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Background Prior research on cognitive and functional outcomes after coronary artery bypass graft (CABG) surgery has largely explored these two domains in isolation. In this study, we assess baseline depression and cognition as risk factors for decline in the Clinical Dementia Rating Sum-of-Boxes (CDR-SB) one month post-CABG surgery, which a combined measure of cognition and function. Design The Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study is a prospective observational cohort study. Setting A tertiary care, academic center. Participants Of a total study sample of 148 patients undergoing CABG surgery, 124 (83.8%) completed one-month follow-up assessment. Mean age was 66.3, 32 (25.8%) female, and 112 (90.3%) White. Measurements Cognition, function and depression were assessed on semi-structured clinical interviews. Cognitive and functional status were defined using CDR-SB; mild or major depression was defined by the Hamilton Depression Rating Scale. Additionally, neuropsychological battery was performed at baseline. Results CDR-SB decline occurred in 18 (14.5%) subjects. Older age, depression, baseline CDR-SB, and postoperative delirium were associated with one-month decline on univariate analysis. Older age (OR 1.1 [1.0-1.2]) and depression (OR 6.2 [1.1-35.0]) remained significant on multivariate regression. In separate models, baseline performance on visual Wechsler memory scale (delayed), Hopkins verbal learning test (immediate and delayed), controlled oral word fluency test, and Trails B predicted CDR-SB decline. Conclusion Roughly one in seven patients experienced CDR-SB decline one month after CABG surgery. Also, preoperative depression deserves recognition for being a predictor of CDR-SB decline one month post-CABG. This article is protected by copyright. All rights reserved.

OBJECTIVES: Although depression is a known risk factor for delirium after coronary artery bypass graft (CABG) surgery, it is unclear whether this risk is independent of delirium risk attributable to cognitive impairment or cerebrovascular disease. This study examines depression (mild or major), mild cognitive impairment (MCI) and cerebrovascular disease (defined as intracranial atherosclerosis) as post-CABG delirium risk factors. DESIGN: Prospective, observational cohort study. SETTING: Tertiary-care academic hospital. PARTICIPANTS: Subjects without dementia undergoing CABG surgery. MEASUREMENTS: Preoperative cognitive assessment included Clinical Dementia Rating and neuropsychological battery; depression was assessed using Depression Interview and Structured Hamilton. Baseline intracranial stenosis was evaluated by transcranial Doppler of bilateral middle cerebral arteries (MCA). Study psychiatrists assessed delirium on postoperative days 2–5 using the Confusion Assessment Method. RESULTS: Our analytic sample comprised 131 subjects—average age 65.8 (9.2) years, 27% female. MCI prevalence was 24%, preoperative depression 10%, lifetime depression 35%, and MCA stenosis (≥ 50%) 28%. Sixteen percent developed delirium. Multivariate analysis revealed that age, MCI (OR 5.1, 95% CI 1.3–20.1), and preoperative depression (OR 9.9, 95% CI 1.3–77.9)—but not lifetime depression—predicted delirium. MCA stenosis and its severity predicted delirium in univariate but not multivariate analysis. Right MCA stenosis severity predicted delirium severity, but left-sided stenosis severity did not. CONCLUSIONS: We establish that the risk of delirium attributable to depression extends beyond the potential moderating influence of cognitive impairment and cerebrovascular disease alone. Even mild depression and cognitive impairment before CABG deserve recognition for their effect on post-CABG cognitive health.

Objectives To summarize evidence on cognitive outcomes after heart valve surgery; secondary aim, to examine whether aortic and mitral valve surgery are associated with different cognitive outcomes. Design Preferred Reporting Items for Systematic Reviews and Meta‐Analyses systematic review and meta‐analysis. Setting Cardiac surgery. Participants Individuals undergoing heart valve surgery. Measurements We searched MEDLINE, EMBASE, and PsycINFO for peer‐reviewed reports of individuals undergoing heart valve surgery who underwent pre‐ and postoperative cognitive assessment. Our initial search returned 1,475 articles, of which 12 were included. Postoperative cognitive results were divided into those from 1 week to 1 month (early outcomes, npooled = 450) and from 2 to 6 months (intermediate outcomes; npooled = 722). No studies with longer‐term outcomes were identified. Results Subjects had moderate early cognitive decline from baseline (Becker mean gain effect size (ES)=−0.39 ± 0.27) that improved slightly by 2 to 6 months (ES=–0.25 ± 0.38). Individuals undergoing aortic valve surgery—who were older on average than those undergoing mitral valve surgery (68 vs 57)—had greater early cognitive decline than those undergoing mitral valve surgery (ES=–0.68 vs −0.12), but both cohorts had similar decline 2 to 6 months postoperatively (ES=–0.27 vs −0.20). Conclusions Heart valve surgery is associated with cognitive decline over the 6 months after surgery, but outcomes beyond 6 months are unclear. These findings highlight the cognitive vulnerability of this population, especially older adults with aortic stenosis. © 2018 American Geriatrics Society and Wiley Periodicals, Inc. J Am Geriatr Soc 66:2327–2334, 2018

Background:Cognitive and functional impairment increase risk for post-coronary artery bypass graft (CABG) surgery delirium (PCD), but how much impairment is necessary to increase PCD risk remains unclear.Methods:The Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study is a prospective, observational cohort study of participants undergoing elective CABG surgery. Pre-operative cognitive and functional status based on Clinical Dementia Rating (CDR) scale and neuropsychological battery are assessed. We defined mild cognitive impairment (MCI) based on either (1) CDR global score 0.5 (CDR-MCI) or (2) performance 1.5 SD below population means on any cognitive domain on neurocognitive battery (MCI-NC). Delirium was assessed daily post-operative day 2 through discharge using the confusion assessment method (CAM) and delirium index (DI). We investigate whether MCI – either definition – predicts delirium or delirium severity.Results:So far we have assessed 102 participants (mean age 65.1 ± 9; male: 75%) for PCD. Twenty six participants (25%) have MCI-CDR; 38 (62% of those completing neurocognitive testing) met MCI-NC criteria. Fourteen participants (14%) developed PCD. After adjusting for age, sex, comorbidity, and education, MCI-CDR, MMSE, and Lawton IADL score predicted PCD on logistic regression (OR: 5.6, 0.6, and 1.5, respectively); MCI-NC did not (OR [95% CI]: 11.8 [0.9, 151.4]). Using similarly adjusted linear regression, MCI-CDR, MCI-NC, CDR sum of boxes, MMSE, and Lawton IADL score predicted delirium severity (adjusted R2: 0.26, 0.13, 0.21, 0.18, and 0.32, respectively).Conclusions:MCI predicts post-operative delirium and delirium severity, but MCI definition alters these relationships. Cognitive and functional impairment independently predict post-operative delirium and delirium severity.

Introduction Although depression is a putative risk factor for delirium after coronary artery bypass graft (CABG) surgery, it is unclear to what extent this risk is independent of cognitive impairment and cerebrovascular disease. This study concurrently examines depression (mild or major), mild cognitive impairment (MCI) and cerebrovascular disease (defined as intracranial atherosclerosis) as post-CABG delirium risk factors. Methods This prospective, observational cohort study recruited and assessed 131 subjects without dementia undergoing CABG surgery at a tertiary-care, academic hospital. Preoperative cognitive assessment included Clinical Dementia Rating and neuropsychological battery; depression was assessed using Depression Interview Structured Hamilton. Baseline intracranial stenosis was evaluated by transcranial Doppler of bilateral middle cerebral arteries (MCA). Study psychiatrists assessed delirium on postoperative days 2–5 using the Confusion Assessment Method. Results Average age of the study sample was 65.8 (SD: 9.2) years, and 27% were female. MCI prevalence was 24%, preoperative depression 10%, lifetime depression 35%, and MCA stenosis (≥ 50%) 28%. Sixteen percent developed delirium. Multivariate analysis revealed that age, MCI (OR 5.1, 95% CI 1.3–20.1), and preoperative depression (OR 9.9, 95% CI 1.3–77.9)—but not lifetime depression—predicted delirium. MCA stenosis and its severity predicted delirium in univariate but not multivariate analysis. Right MCA stenosis severity predicted delirium severity but left-sided stenosis severity did not. Conclusions Our findings indicate that the risk of delirium attributable to depression could extend beyond the potential moderating influence of cognitive impairment and cerebrovascular disease. Even mild depression and cognitive impairment before CABG appear to deserve recognition for their effect on post-CABG cognitive health. This research was funded by The NOAHS study (PI: HB Lee) is supported by R01 MH085740. Exploratory analysis of this study was supported by the CEDARTREE Program (K07 AG041835; PI: SK Inouye).

Thoracic aortic mycotic aneurysms caused by Aspergillus fumigatus postoperatively are rare and devastating complications. These cases are usually attributed to intraoperative contamination of surgical equipment. We present a patient who had an ascending aortic mycotic aneurysm 20 weeks post aortic valve replacement. A high index of suspicion allowed for diagnosis and prompt treatment, although the patient presented in an unusual manner. Treatment included both medical and surgical therapy to minimize morbidity and mortality. Despite treatment our patient suffered long-lasting consequences due to the aggressive nature of the disease. Cases presented in the literature and this experience show that a high index of suspicion must be maintained in such patients regardless of immune status and postoperative interval, in order to avoid long-lasting sequelae.

Background The number of alternatives to intra-aortic balloon counterpulsation in the treatment of anticipated and established acute circulatory failure is growing. Despite the clinical importance and significant cost of short-term mechanical circulatory support (MCS) devices, the state of their present use has not been analyzed on a national scale. Objectives The purpose of this study was to characterize the demographics, treatment practices, survival rates, and cost of short-term MCS. Methods In this serial cross-sectional study, we analyzed all adult patients receiving short-term MCS in the United States from 2004 to 2011 by using the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project. Results From 2007 to 2011, use of percutaneous devices for short-term MCS increased by 1,511% compared with a 101% increase in nonpercutaneous devices. Mortality rates declined over this period (p for trend = 0.027) from 41.1% in 2004 to 2007 to 33.4% in 2008 to 2011. A similar trend was observed for the subset of patients with cardiogenic shock, decreasing from 51.6% to 43.1% (p for trend = 0.012). Hospital costs also declined over this period (p for trend = 0.011). Multivariable analysis revealed balloon pumps (odds ratio [OR]: 2.00; 95% confidence interval [CI]: 1.58 to 2.52), coagulopathy (OR: 2.35; 95% CI: 1.88 to 2.94), and cardiopulmonary resuscitation (OR: 3.50; 95% CI: 2.20 to 5.57) before short-term MCS were among the most significant predictors of mortality. Conclusions Use of short-term MCS in the United States has increased rapidly, whereas rates of in-hospital mortality have decreased. These changes have taken place in the context of declining hospital costs associated with short-term MCS.

Background Disseminated nontuberculous mycobacterium infections have occurred following surgical procedures involving extracorporeal circulation; contaminated water from heater-cooler devices (HCDs) has been implicated as the source. The purpose of this review was to evaluate the public health concern and to educate physicians who care for this patient population. Methods The Food and Drug Administration Medical Device Reporting (MDR) database was queried for reports received between January 2010 and August 2016 for patient infections and device contaminations associated with the use of HCDs. Reports were reviewed for type of infection, patient demographics or outcome, reporting country, HCD manufacturer, and the time to event occurrence. Results A total of 339 MDR reports involving 99 facilities and 5 HCD manufacturers were found. MDR reports originated within (n = 154) and outside the United States (n = 185), and included 107 MDR reports describing patient infections involving at least 86 patients and 232 MDR reports describing HCD contamination without known patient infections. The MDR reports identified the surgical procedure in 94 reports and infection location in 83 reports. The time from surgical procedure using an HCD to infection diagnosis was calculable in 67 reports and was reported up to 60 months following the initial surgery. Nontuberculous mycobacterium was the most frequent organism identified, with M. chimaera being the predominate isolate. Conclusions Nontuberculous mycobacterium infections associated with HCDs used during cardiothoracic surgery may have a long latency period and may be lethal. Cardiothoracic surgeon awareness or involvement in this issue is critical in helping to mitigate this emerging public health concern.

Objective Integrated 6-year cardiothoracic surgical residency programs have recently been implemented in the United States. We report the results of the first published nationwide survey assessing the motivations, satisfaction, and ambitions of integrated 6-year residents. Methods A 63-question web-based survey was distributed to 83 residents enrolled in 21 Accreditation Council for Graduate Medical Education–accredited integrated 6-year programs in November 2013. There was an outstanding 69% response rate. Results The median age of integrated 6-year residents was 29 years with women comprising 24%. A clear majority had faculty mentorship (95%) and significant clinical exposure in medical school. Focused (100%) and abbreviated (74%) training curricula were identified as the top advantages of integrated 6-year programs; the format itself was a significant factor (46%) in career choice. Most integrated 6-year residents (95%) were satisfied with their program; 80.7% were satisfied with their operative experience thus far. Career plans skewed toward adult cardiac surgery (67%), followed by pediatric cardiac (24%) and general thoracic (9%) surgery; 49% were not particularly concerned about future employment, with 65% foreseeing an increase in opportunities. Specialized training (eg, aortic, heart failure, minimally invasive, congenital) was anticipated by 77%. Most integrated 6-year residents envision an academic career (94.7%). Conclusions This survey takes an important snapshot of the nascent integrated 6-year format. Mentorship and intense clinical exposure are critical in attracting applicants. Purported advantages of the format are holding true among integrated 6-year residents, with the majority satisfied with their programs. These early data indicate that this format holds significant promise in attracting and retaining highly qualified trainees to academic cardiothoracic surgery.

Malignant pericardial disease in the setting of lung cancer portends a grave prognosis. We present a case of malignant pericardial tamponade and subsequent complications. A 61-year-old man presented with acute pericardial tamponade after having undergone a video-assisted left upper lobe

BackgroundImmunologic incompatibility has implications for primary graft failure, rejection, and survival in heart transplantation. To our knowledge, this is the first large cohort study investigating the impact of ABO-compatible versus identical blood type matching on post heart transplantation survival.MethodsWe used a nationwide sample (2000-2010) within the United Network for Organ Sharing database. Stratification was between ABO-identical and ABO-compatible heart transplantations for univariate and multivariate analyses. The primary end point was graft failure from all causes. Posttransplant survival was compared between groups using Cox proportional hazard and logistic regression models.ResultsA total of 17,951 patients met inclusion criteria, and 2684 (approximately 15%) underwent ABO-compatible heart transplantation. ABO-compatible recipients were generally sicker than ABO-identical recipients before transplant because more were status 1A, in the intensive care unit, and receiving mechanical ventilatory support (P

Background The aim of this study was to evaluate nationwide outcomes of ventricular assist device (VAD) implantation in elderly patients in the United States. Methods Patients undergoing VAD implantation between 2003 and 2008 were identified in the Nationwide Inpatient Sample. The primary outcome was inpatient mortality following VAD implantation. Secondary outcomes included disposition following discharge and costs of care. After stratification based on primary versus postcardiotomy VAD support, outcomes were compared between controls aged 60–69 years and elderly patients aged ≥70 years. Results A total of 2787 patients aged 60–69 years and 1472 patients aged ≥70 years underwent VAD implantation during the study period. Unadjusted mortality rates were comparable between elderly and control patients in both primary support (35.7% vs. 32.1%, p = 0.61) and postcardiotomy support (58.1% vs. 56.1%, p = 0.70). Similarly, in risk-adjusted multivariable logistic regression analysis incorporating clinically relevant variables, age ≥70 did not exert an independent effect on inpatient mortality for either indication. Inpatient costs in the elderly were lower than controls in the primary support cohort, although costs per day were similar, with comparable overall costs between age groups in the postcardiotomy cohort. Elderly survivors were discharged to a facility more frequently than control survivors (primary: 49.9% vs. 29.6%, p = 0.007; postcardiotomy: 67.4% vs. 45.7%, p = 0.03). Conclusions This large-cohort population-based analysis provides a useful framework for inpatient prognosis and resource utilization in elderly patients undergoing VAD implantation. Although mortality rates and costs were found to be comparable between elderly patients and those aged 60–69 years, these rates were nonetheless significant. This combined with more frequent discharge-to-facility in elderly survivors underscores the importance of careful patient selection in this population. doi: 10.1111/jocs.12066 (J Card Surg 2013;28:183–189)

OBJECTIVE To evaluate the contribution of institutional volume and other unmeasured institutional factors beyond volume to the between-center variability in outcomes after orthotopic heart transplantation (OHT). BACKGROUND It is unclear if institutional factors beyond volume have a significant impact on OHT outcomes. METHODS The United Network for Organ Sharing registry was used to identify OHTs performed between 2000 and 2010. Separate mixed-effect logistic regression models were constructed, with the primary endpoint being post-OHT mortality. Model A included only individual centers, model B added validated recipient and donor risk indices as well as the year of transplantation, and model C added institutional volume as a continuous variable to model B. The reduction in between-center variability in mortality between models B and C was used to define the contribution of institutional volume. Kaplan-Meier survival curves were also compared after stratifying patients into equal-size tertiles based on center volume. RESULTS A total of 119 centers performed OHT in 19,156 patients. After adjusting for transplantation year and differences in recipient and donor risk, decreasing center volume was associated with an increased risk of 1-year mortality (P < 0.001). However, procedural volume only accounted for 16.7% of the variability in mortality between centers, and significant between-center variability persisted after adjusting for institutional volume (P

This study examined whether institutional volume impacts outcomes after orthotopic heart transplantation (OHT) utilizing marginal donors.Adult patients undergoing OHT with the use of marginal donors between 2000 and 2010 were identified in the United Network for Organ Sharing database. A previously derived and validated donor risk score (range, 1 to 15) was used to define marginal donors as those in the 90th percentile of risk (score≥7). Patients were stratified into equal-size tertiles based on overall institutional OHT volume. Posttransplant outcomes were compared between these center cohorts.A total of 3,176 OHTs utilizing marginal donors were identified. In Cox regression analysis, recipients undergoing OHT at low-volume centers were at significantly increased risk of 30-day (hazard ratio 1.82 [1.31 to 2.54], p0.001), 1-year (hazard ratio 1.40 [1.14 to 1.73], p=0.002), and 5-year posttransplant mortality (hazard ratio 1.29 [1.10 to 1.52], p=0.02). These findings persisted after adjusting for recipient risk, differences in donor risk score, and year of transplantation (each p0.05). In Kaplan-Meier analysis, there was a similar trend of decreasing 1-year survival with decreasing center volume: high (86.0%), intermediate (85.7%), and low (81.2%; log rank p=0.003). Drug-treated rejection within the first post-OHT year was more common in low-volume versus high-volume centers (34.3% versus 24.2%, p0.001). At an overall mean follow-up of 3.4±2.9 years, low-volume centers also had higher incidences of death due to malignancy (2.8% versus 1.3%, p=0.01) or infection (6.2% versus 4.1%, p=0.02).Consolidating the use of marginal donors to higher volume centers may be prudent in improving post-OHT outcomes in this higher risk patient subset.