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Background: Atrial fibrillation (AF) occurs commonly after cardiac surgery and is associated with multiple adverse outcomes. Older randomized trials suggested that perioperative β- blockade reduced postoperative AF, and The Society of Thoracic Surgeons (STS) coronary artery bypass grafting (CABG) composite measure includes β-blocker administration preoperatively within 24 hours of surgery and at discharge. However, some more recent studies suggest preoperative β-blockade has limited value and question its continuation as an STS quality measure., Methods: In 2022, an STS Preoperative Beta Blocker Working Group was formed with representatives from the STS and the Society of Cardiovascular Anesthesiologists. Published randomized trials, observational studies, societal guidelines, and the current state of available data from the STS Adult Cardiac Surgery Database (ACSD) were reviewed., Results: Review of existing studies reveals substantial heterogeneity or insufficient detail regarding specific β-blockers used, timing of initiation, management of patients on chronic β-blockade, and whether other proarrhythmic or antiarrhythmic drugs were used concurrently. Further, β-blocker data currently collected in the STS ACSD lack sufficient granularity., Conclusions: Because a new randomized trial seems unlikely, the Working Group believes that more granular data on real-world practice would facilitate assessment of the value of preoperative β-blockade in the current era, development of best practice recommendations, and evaluation of their continued appropriateness as an STS quality metric. STS ACSD participants have been invited to participate in a voluntary survey whose additional data, when linked to STS ACSD records, will better delineate contemporary β-blocker practice and outcomes., Competing Interests: Disclosures All authors are involved in a joint Society of Thoracic Surgeons-Society of Cardiovascular Anesthesiologists working group, and the physician authors are members of various task forces and workforces within their respective professional societies. Two authors, Robert Habib and Carole Krohn, are employed by The Society of Thoracic Surgeons. The other authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Background: Acute kidney injury (AKI) frequently complicates cardiac surgery and is more common among Black patients. We evaluated determinants of race-based differences in AKI rates., Methods: Serum creatinine-based criteria were used to identify adult cardiac surgical patients having postoperative AKI in the Perfusion Measures and Outcomes (PERForm) Registry (July 1, 2014, to June 30, 2019). Patient characteristics, operative details, and outcomes were compared by race (Black vs White) after excluding patients with preoperative dialysis, missing preoperative or postoperative creatinine, or other races. A mixed effects model (adjusting for demographics, comorbidities, surgical factors) used hospital as a random effect to predict postoperative stage 2 or 3 AKI. Propensity score analyses were conducted to evaluate robustness of the primary analyses., Results: The study cohort included 34 520 patients (8% Black). More Black patients than White patients were female (43% vs 27%, P < .001), and had hypertension (93% vs 87%, P < .001) and diabetes mellitus (51% vs 41%, P < .001). Acute kidney injury of stage 2 or greater occurred in 1697 patients (5%), more often among Black than White patients (8% vs 5%, P < .001). Intraoperatively, Black patients had lower nadir hematocrits (23 vs 26, P < .001), and were more likely to be given transfusions (22% vs 14%, P < .001). After adjustment, Black race (compared with White) independently predicted odds for postoperative AKI (adjusted odds ratio 1.50; 95% confidence interval, 1.26 to 1.78). The multivariable findings were similar in propensity score analyses., Conclusions: Despite accounting for differences in risk factors and intraoperative practices, Black patients had a 50% increased odds for having moderate-severe postoperative AKI compared with White patients. Additional evaluations are warranted to identify potential targets to address racial disparities in AKI outcomes., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Failure to rescue (FTR) focuses on the ability to prevent death among patients who have postoperative complications. The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed a new, risk-adjusted FTR quality metric for adult cardiac surgery., Methods: The study population was taken from 1118 STS Adult Cardiac Surgery Database participants including patients who underwent isolated CABG, aortic valve replacement with or without CABG, or mitral valve repair or replacement with or without CABG between January 2015 and June 2019. The FTR analysis was derived from patients who had one or more of the following complications: prolonged ventilation, stroke, reoperation, and renal failure. Data were randomly split into 70% training samples (n = 89,059) and 30% validation samples (n = 38,242). Risk variables included STS predicted risk of mortality, operative procedures, and intraoperative variables (cardiopulmonary bypass and cross-clamp times, unplanned procedures, need for circulatory support, and massive transfusion)., Results: Overall mortality for patients undergoing any of the index operations during the study period was 2.6% (27,045 of 1,058,138), with mortality of 0.9% (8316 of 930,837), 8% (7618 of 94,918), 30.6% (8247 of 26,934), 51.9% (2661 of 5123), and 62.3% (203 of 326), respectively, among patients having none, one, two, three, or four complications. The FTR risk model calibration was excellent, as were model discrimination (c-statistic 0.806) and the Brier score (0.102). Using 95% Bayesian credible intervals, 62 participants (5.6%) performed worse and 53 (4.7%) performed better than expected., Conclusions: A new risk-adjusted FTR metric has been developed that complements existing STS performance measures. The metric specifically assesses institutional effectiveness of postoperative care, allowing hospitals to target quality improvement efforts., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Society of Thoracic Surgeons (STS) original coronary artery bypass graft surgery (CABG) composite measure uses a 1-year analytic cohort and 98% credible intervals (CrI) to classify better than expected (3-star) performance or worse than expected (1-star) performance. As CABG volumes per STS participant (eg, hospital or practice group) have decreased, it has become more challenging to classify performance categories using this approach, especially for lower volume programs, and alternative approaches have been explored., Methods: Among 990 STS Adult Cardiac Surgery Database participants, performance classifications for the CABG composite were studied using various analytic cohorts: 1 year (current approach, 2017); 3 years (2015 to 2017); last 450 cases within 3 years; and most recent year (2017) plus additional cases to 450 total. We also compared 98% CrI with 95% CrI (used in other STS composite measures)., Results: Using 3 years of data and 95% CrIs, 113 of 990 participants (11.4%) were classified 1-star and 198 (20%) 3-star. Compared with 1-year analytic cohorts and 98% CrI, the absolute and relative increases in the proportion of 3-star participants were 14 percentage points and 233% (n = 198 [20%] vs n = 59 [6%]). Corresponding changes for 1-star participants were 6.5 percentage points and 133% (n = 113 [11.4%] vs n = 48 [4.9%]). These changes were particularly notable among lower volume (fewer than 199 CABG per year) participants. Measure reliability with the 3-year, 95% CrI modification is 0.78., Conclusions: Compared with current STS CABG composite methodology, a 3-year analytic cohort and 95% CrI increases the number and proportion of better or worse than expected outliers, especially among lower-volume Adult Cardiac Surgery Database participants. This revised methodology is also now consistent with other STS procedure composites., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the world's premier clinical outcomes registry for adult cardiac surgery and a driving force for quality improvement in cardiac surgery. Echocardiographic data provide a wealth of hemodynamic, structural, and functional data and have been part of STS ACSD data collection since its inception. An increasing body of evidence suggests that the use of echocardiography in patients undergoing cardiac surgery has a positive impact on postoperative outcomes. In this report, we describe and summarize the type and rate of reporting of echocardiography-related variables in the STS ACSD, including the Adult Cardiac Anesthesiology Module, from July 2017 to December 2019 for the most frequently performed cardiac surgical procedures. With this review, we aim to increase awareness of the importance of collecting accurate and consistent echocardiography data in the STS ACSD and to highlight opportunities for growth and improvement., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Pneumonia is the most prevalent healthcare-associated infection after coronary artery bypass grafting (CABG), but the relative effectiveness of strategies to reduce its incidence remains unclear. We evaluated the relationship between healthcare-associated infection recommendations and risk of pneumonia after CABG., Methods: Pneumonia prevention practice recommendations were developed based on literature review and analysis of semistructured interviews with key health care personnel across centers with low (<5.9%), medium (5.9%-6.1%), and high (>6.1%) rates of pneumonia. These practices were implemented among 2482 patients undergoing CABG from 2016 to 2017 across 18 centers. The independent effect of each practice in reducing pneumonia was assessed using multivariable logistic regression, adjusting for baseline risk and center. A composite (bundle) score was calculated as the number of practices (0 to 4) each patient received., Results: Recommended pneumonia prevention practices included lung protective ventilation management, early extubation, progressive ambulation, and avoidance of postoperative bronchodilator therapy. Pneumonia occurred in 2.4% of patients. Lung protective ventilation (adjusted odds ratio [OR adj ], 0.45; 95% confidence interval [CI], 0.22-0.92), ambulation (OR adj , 0.08; 95% CI, 0.04-0.17), and postoperative ventilation of less than 6 hours (OR adj , 0.47; 95% CI, 0.26-0.87) were significantly associated with lower odds of pneumonia. Postoperative bronchodilator therapy (OR adj , 4.83; 95% CI, 2.20-10.7) was significantly associated with higher odds. Risk-adjusted rates of pneumonia, operative mortality, and intensive care unit length of stay were lower in patients with higher bundle scores (all P-trend < .01)., Conclusions: These pneumonia prevention recommendations may serve as effective targets for avoiding postoperative healthcare-associated infections., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Society of Thoracic Surgeons Adult Cardiac Surgery Database is one of the most mature, comprehensive, and respected clinical data registries in health care. Through nearly three decades of growth and refinement, it is widely recognized for accurately benchmarking risk-adjusted outcomes in cardiac surgery and serves as the foundation for all quality measurement and improvement activities of The Society of Thoracic Surgeons. This is the fourth in a series of annual reports that provides updated national outcomes, volume trends, and database-related developments in quality measurement and performance improvement., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Transcatheter aortic valve replacement (TAVR) has increased in volume as an alternative to surgical aortic valve replacement (SAVR). Comparisons of total episode expenditures, although largely ignored thus far, will be key to the value proposition for payers., Methods: We evaluated 6,359 Blue Cross Blue Shield of Michigan and Medicare fee-for-service beneficiaries undergoing TAVR (17 hospitals, n = 1,655) or SAVR (33 hospitals, n = 4,704) in Michigan between 2012 and 2016. Payments through 90 post-discharge days between TAVR and SAVR were price-standardized and risk-adjusted. Centers were divided into terciles of procedural volume separately for TAVR and SAVR, and payments were compared between lowest and highest terciles., Results: Payments (± SD) were higher for TAVR than SAVR ($69,388 ± $22,259 versus $66,683 ± $27,377, p < 0.001), while mean hospital length of stay was shorter for TAVR (6.2 ± 5.6 versus 10.2 + 7.5 days, p < 0.001). Index hospitalization payments were $4,374 higher for TAVR (p < 0.001), whereas readmission and post-acute care payments were $1,150 (p = 0.001) and $739 (p = 0.004) lower, respectively, and professional payments were similar. For SAVR, high-volume centers had lower episode payments (difference: 5.0%, $3,255; p = 0.01) and shorter length of stay (10.0 ± 7.5 versus 11.1 ± 7.9 days, p = 0.002) than low volume centers. In contrast, we found no volume-payment relationship among TAVR centers., Conclusions: Episode payments were higher for TAVR, despite shorter length of stay. Although not a driver for TAVR, center SAVR volume was inversely associated with payments. These data will be increasingly important to address value-based reimbursement in valve replacement surgery., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Previous work identified a direct relationship between frailty and adverse outcomes in cardiac surgery, but assessment of the effect across subgroups of patients has largely been ignored. This study identified whether the association of frailty (measured by gait speed) with adverse outcomes differed across subgroups of patients., Methods: The study evaluated 53,932 patients who underwent cardiac operations between 2011 and 2016 across 33 Michigan institutions. Five-meter gait speed (in seconds) was divided into groups: faster (<5.0 seconds), intermediate (5.0 to 5.99 seconds), and slower (≥6.0 seconds). The study used mixed logistic regression to estimate the relationship between increasing gait speed time and a patient's odds of major morbidity or mortality, by adjusting for patient-related demographics, disease characteristics, surgeon, and hospital. Effect modification by subgroup of patients and gait speed test time was tested with interaction terms. The study's secondary end point was an analysis of discharge disposition., Results: Nearly one fourth (22.7%) of patients had at least one gait speed test. Slower (34% of patients) versus faster (28%) patients were older (72.5 years vs 62.6 years), had more comorbidities, and had the primary outcome (16.6% vs 9.5%) (p < 0.0001). Significant interactions with gait speed existed for patients' comorbidities (chronic lung disease, atrial fibrillation, p < 0.05), although marginal interactions existed for patients' age (p = 0.059) and diabetes (p = 0.063). Slower patients were more often discharged to a facility rather than home., Conclusions: Slower gait speed was associated with increased odds of major morbidity or mortality. This effect was amplified among patients with preexisting comorbidities. Future studies should evaluate the impact of preprocedural interventions on frailty, including those aimed at addressing comorbidities., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Despite newer-generation valves using smaller-sized sheaths, 10% to 20% of patients undergoing transcatheter aortic valve replacement (TAVR) require nonfemoral artery access for valve delivery. To avoid a transthoracic procedure, we have used transcarotid (TC) and transcaval (TCav) approaches in these patients. This study compared the results of a contemporary experience with transfemoral (TF), TC, and TCav approaches., Methods: Between January 2015 and March 2017, 491 patients underwent TAVR at our institution, of which 463 were included in this analysis. Valve delivery was TF in 373 patients, TCav in 58, and TC in 32. Patient characteristics and outcomes, including 1-year survival, were compared., Results: Preoperative demographics and postoperative outcomes were similar for the three groups with several exceptions. TCav patients had higher The Society of Thoracic Surgeons risk score than TF patients (8.0 ± 5.2 vs 6.1 ± 4.3, p = 0.004). Lung disease, cerebrovascular disease, and peripheral vascular disease were more common in TC and TCav patients. Median length of stay was 2 days for TF, 3 days for TC, and 4 days for TCav (TF vs TCav, p = 0.001). Procedural mortality, percentage discharged home, and the 30-day readmission rate were similar for all. Unadjusted Kaplan-Meier survival was also similar at 1 year (TF, 86%; TC, 83%; TCav, 80%)., Conclusions: Patients unsuitable for TF TAVR treated with TC or TCav access had 30-day/in-hospital and 1-year survival similar to a contemporary cohort undergoing TF access. Avoiding surgical entry to the chest may offer procedural and intermediate-term outcomes equivalent to TF TAVR., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Through nearly 3 decades of iterative refinement, The Society of Thoracic Surgeons Adult Cardiac Surgery Database has evolved into one of the most comprehensive and respected clinical data registries in health care. It is a widely acknowledged exemplar for accurately benchmarking risk-adjusted outcomes in cardiac surgery and underpins all quality measurement and improvement activities of The Society of Thoracic Surgeons. This is the latest in a series of annual reports that outlines current national aggregate outcomes and volume trends in cardiac surgery and summarizes database-related work in quality measurement and performance improvement during the past year., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac valve disease is common in patients with end-stage heart failure undergoing left ventricular assist device implantation (LVAD). The aim of this study was to determine if preoperative mitral regurgitation (MR) affects outcomes and hemodynamics in patients after LVAD implantation., Methods: From March 2006 through May 2015, 238 consecutive patients underwent LVAD implantation. Patient cohorts included less than moderate to severe MR (< moderate-severe, n = 195) and greater than or equal to moderate to severe MR (≥ moderate-severe, n = 43). Demographics, operative characteristics, postoperative outcomes, hemodynamic and echocardiographic data, and resolution of MR were compared at 30 and 180 days post-LVAD., Results: Significant hemodynamic improvements were seen in central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, cardiac index, left ventricular ejection fraction, and left ventricular end-diastolic diameter, irrespective of preoperative MR severity. Significant resolution of MR occurred across both cohorts, with only 4 of 168 (2.4%) patients with ≥ moderate-severe MR at 180 days post-LVAD. There were no differences in complications or survival between MR severity cohorts postoperatively., Conclusions: LVAD implantation unloads the left ventricle to promote left ventricle reverse remodeling and correct functional MR across all severity levels. The resolution of MR is sustained at 180 days post-LVAD. These results coupled with no survival difference with uncorrected MR between < moderate-severe MR and ≥ moderate-severe MR makes concomitant mitral valve repair or replacement at the time of LVAD implantation unnecessary., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Although blood transfusions are common and have been associated with adverse sequelae after cardiac surgical procedures, few contemporaneous models exist to support clinical decision making. This study developed a preoperative clinical decision support tool to predict perioperative red blood cell transfusions in the setting of isolated coronary artery bypass grafting., Methods: We performed a multicenter, observational study of 20,377 patients undergoing isolated coronary artery bypass grafting among patients at 39 hospitals participating in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative's PERFusion measures and outcomes (PERForm) registry between 2011 and 2015. Candidates' preoperative risk factors were identified based on previous work and clinical input. The study population was randomly divided into a 70% development sample and a 30% validation sample. A generalized linear mixed-effect model was developed to predict perioperative red blood cell transfusion. The model's performance was assessed for calibration and discrimination. Sensitivity analysis was performed to assess the robustness of the model in different clinical subgroups., Results: Transfusions occurred in 36.8% of patients. The final regression model included 16 preoperative variables. The correlation between the observed and expected transfusions was 1.0. The risk prediction model discriminated well (receiver operator characteristic [ROC] development , 0.81; ROC validation , 0.82) and had satisfactory calibration (correlation between observed and expected rates was r = 1.00). The model performance was confirmed across medical centers and clinical subgroups., Conclusions: Our risk prediction model uses 16 readily obtainable preoperative variables. This model, which provides a patient-specific estimate of the need for transfusion, offers clinicians a guide for decision making and evaluating the effectiveness of blood management strategies., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Established in 1989, The Society of Thoracic Surgeons Adult Cardiac Surgery Database is one of the most comprehensive clinical data registries in health care. It is widely regarded as the gold standard for benchmarking risk-adjusted outcomes in cardiac surgery and is the foundation for all quality measurement and improvement activities of The Society of Thoracic Surgeons. This is the second in a series of annual reports that summarizes current aggregate national outcomes in cardiac surgery and reviews database-related activities in the areas of quality measurement and performance improvement during the past year., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The art and science of outcomes analysis, quality improvement, and patient safety continue to evolve, and cardiothoracic surgery leads many of these advances. The Society of Thoracic Surgeons (STS) National Database is one of the principal reasons for this leadership role, as it provides a platform for the generation of knowledge in all of these domains. Understanding these topics is a professional responsibility of all cardiothoracic surgeons. Therefore, beginning in January 2016, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides a summary of the status of the STS National Database as of October 2016 and summarizes the articles about the STS National Database that appeared in The Annals of Thoracic Surgery 2016 series, "Outcomes Analysis, Quality Improvement, and Patient Safety.", (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The incidence of atrial fibrillation (AF) among patients undergoing left ventricular assist device (LVAD) implantation is high. However, the impact of AF on clinical outcomes has not been clarified. We reviewed our 9-year experience of continuous flow (CF) LVADs to determine the impact of preoperative AF on stroke, device thrombosis, and survival., Methods: Between March 2006 and May 2015, 231 patients underwent implantation of 240 CF LVADs, 127 (52.9%) as bridge to transplantation and 113 (47.1%) as destination therapy. Effect of AF on postoperative outcomes was assessed by using Kaplan-Meier survival and Cox proportional hazard regression., Results: There were 78 patients (32.5%) with preoperative AF with a mean age of 55.7 ± 11.4 years. A similar incidence of stroke was found in patients with and without AF, 12.8% versus 16.0%, respectively (p = 0.803). Survival was similar, with 1-, 6-, 12-, and 24-month survivals of 96.2%, 91.7%, 84.5%, and 69.2%, respectively, for AF patients, versus 93.1%, 85.0%, 79.4%, and 74.1%, respectively, for non-AF patients (p = 0.424). Preoperative AF was not a significant independent predictor of survival with the use of Cox proportional hazard regression (hazard ratio 1.08, 95% confidence interval: 0.66 to 1.76)., Conclusions: Preoperative AF was associated with a similar incidence of postoperative stroke, device thrombosis, and survival. On the basis of these data, it seems unnecessary to perform a left atrial appendage ligation or to alter postoperative anticoagulation in patients with AF undergoing LVAD implantation., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Continuous-flow left ventricular assist devices (LVADs) have become the standard of care for patients with advanced heart failure. The goal of this study was to review our 9-year institutional experience., Methods: From March 2006 through May 2015, 231 patients underwent implantation of 240 CF LVADs, HeartMate II LVAD (Thoratec Corp., Pleasanton, CA; n = 205) or HVAD (HeartWare Inc., Framingham, MA; n = 35). Of these, 127 devices (52.9%) were implanted as bridge to transplantation (BTT) and 113 (47.1%) as destination therapy (DT)., Results: Mean age was 51.2 ± 11.9 years for BTT patients and 58.2 ± 11.4 years for DT patients (p < 0.001). There was a higher incidence of preoperative diabetes, renal insufficiency, peripheral vascular disease, and previous cardiac operation in DT patients (p < 0.05). Survival was higher for BTT patients, with 1-, 6-, 12-, and 24-month survivals of 91.0%, 90.0%, 88.5%, and 72.1%, respectively, versus 85.3%, 81.1%, 75.6%, and 59.0%, respectively, for DT patients (p = 0.038). Gastrointestinal bleeding was the most common complication (29.6%), followed by right ventricular failure (22.5%) and stroke (15.0%), with a similar incidence for BTT and DT patients. Preoperative liver biopsy (hazard ratio [HR] 2.27, p = 0.036), mechanical support (HR 1.82, p = 0.025), aspartate transaminase (HR 1.07, p = 0.001), and alanine aminotransferase (HR 0.95, p = 0.024) were severe independent predictors of survival in multivariate analysis., Conclusions: These data indicate excellent survival for BTT and DT patients on long-term LVAD support. However, for LVAD therapy to become a plausible alternative to heart transplantation, we need to further decrease the incidence of postoperative complications., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Postoperative pneumonia is the most prevalent of all hospital-acquired infections after isolated coronary artery bypass graft surgery (CABG). Accurate prediction of a patient's risk of this morbid complication is hindered by its low relative incidence. In an effort to support clinical decision making and quality improvement, we developed a preoperative prediction model for postoperative pneumonia after CABG., Methods: We undertook an observational study of 16,084 patients undergoing CABG between the third quarter of 2011 and the second quarter of 2014 across 33 institutions participating in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. Variables related to patient demographics, medical history, admission status, comorbid disease, cardiac anatomy, and the institution performing the procedure were investigated. Logistic regression through forward stepwise selection (p < 0.05 threshold) was utilized to develop a risk prediction model for estimating the occurrence of pneumonia. Traditional methods were used to assess the model's performance., Results: Postoperative pneumonia occurred in 3.30% of patients. Multivariable analysis identified 17 preoperative factors, including demographics, laboratory values, comorbid disease, pulmonary and cardiac function, and operative status. The final model significantly predicted the occurrence of pneumonia, and performed well (C-statistic: 0.74). These findings were confirmed through sensitivity analyses by center and clinically important subgroups., Conclusions: We identified 17 readily obtainable preoperative variables associated with postoperative pneumonia. This model may be used to provide individualized risk estimation and to identify opportunities to reduce a patient's preoperative risk of pneumonia through prehabilitation., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We characterized the midterm impact of transcatheter aortic valve replacement (TAVR) on surgical aortic valve replacement (SAVR) volume, patient profiles, and outcomes in Michigan., Methods: We analyzed data obtained after SAVR (n = 15,288) and TAVR (n = 1,783) using the Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative from 2006 to 2015. During this period, 17 of 33 hospitals developed TAVR programs., Results: Annual SAVR volume increased by 38.1% at TAVR hospitals and by 20.4% at non-TAVR hospitals, (p trend < 0.001). In TAVR hospitals, the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) decreased before (4.7% ± 5.1%) and after (3.5% ± 3.6%) initiation of TAVR (p < 0.001). Rates of 30-day mortality (pre-TAVR, 3.9% vs post-TAVR, 2.7%; p < 0.001) and renal failure (pre-TAVR, 5.2% vs post-TAVR, 3.3%; p < 0.001) but not stroke (pre-TAVR, 1.9% vs post-TAVR, 1.7%; p = 0.47) were lower after TAVR implementation. Length of stay decreased from 9.0 to 8.5 days (p < 0.001). When analyzing high-risk patients undergoing SAVR (ie, PROM >8%), neither mortality, stroke, nor renal failure was different (all p > 0.15). Despite a reduction in the STS-PROM, non-TAVR hospitals did not display changes in mortality, stroke, or renal failure for either the entire or the high-risk SAVR cohorts after initiation of TAVR in Michigan., Conclusions: TAVR implementation in Michigan has dramatically increased overall SAVR volume. This phenomenon has occurred with a concomitant decrease in preoperative risk profile and has improved early SAVR outcomes, particularly at TAVR hospitals, but surprisingly not in patients considered at high preoperative risk. As TAVR use increases, these issues may be further clarified and elucidated., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Society of Thoracic Surgeons Adult Cardiac Database is one of the longest-standing, largest, and most highly regarded clinical data registries in health care. It serves as the foundation for all quality measurement and improvement activities of The Society of Thoracic Surgeons. This report summarizes current aggregate national outcomes in adult cardiac surgery and reviews database-related activities in the areas of quality measurement and performance improvement., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Society of Thoracic Surgeons (STS) National Database is the foundation for most of the Society's quality, research, and patient safety activities. Beginning in January 2016 and repeating each year, The Annals of Thoracic Surgery will publish a monthly Database series of scholarly articles on outcomes analysis, quality improvement, and patient safety. Six articles will be directly derived from the STS National Database and will be published every other month: three articles on outcomes and quality (one each from the STS Adult Cardiac Surgery Database, the STS Congenital Heart Surgery Database, and the STS General Thoracic Surgery Database), and three articles on research (one from each of these three specialty databases). These six articles will alternate with five additional articles on topics related to patient safety. The final article, to be published in December, will provide a summary of the prior 11 manuscripts. This series will allow STS and its Workforces on National Databases, Research Development, and Patient Safety to convey timely information aimed at improving the quality and safety of cardiothoracic surgery., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Perioperative red blood cell transfusions (RBC) are associated with increased morbidity and mortality after cardiac surgery. Acute normovolemic hemodilution (ANH) is recommended to reduce perioperative transfusions; however, supporting data are limited and conflicting. We describe the relationship between ANH and RBC transfusions after cardiac surgery using a multi-center registry., Methods: We analyzed 13,534 patients undergoing cardiac surgery between 2010 and 2014 at any of the 26 hospitals participating in a prospective cardiovascular perfusion database. The volume of ANH (no ANH, <400 mL, 400 to 799 mL, ≥ 800 mL) was recorded and linked to each center's surgical data. We report adjusted relative risks reflecting the association between the use and amount of ANH and the risk of perioperative RBC transfusion. Results were adjusted for preoperative risk factors, procedure, body surface area, preoperative hematocrit, and center., Results: The ANH was used in 17% of the patients. ANH was associated with a reduction in RBC transfusions (RRadj [adjusted risk ratio] 0.74, p < 0.001). Patients having 800 mL or greater of ANH had the most profound reduction in RBC transfusions (RRadj 0.57, p < 0.001). Platelet and plasma transfusions were also significantly lower with ANH. The ANH population had superior postoperative morbidity and mortality compared with the no ANH population., Conclusions: There is a significant association between ANH and reduced perioperative RBC transfusion in cardiac surgery. Transfusion reduction is most profound with larger volumes of ANH. Our findings suggest the volume of ANH, rather than just its use, may be an important feature of a center's blood conservation strategy., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Reports have associated nadir hematocrit (Hct) on cardiopulmonary bypass with the occurrence of renal dysfunction. Recent literature has suggested that women, although more often exposed to lower nadir Hct, have a lower risk of postoperative renal dysfunction. We assessed whether this relationship held across a large multicenter registry., Methods: We undertook a prospective, observational study of 15,221 nondialysis-dependent patients (10,376 male, 68.2%; 4,845 female, 31.8%) undergoing cardiac surgery between 2010 and 2014 across 26 institutions in Michigan. We calculated crude and adjusted OR between nadir Hct during cardiopulmonary bypass and stage 2 or 3 acute kidney injury (AKI), and tested the interaction of sex and nadir Hct. The predicted probability of AKI was plotted separately for men and women., Results: Nadir Hct less than 21% occurred among 16.6% of patients, although less commonly among men (9.5%) than women (31.9%; p < 0.001). Acute kidney injury occurred among 2.7% of patients, with small absolute differences between men and women (2.6% versus 3.0%, p = 0.20). There was a significant interaction between sex and nadir Hct (p = 0.009). The effect of nadir Hct on AKI was stronger among male patients (adjusted odds ratio per 1 unit decrease in nadir Hct 1.10, 95% confidence interval: 1.05 to 1.13) than female patients (adjusted odds ratio 1.01, 95% CI: 0.96, 1.06)., Conclusions: Lower nadir Hct was associated with an increased risk of AKI, and the effect appears to be stronger among men than women. Understanding of the mechanism underlying this association remains uncertain, although these results suggest the need to limit exposure to lower nadir Hct, especially for male patients., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Pneumonia, a known complication of coronary artery bypass grafting (CABG), significantly increases a patient's risk of morbidity and mortality. Although not well characterized, red blood cell (RBC) transfusions may increase a patient's risk of pneumonia. We describe the relationship between RBC transfusion and postoperative pneumonia after CABG., Methods: A total of 16,182 consecutive patients underwent isolated CABG between 2011 and 2013 at 1 of 33 hospitals in the state of Michigan. We used multivariable logistic regression to estimate the relative odds of pneumonia associated with the use or number of RBC units (0, 1, 2, 3, 4, 5, and ≥ 6). We adjusted for predicted risk of mortality, preoperative hematocrit values, history of pneumonia, cardiopulmonary bypass duration, and medical center. We confirmed the strength and direction of these relationships among selected clinical subgroups in a secondary analysis., Results: Five hundred seventy-six (3.6%) patients had pneumonia and 6,451 (39.9%) received RBC transfusions. There was a significant association between any RBC transfusion and pneumonia (adjusted odds ratio [ORadj], 3.4; p < 0.001). There was a dose response between number of units and odds of pneumonia, with a ptrend less than 0.001. Patients receiving only 2 units of RBCs had a 2-fold (ORadj, 2.1; p < 0.001) increased odds of developing pneumonia. These findings were consistent across clinical subgroups., Conclusions: We found a significant volume-dependent association between an increasing number of RBCs and the odds of pneumonia, which persisted after risk adjustment. Clinical teams should explore opportunities for preventing a patient's risk of RBC transfusions, including reducing hemodilution or adopting a lower transfusion threshold in a stable patient., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: With the introduction of version 2.73, several new patient risk factors are now captured in The Society of Thoracic Surgeons' (STS) Adult Cardiac Surgery Database. We sought to evaluate the potential association of these risk factors with mortality., Methods: We reviewed all patients with an STS predicted risk of mortality in our statewide quality collaborative database from July 2011 to September 2013 (N = 19,743). Univariate analyses were used to determine significant associations between mortality and the new risk factors in version 2.73. We then performed multivariable analysis, incorporating the STS predicted risk of mortality into our regression., Results: In the univariate model, patients with illicit drug use, syncope, unresponsive neurologic state, cancer within the last 5 years, current smoking history, other tobacco use, or sleep apnea had no significant difference in mortality (p > 0.05). Patients with liver disease, elevated Model for End-Stage Liver Disease score, mediastinal radiation, prolonged 5-meter walk test, home oxygen use, inhaled medications or bronchodilator therapy, decreased forced expiratory volume, and history of recent pneumonia had significant increases in operative mortality (p < 0.05). In multivariable analysis incorporating the STS predicted risk models, liver disease, elevated Model for End-Stage Liver Disease score, prolonged 5-meter walk test, home oxygen use, bronchodilator therapy, and abnormal pulmonary function tests were independently predictive of mortality., Conclusions: Several of the new STS data variables were significantly associated with operative mortality after cardiac surgery. The addition of these patient factors improves our understanding of evolving patient demographics and comorbid conditions and their impact on perioperative risk. This will improve both shared decision making and assessments of provider performance., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Prior studies have implicated transfusion as a risk factor for mortality in coronary artery bypass graft surgery (CABG). To further our understanding of the true association between transfusion and outcome, we specifically analyzed the subgroup of patients who died after undergoing CABG., Methods: A total of 34,362 patients underwent isolated CABG between January 2008 and September 2013 and were entered into a statewide collaborative database; 672 patients (2.0%) died and form the basis for this study. Univariate analysis compared preoperative and intraoperative variables, as well as postoperative outcomes, between those with and without transfusion in both unadjusted cohorts and those matched by predicted risk of mortality (PROM). Mortality was further evaluated with phase of care analysis., Results: Of the 672 deaths, 566 patients (84.2%) received a transfusion of red blood cells. The PROM was 7.5% for the transfused patients versus 4.3% for those not transfused (p < 0.001). Transfused patients were older, more often female, had more emergency, on-pump, and redo procedures, and had a lower preoperative and on-bypass nadir hematocrit. Most other demographics were similar between the groups. Postoperatively, transfused patients were ventilated longer, had more renal and multisystem organ failure, and were more likely to die of infectious and pulmonary causes after longer intensive care unit and overall lengths of stay., Conclusions: Significant differences in PROM and the postoperative course leading to death between those with and without transfusion suggest the role of transfusion may be secondary to other patient-related factors. Recognizing that the relationship between transfusion and outcome after CABG remains incompletely understood, these findings are suggestive of a complex interaction of many variables., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Off-pump coronary bypass surgery (CABG) has been advocated to avoid the physiologic perturbations related to cardiopulmonary bypass and improve outcomes compared with on-pump CABG. Previous reports have been inconsistent, and thus its benefits remain uncertain. This retrospective study compared outcomes between on-pump and off-pump CABG from a large multicenter cohort of propensity-matched patients., Methods: The study consisted of 21,640 patients (19,639 [90.8%] on-pump, 2,001 [9.2%] off-pump) who underwent isolated CABG between January 1, 2008, and June 30, 2011, and were entered into a statewide collaborative database. Univariate analysis compared 37 baseline characteristics between on-pump and off-pump procedures. Patients were matched 1:1 based on similarities in propensity scores derived from statistically significant baseline characteristics. Propensity scores and surgery type were used in conditional logistic regression models for predicting each of 14 postoperative outcomes using the sample of 3,898 matched procedures., Results: Patients undergoing off-pump CABG had significantly fewer complications overall, including decreased red blood cell transfusion, stroke, intensive care unit and ventilator time, reoperation for bleeding, and length of stay. There was no difference in renal failure, wound infection, discharge location, or 30-day readmission rate. Although off-pump patients received fewer bypass grafts per patient (2.5 ± 1.2 versus 3.0 ± 1.1; p < 0.001), operative mortality was similar for the two groups (1.8% on-pump versus 2.3% off-pump; p = 0.30)., Conclusions: Off-pump CABG was associated with less morbidity, shorter length of stay, and similar mortality compared with on-pump procedures, suggesting that it can be a safe and effective alternative to standard on-pump CABG. However, the limited use of off-pump CABG in this multicenter analysis may restrict the generalizability of these results, and realistically defines the limited degree of acceptance of this technique in a real-world environment., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study examined the relationship between transfusion of 1 or 2 units of red blood cells (RBCs) and the risk of morbidity and mortality after isolated on-pump coronary artery bypass grafting (CABG)., Methods: A total of 22,785 consecutive patients underwent isolated on-pump CABG between January 1, 2008, and December 31, 2011 in Michigan. We excluded 5,950 patients who received three or more RBC units. Twenty-one preoperative variables significantly associated with transfusion by univariate analysis were included in a logistic regression model predicting transfusion, and propensity scores were calculated. Transfusion and the propensity score covariate were included in additional logistic regression models predicting mortality and each of 11 postoperative outcomes., Results: Operative mortality for the study cohort of 16,835 patients was 0.8% overall, 0.5% for the 10,884 patients with no transfusion, and 1.3% for the 5,951 patients who received transfusion of 1 or 2 units (odds ratio 2.44; confidence interval 1.74 to 3.42; p < 0.0001). The association between transfusion and mortality lessened after propensity adjustment but remained highly significant (odds ratio 1.86; confidence interval 1.21 to 2.87; p = 0.005). Of the 11 postoperative outcomes studied, all but sternal wound infection and need for dialysis were also significantly associated with transfusion., Conclusions: Transfusion of as little as 1 or 2 units of RBCs is common and is significantly associated with increased morbidity and mortality after on-pump CABG. The relationship persists after adjustment for preoperative risk factors. These results suggest that aggressive attempts at blood conservation and avoidance of even small amounts of RBC transfusion may improve outcomes after CABG., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Between January 2008 and December 2012, a multicenter quality collaborative initiated a focus on blood conservation as a quality metric, with educational presentations and quarterly reporting of institutional-level perioperative transfusion rates and outcomes. This prospective cohort study was undertaken to determine the effect of that initiative on transfusion rates after isolated coronary artery bypass grafting (CABG)., Methods: Between January 1, 2008, and December 31, 2012, 30,271 patients underwent isolated CABG in Michigan. Evaluated were annual crude and adjusted trends in overall transfusion rates for red blood cells (RBCs), fresh frozen plasma (FFP), and platelets, and in operative death., Results: Transfusion rates continuously decreased for all blood products. RBC use decreased from 56.4% in 2008 (baseline) to 38.3% in 2012, FFP use decreased from 14.8% to 9.1%, and platelet use decreased from 20.5% to 13.4% (ptrend < 0.001 for all). A significant reduction occurred in deep sternal wound infection, reoperation for bleeding, renal failure, prolonged ventilation, initial ventilator time, and intensive care unit duration. The percentage of patients discharged home significantly increased (ptrend < 0.001). Mortality rates did not differ significantly (ptrend = 0.11)., Conclusions: In a multicenter quality collaborative, increased attention to transfusion-related outcomes and blood conservation techniques, coincident with regular reporting and review of perioperative transfusion rates as a quality metric, was associated with a significant decrease in blood product utilization. These reductions were concurrent with significant improvement in most perioperative outcomes. This intervention was also safe, as it was not associated with any increases in mortality., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In the setting of a statewide quality collaborative approach to the review of cardiac surgical mortalities in intensive care units (ICUs), variations in complication-related outcomes became apparent. Utilizing "failure to rescue" methodology (FTR; the probability of death after a complication), we compared FTR rates after adult cardiac surgery in low, medium, and high mortality centers from a voluntary, 33-center quality collaborative., Methods: We identified 45,904 patients with a Society of Thoracic Surgeons predicted risk of mortality who underwent cardiac surgery between 2006 and 2010. The 33 centers were ranked according to observed-to-expected ratios for mortality and were categorized into 3 equal groups. We then compared rates of complications and FTR., Results: Overall unadjusted mortality was 2.6%, ranging from 1.5% in the low-mortality group to 3.6% in the high group. The rate of 17 complications ranged from 19.1% in the low group to 22.9% in the high group while FTR rates were 6.6% in the low group, 10.4% in the medium group, and 13.5% in the high group (p < 0.001). The FTR rate was significantly better in the low mortality group for the majority of complications (11 of 17) with the most significant findings for cardiac arrest, dialysis, prolonged ventilation, and pneumonia., Conclusions: Low mortality hospitals have superior ability to rescue patients from complications after cardiac surgery procedures. Outcomes review incorporating a collaborative multi-hospital approach can provide an ideal opportunity to review processes that anticipate and manage complications in the ICU and help recognize and share "differentiators" in care., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Deteriorating renal function is common in patients with advanced heart failure and is associated with poor outcomes. The relationship between renal function and left ventricular assist device (LVAD) implantation is complex and has been explored in multiple studies with contradictory results. The aim of our study is to examine the significance of postoperative renal failure after implantation of a continuous-flow LVAD and its relationship to outcomes., Methods: From March 2006 to July 2011, 100 patients underwent implantation of a HeartMate II (Thoratec Corp, Pleasanton, CA) or HeartWare (Heart International, Inc, Framingham, MA) LVAD at our institution. Patients were stratified based on postoperative development of acute renal failure (ARF). Variables were compared using 2-sided t tests, χ(2) tests, Cox proportional hazards models, and log-rank tests to determine whether there was a difference between the 2 groups and whether postoperative renal failure was a significant independent predictor of outcome., Results: We identified 28 patients (28%) with postoperative ARF and 72 patients (72%) without postoperative ARF. The 2 groups were similar with regard to demographics and comorbidities. The patients with ARF were more likely to be intubated preoperatively (14.3% versus 1.4%; p = 0.021) and had higher preoperative central venous pressure (CVP) (14.3 mm Hg versus 10.7 mm Hg; p = 0.015). Postoperatively patients with ARF had a longer hospital stay (32.4 versus 18.7; p = 0.05), were more likely to experience right ventricular (RV) failure (25% versus 5.6%; p = 0.01) and ventilator-dependent respiratory failure (VDRF) (28.6% versus 6.9%; p = 0.007). There was a significant difference when comparing the ARF and non-ARF groups for 30-day (17.9% versus 0%; p < 0.001), 180-day (28.6% versus 2.8%; p < 0.001), and 360-day mortality (28.6% versus 6.9%; p = 0.012)., Conclusions: Patients in whom ARF developed after LVAD implantation had a higher rate of VDRF and RV failure and a longer length of stay (LOS). Postoperative ARF was associated with higher mortality at the 30-day, 180-day, and 360-day intervals. ARF after LVAD may be an early marker of poor outcome, particularly RV failure, and may be an opportunity for early intervention and rescue., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Continuous flow (CF) left ventricular assist devices (LVADs) have yielded improved outcomes in patient survival and quality of life compared with first-generation pulsatile pumps; however, they have been associated with an increased incidence of postimplant aortic valve insufficiency (AI), which can have can have serious clinical consequences if not diagnosed and treated expeditiously. We reviewed our experience with AI after LVAD since the start of our CF LVAD program. From March 2006 through July 2011, 94 patients with chronic heart failure underwent implantation of a HeartMate II (HM II) LVAD. Severe AI developed in three patients after CF LVAD implantation. The clinical records of these patients were reviewed to analyze the presenting signs and symptoms of AI, identify the duration of LVAD support when the AI occurred, how the AI was treated, and the outcomes., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of this study was to define the potential for long-term survival with severe left ventricular dysfunction after coronary bypass and to quantify any improvement in overall functional status., Methods: Left ventricular dysfunction was confirmed preoperatively and the long-term survival and functional outcome after bypass was determined by follow-up studies obtained during the span of a decade., Results: From 1/1990 to 12/1999, 86 patients with severe left ventricular dysfunction (mean ejection fraction, 0.18 +/- 0.03; range, 0.10 to 0.20) underwent coronary artery bypass grafting. There were 10 perioperative deaths (11% mortality). The mean survival was 55 months (standard deviation +/- 34 months; range, 2 to 141 months) with an actual 5-year survival rate of 59% (actuarial 5-year 65%, 10-year 33%). Echocardiography obtained between 1 and 6 months, 6 months and 1 year, 1 and 2 years, 2 and 4 years, 4 and 6 years, and 6 and 11 years showed the ejection fraction improved to 0.29 +/- 0.08 (p < 0.001), 0.31 +/- 0.14 (p < 0.002), 0.35 +/- 0.08 (p < 0.001), 0.27 +/- 0.10 (p = 0.002), 0.36 +/- 0.14 (p = 0.004), and 0.30 +/- 0.11 (p = 0.004), respectively. At 1 to 6 months, 6 months to 1 year, and 1 to 2 years, the diastolic left ventricular dimension was unchanged, but the systolic left ventricular dimension decreased significantly from 5.02 +/- 0.77 cm to 4.26 +/- 0.91 cm (p = 0.046), 3.98 +/- 1.43 cm (p = 0.08), and 4.10 +/- 1.14 cm (p = 0.07). The preoperative New York Heart Association classification for all patients improved from 2.8 +/- 0.8 to 1.6 +/- 0.7 (p < 0.001) after a mean of 53 months (standard deviation +/- 34 months)., Conclusions: Patients with severe left ventricular dysfunction can derive long-term benefit from coronary bypass through improved left ventricular contractility as documented by a significantly decreased systolic left ventricular dimension and increased ejection fraction. Successful bypass is associated with a 59% actual 5-year survival rate and significantly improved New York Heart Association functional class.

Background: We examined the effects of passive containment of the cardiac ventricles with a surgically placed epicardial prosthetic wrap on indexes of left ventricular (LV) remodeling in dogs with heart failure., Methods: Heart failure (LV ejection fraction 30% to 40%) was produced in 12 dogs by intracoronary microembolization. Six dogs underwent mid-sternotomy and pericardiotomy with placement of a preformed-knitted polyester device (Acorn Cardiac Support Device [CSD], Acorn Cardiovascular, Inc, St. Paul, MN) snugly around the ventricles and anchored to the atrioventricular groove. Six dogs did not undergo surgery and served as controls. Dogs were followed for 3 months prior to sacrifice., Results: In controls, LV end-diastolic volume increased after 3 months (67 +/- 12 versus 83 +/- 8 ml; p = 0.04), while in CSD-treated dogs, it decreased (68 +/- 10 versus 61 +/- 10 ml; p = 0.002). CSD-containment of LV size was associated with increased LV systolic fractional area of shortening, while in controls, fractional area of shortening decreased. CSD-treated dogs also showed amelioration of myocyte hypertrophy and attenuation of interstitial fibrosis compared to controls., Conclusions: In dogs with heart failure, passive epicardial containment of the ventricles with the Acorn CSD ameliorates LV remodeling and improves LV systolic function.

As more high-risk patients undergo percutaneous transluminal coronary angioplasty (PTCA), the changing profiles of PTCA patients who may require emergent coronary artery bypass grafting may alter operative morbidity and mortality. This study compared profiles of recent patients undergoing emergent coronary artery bypass grafting after a failed PTCA with earlier patients to determine their impact on operative results. From 1980 to 1988, 53 patients underwent emergent coronary artery bypass grafting after a failed PTCA at the Boston University Medical Center. These patients were divided into two groups based on the year of the PTCA: group I, 1980 to 1985 (n = 18); and group II, 1986 to 1988 (n = 35). Group II patients tended to be older (age greater than or equal to 65 years, 47% group II versus 11% group I), were more likely to have unstable angina before PTCA (74% versus 33%), and had lower ejection fractions (0.53 +/- 0.02 versus 0.63 +/- 0.05) and more vessels with 50% or greater stenosis (2.1 +/- 0.2 versus 1.6 +/- 0.2). Nevertheless, there was no significant difference in the incidence of perioperative myocardial infarcts using enzyme and electrocardiographic criteria (37% in group II versus 39% in group I), 30-day operative mortality (11% in group II versus 11% in group I), or major postoperative complications (14% in group II versus 22% in group I). We conclude that despite the changing profiles of patients undergoing PTCA, which include older patients with more extensive coronary artery disease and lower ejection fractions, operative results after emergent coronary artery bypass grafting for failed PTCAs remain unchanged.