (smoking, diabetes, dyslipidemia) and low left ventricular (LV) function. The 30-day operative mortality rate increased significantly with age ('Young': 1.7%, 'Middle': 2.3%, 'Old': 4.3%, P<0.0001). Renal dysfunction, arrhythmia, preoperative inotropes, and emergency surgery were the predictors for mortality common to all groups. Besides these, 'Young' only had cardiac factors as additional risks, whereas various factors including cardiac parameters, redo sternotomy, peripheral vascular disease, and chronic lung disease were the additional risks in the elderly. Thus, the elderly population was vulnerable to any kind of factors, and preoperative systemic evaluation was crucial in the elderly to help define the appropriate surgical candidates.

Background: Risk models of coronary artery bypass grafting (CABG) using a large database are useful for improving surgical quality. To obtain accurate, high-quality assessments of the surgical outcomes, each country should maintain its own database. This study was conducted to collect Japanese data and prepare a risk stratification of isolated CABG procedures using the Japan Adult Cardiovascular Surgery Database (JACVSD)., Methods: We analyzed 7133 CABG-only records from 97 participating sites throughout Japan using a data entry form with 255 variables that was sent to the JACVSD office by our Web-based data collection system. The statistical model was constructed by multiple logistic regression. Model discrimination was tested using the area under the receiver operating characteristic curve (C index). Model calibration was tested by the Hosmer-Lemeshow test., Results: Of 7133 operations, 47.2% had diabetes mellitus, 14.0% were urgent, and 15.6% involved peripheral vascular disease. The observed 30-day and operative mortality rates were 2.02% and 2.72%, respectively. Significant variables with high odds ratios included emergency or salvage status (3.71), preoperative creatinine value exceeding 3.0 mg/dL (3.59), aortic valve stenosis (3.01), and moderate to severe chronic lung disease (2.86). Hosmer-Lemeshow test and C-index values for 30-day mortality were satisfactory at 0.96 and 0.85, respectively., Conclusions: The results obtained in Japan were at least as good as those reported elsewhere. The performance of our risk model also matched those of the Society of Thoracic Surgeons National Adult Cardiac Database and the European Society Database.

Background: Since the Japanese government updated the medical practice laws, each hospital has to submit procedural volume from April 2007 and may sometime in the future have to submit some outcome indicators. It is very important to examine whether procedural volume is accurate and appropriate., Methods: We analyzed 4581 procedures from 36 centers between 2003 and 2005 by clinical database. The effect of hospital volume on each outcome was tested by a hierarchical mixed-effects logistic regression model, covering clinical risk factors, procedural year, clinical processes, and hospital volume/surgeon volume as a fixed effect and random intercepts for sites., Results: Logistic regression model revealed a significant association between hospital bypass graft volume and 30-day mortality (P < .05) and operative mortality (P < .01). Surgeon procedural volume, however, did not have a significant effect on those outcomes. The effect of hospital procedural volume was associated with better outcomes in most patient subgroups: age younger than 65 years (P < .05), age 65 years and older (P < .01), low risk (P = .58), and high risk (P < .01)., Conclusion: In Japan, high-volume compared with low-volume providers had better outcomes. As for public reporting in Japan, hospital-based evaluation might be more credible than surgeon-based evaluation. Although minimal volume standards might be effective to improve quality to some extent, volume has limitations as a marker of quality because of its wide range of variance.

Open in new tab Download slide Open in new tab Download slide OBJECTIVES The aim of this study was to compare the incidence of operative death and postoperative complications between primary and reoperation valve surgeries and to identify independent risk factors for these events among valve-reoperation patients. METHODS Between 2013 and 2015, 54 269 patients who underwent valve surgery were retrospectively analyzed using the Japan Cardiovascular Surgery Database. They were divided into the primary (group P; n  = 49 833) and reoperation (group R; n  = 4436) surgery groups. Among the reoperation patients, we conducted multivariable logistic regression analyses to identify risk factors for the incidences of operative mortality and postoperative complications. Then, we also conducted propensity score matched analyses to compare the incidences of these 2 outcomes for primary versus reoperation procedures separately for patients with and without infective endocarditis (IE). RESULTS Incidences of postoperative mortality (4.6% vs 9.1%; P  < 0.001) and any complications (36.6% vs 41.4%; P  < 0.001) were higher in the reoperation group. For patients undergoing reoperation, strong risk factors for operative mortality included urgency status, ejection fraction <30%, IE, dialysis, chronic kidney disease, New York Heart Association class 3/4, concomitant coronary artery bypass grafting and aorta procedure, tricuspid valve surgery only, multivalve surgery and age. In the propensity score matched cohort, the relative odds of operative mortality were 1.53 (95% confidence interval: 1.26–1.86, P  < 0.001) among patients with IE and were 1.58 (95% confidence interval: 1.18–2.13, P  < 0.002) among those without. CONCLUSIONS Outcomes for reoperation were significantly worse than those for primary surgery. At the primary operation, the risk of reoperation should be considered and when considering the indications for reoperation, the preoperative state, surgical timing and intervention method should be considered. [ABSTRACT FROM AUTHOR]

OBJECTIVES The use of an anastomosis assist device during coronary artery bypass grafting (CABG) is considered less invasive for the ascending aorta than the use of a side-biting clamp (Side-clamp) and to possibly be associated with a lower incidence of postoperative stroke. However, this benefit has not yet been clearly demonstrated. This study was to evaluate whether the use of an anastomosis assist device will minimize the postoperative stroke and other complications in patients undergoing off-pump CABG in comparison with the use of the Side-clamp. METHODS Patients undergoing isolated off-pump CABG were retrospectively reviewed using the Japan Adult Cardiovascular Surgery Database (2013–2016). We performed a one-to-one matched analysis based on the estimated propensity scores of those who underwent off-pump CABG with an anastomosis assist device (Device group, n  = 14 213) or a side-biting clamp (Side-clamp group, n  = 7374) and obtained 2 cohorts (n  = 7348 each). We compared the early outcomes and the details of postoperative complications using the Pearson's χ 2 test. P -values of <0.05 were considered to indicate statistical significance. RESULTS No significant differences were observed in the rates of 30-day mortality (Side-clamp versus Device: 0.8% vs 0.8%, P  = 0.93) or stroke (1.4% vs 1.4%, P  = 0.46). Transient ischaemic attack/reversible ischaemic neurological deficit/delirium occurred more frequently in the Side-clamp group (1.3% vs 0.9%, P  = 0.020), whereas new-onset atrial fibrillation (11.0% vs 12.8%, P  < 0.001) and prolonged ventilation (2.0% vs 2.9%, P  < 0.001) occurred more frequently in the Device group. There was no difference in the length of intensive care unit stay. CONCLUSIONS The use of an anastomosis assist device partially provided better results with regard to the transient neurological complications; however, no overall benefit was observed in this study. [ABSTRACT FROM AUTHOR]

OBJECTIVES The benefits of off-pump coronary artery grafting (OPCAB) have been demonstrated. Especially in patients with a high number of comorbidities, redo coronary artery bypass grafting (CABG) remains a difficult entity of CABG, because patients are likely to have multiple risk factors and often have diseased patent grafts with adhesions. The aim of the present study was to evaluate the effects of the OPCAB technique in redo CABG on mortality and morbidity using data from the Japan Cardiovascular Surgery Database (JCVSD). METHODS We analysed 34 980 patients who underwent isolated CABG between 2008 and 2011, as reported in the JCVSD. Of these, 1.8% of patients (n = 617/34980) had undergone redo CABG, including those who underwent OPCAB (n = 364; 69%) and on-pump CABG (n = 253; 41%). We used propensity score (PS) matching with 13 preoperative risk factors to adjust for differences in baseline characteristics between the redo OPCAB and on-pump redo CABG groups. By one-to-one PS matching, we selected 200 pairs from each group. RESULTS There were no significant differences in patient background between the redo OPCAB and on-pump redo CABG groups after PS matching. There was no significant difference in the mean number of distal anastomoses after matching (2.41 ± 1.00 vs 2.21 ± 1.04, P = 0.074); nevertheless, the mean operation time was significantly shorter in the redo OPCAB than the on-pump redo CABG group (353.7 vs 441.3 min, P < 0.00010). Patients in the redo OPCAB group had a lower 30-day mortality rate (3.5 vs 7.0%, P = 0.18), a significantly lower rate of composite mortality or major morbidities (11.0 vs 21.5%, P = 0.0060), a significantly lower rate of prolonged ventilation (>24 h) (7.0 vs 15.0%, P = 0.016), a significantly shorter duration of intensive care unit (ICU) stay (ICU stay ≥8 days) (7.0 vs 14.5%, P = 0.023) and a significantly decreased need for blood transfusions (71.5 vs 94.0%, P < 0.00010) than patients in the on-pump redo CABG group. CONCLUSION The off-pump technique reduced early operative mortality and the incidences of major complications in redo CABG. [ABSTRACT FROM AUTHOR]

Background: Deep sternal wound infection (DSWI) is a serious postoperative complication of cardiac surgery. In this study we investigated the incidence of DSWI and effect of re-exploration for bleeding on DSWI mortality. Methods: We reviewed 73,700 cases registered in the Japan Adult Cardiovascular Surgery Database (JACVSD) during the period from 2004 to 2009 and divided them into five groups: 26,597 of isolated coronary artery bypass graft (CABG) cases, 23,136 valvular surgery cases, 17,441 thoracic aortic surgery cases, 4,726 valvular surgery plus CABG cases, and 1,800 thoracic aortic surgery plus CABG cases. We calculated the overall incidence of postoperative DSWI, incidence of postoperative DSWI according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI cases according to operative procedure, 30-day mortality and operative mortality of postoperative DSWI according to whether re-exploration for bleeding, and the intervals between the operation and deaths according to whether re-exploration for bleeding were investigated. Operative mortality is defined as inhospital or 30-day mortality. Risk factors for DSWI were also examined. Results: The overall incidence of postoperative DSWI was 1.8%. The incidence of postoperative DSWI was 1.8% after isolated CABG, 1.3% after valve surgery, 2.8% after valve surgery plus CABG, 1.9% after thoracic aortic surgery, and 3.4% after thoracic aortic surgery plus CABG. The 30-day and operative mortality in patients with DSWI was higher after more complicated operative procedures. The incidence of re-exploration for bleeding in DSWI cases was 11.1%. The overall 30-day/operative mortality after DSWI with re-exploration for bleeding was 23.0%/48.0%, and it was significantly higher than in the absence of re-exploration for bleeding (8.1%/22.0%). The difference between the intervals between the operation and death according to whether re-exploration for bleeding had been performed was not significant. Age and cardiogenic shock were significant risk factors related to re-exploration for bleeding, and diabetes control was a significant risk factor related to DSWI for all surgical groups. Previous CABG was a significant risk factor related to both re-exploration for bleeding and DSWI for all surgical groups. Conclusions: The incidence of DSWI after cardiac surgery according to the data entered in the JACVSD registry during the period from 2004 to 2009 was 1.8%, and more complicated procedures were followed by higher incidence and mortality. When re-exploration for bleeding was performed, mortality was significantly higher than when it was not performed. Prevention of DSWI and establishment of an effective appropriate treatment for DSWI may improve the outcome of cardiac surgery. [ABSTRACT FROM AUTHOR]

Abstract: Objective: While isolated coronary artery bypass grafting (CABG) poses major risks as well as benefits to cardiovascular surgery, procedures such as thoracic aortic surgery and combined CABG surgeries are also important contributors to mortality and morbidity. The objective of this study was to create and validate risk models including high-risk cardiovascular procedures to improve quality. Methods: The Japan Cardiovascular Surgery Database of patients enrolled cardiovascular surgical patients between January 2005 and December 2007. Data were collected at presentation and by physician review of clinical records and were verified through third-party surgeons’ auditing. We analyzed 36780 procedures in 120 hospitals. Using logistic regression, risk models were generated and validated by split-sample validation. Results: In this analysis, 11948 procedures were isolated CABG, 11760 were valve surgeries, and 8440 were thoracic aortic surgeries. In a 30-day operative mortality risk model, 37 variables were significantly associated with outcome. In comparison to isolated CABG, the odds ratios (ORs) for a 30-day mortality were 1.81 for valve surgery (2.62 in mitral valve replacement and 2.72 in aortic valve plus mitral valve procedures) and 2.36 for thoracic aortic surgery (4.34 if indicated by rupture, 3.16 if involving only arch, 4.38 if involving distal aorta, 3.75 if descending, and 5.97 if thoraco-abdominal aorta). CABG combined with other procedures (n =3599) had increased risks in each morbidity risk model (OR: 1.21 in reoperation, 1.60 in stroke, 1.23 in dialysis, 1.97 in infection, and 1.40 in prolonged ventilation). The predictive power of our models is valued by a C-statistic of 0.830 for a 30-day postoperative mortality, 0.639 for reoperation, 0.726 for stroke, 0.817 for dialysis, 0.692 for infection, and 0.796 for prolonged ventilation. Conclusions: Though performance of isolated CABG surgery was stable in this era, CABG combined with valve or thoracic aortic surgery was still a high-risk procedure. Given better recognition of high patient risk from these models, earlier targeted perioperative interventions may reduce adverse effects. [Copyright &y& Elsevier]

Background: Percutaneous coronary intervention (PCI) is performed in a wide range of institutions. We sought to assess the relationship between coronary artery bypass grafting (CABG) volume relative to PCI volume and clinical outcome using nationally representative PCI and CABG registries in Japan. Methods: This was a collaborative, registry-based cohort study enrolling patients undergoing percutaneous coronary intervention in 2013–2014 using Japanese nationwide registry (J-PCI) with follow up until discharge. The absolute volume of CABG for each hospital was calculated using additional data from Japan CardioVascular Surgery Database (JCVSD). Patients undergoing their first PCI registered in the registry (N = 220,934), at 943 facilities were studied. Main outcomes were in-hospital mortality, and incidence of composite of in-hospital death and postprocedural complications. Results: Among the 220,934 patients, 162,411 were men, with a mean age of 69.7 (SD 11.6) years. Patients underwent PCI at hospitals with varying CABG volume: The overall in-hospital mortality and composite event rate for PCI patients was 0.9% and 2.4%, respectively. CABG volume was associated with the in-hospital mortality of PCI at facilities performing less than 200 PCIs per year, but not at facilities performing 200 or more. Similarly, in-hospital mortality or complication was associated with PCI volume <200 only if no CABG is done at the facility. The result remained largely consistent in subgroup of patients presenting with acute coronary syndrome or even after excluding these institutions with extremely low number of PCI (<50 cases/year) or CABG (<15 cases / year). Conclusions: In a nationwide registry-based analysis, the surgical volume was associated with patients' clinical outcome after PCI, when limited number of PCIs were performed at the facility. [ABSTRACT FROM AUTHOR]