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Machine learning may enhance prediction of outcomes after coronary artery bypass grafting (CABG). We sought to develop and validate a dynamic machine learning model to predict CABG outcomes at clinically relevant pre- and postoperative time points.The Society of Thoracic Surgeons (STS) registry data elements from 2086 isolated CABG patients were divided into training and testing datasets and input into Extreme Gradient Boosting decision-tree machine learning algorithms. Two prediction models were developed based on data from preoperative (80 parameters) and postoperative (125 parameters) phases of care. Outcomes included operative mortality, major morbidity or mortality, high cost, and 30-day readmission. Machine learning and STS model performance were assessed using accuracy and the area under the precision-recall curve (AUC-PR).Preoperative machine learning models predicted mortality (accuracy, 98%; AUC-PR = 0.16; F1 = 0.24), major morbidity or mortality (accuracy, 75%; AUC-PR = 0.33; F1 = 0.42), high cost (accuracy, 83%; AUC-PR = 0.51; F1 = 0.52), and 30-day readmission (accuracy, 70%; AUC-PR = 0.47; F1 = 0.49) with high accuracy. Preoperative machine learning models performed similarly to the STS for prediction of mortality (STS AUC-PR = 0.11; P = .409) and outperformed STS for prediction of mortality or major morbidity (STS AUC-PR = 0.28; P.001). Addition of intraoperative parameters further improved machine learning model performance for major morbidity or mortality (AUC-PR = 0.39; P.01) and high cost (AUC-PR = 0.64; P.01), with cross-clamp and bypass times emerging as important additive predictive parameters.Machine learning can predict mortality, major morbidity, high cost, and readmission after isolated CABG. Prediction based on the phase of care allows for dynamic risk assessment through the hospital course, which may benefit quality assessment and clinical decision-making.

Background The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures. Methods Using July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration. Results C-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample. Conclusions New STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.

Background Cardiothoracic surgery is one of the more highly litigated medical specialties, and coronary artery bypass grafting (CABG) constitutes a substantial portion of cardiothoracic surgery cases. Therefore, understanding litigations relating to CABG would be of benefit to surgeons working to uphold the standards of care that their patients seek and minimize their own legal liability. This study analyzed CABG litigations to identify predictive factors of litigation and verdict type. Methods This study utilized the Westlaw legal database to compile litigations from 1994-2019 across the United States, and resulted in 307 total litigations. After individual screening, 211 litigations met the criteria for inclusion, and were analyzed for demographic, clinical, chronological, and verdict characteristics. Results Litigations were present in 33 US states, with California, New York, and Florida having the most litigations. Defendant verdicts were reached in 67.78% of litigations, followed by 20.38% of plaintiff verdicts, and 11.85% of settlements. Plaintiff verdicts were associated with the incidence of myocardial infarction during hospitalization. The winter season had the most litigations (42.18%), and the most defendant verdicts (37.76%). Patient mortality occurred in 47.39% of litigations. The most common alleged reason for litigation was a procedural error (55.45%). Conclusions Defendant verdicts were significantly associated with an alleged reason of procedural errors, an alleged reason of a failure to monitor, and congestive heart failure present in patients. The common nature of defendant verdicts, and the significantly greater occurrence of defendant verdicts during the highly litigated winter season, suggest that surgeons frequently satisfy the legal standard of care.

BACKGROUND Medicaid expansion (ME) under the Affordable Care Act has reduced the number of uninsured patients, although its preferential effects on vulnerable populations have been mixed. This study examined whether ME preferentially improved cardiac surgery use by insurance strata, race, and income level. METHODS Non-elderly adults (aged 18-64 years) who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or mitral valve repair were identified in the State Inpatient Databases for 3 expansion states (Kentucky, New Jersey, and Maryland) and 2 non-expansion states (North Carolina and Florida) from 2012 to the third quarter of 2015. We used adjusted Poisson interrupted time series to determine the impact of ME on cardiac surgery use for Medicaid or uninsured (MCD/UIS) patients, racial and ethnic minorities, and individuals from low-income areas. RESULTS In expansion states, use among non-White MCD/UIS patients had a positive trend after ME (2.3%/quarter; P = .156), whereas use for White MCD/UIS patients fell (-1.7%/quarter; P = .117). In contrast, use among non-White MCD/UIS in non-expansion states decreased by 4.4% (P < .001) which was a greater decline than among White MCD/UIS patients (-1.8%/quarter; P = .057). There was no substantial effect of ME on cardiac surgery use for MCD/UIS patients from low- versus high-income areas. CONCLUSIONS These findings demonstrate that the use of cardiac surgical procedures was generally unchanged after ME; however, nonsignificant trend differences suggest a narrowing gap between vulnerable and non-vulnerable groups in ME states. These preliminary findings help describe the association of insurance coverage as a driver of cardiac surgery use among vulnerable patients.

Background The current representation of female patients and racial and ethnic minorities in cardiovascular trials is unclear. We evaluated these groups’ inclusion in U.S. cardiovascular trials. Methods Using publicly available data from ClinicalTrials.gov , we evaluated cardiovascular trials pertaining to coronary artery bypass grafting (CABG), heart valve disease, aortic aneurysm, ventricular assist devices, and heart transplantation. This yielded 178 U.S. trials (159 completed, 19 active but not recruiting) started between September 1998 and May 2017, with 237,132 participants. To examine female patients’ and racial and ethnic minorities’ representation in these trials, we calculated participation-to-prevalence ratios (PPRs). Values of 0.8 to 1.2 reflect similar representation. Results All 178 trials reported sex distribution, whereas only 76 (42.7%) trials reported racial distribution and 52 (29.2%) trials reported ethnic (Hispanic vs non-Hispanic) distribution. Among all trials, participants were 28.3% female, 11.2% were Hispanic/Latino, 4.0% were African American, 10.4% were Asian, and 2.3% were other. The CABG PPR for female patients was 0.64, for Hispanic patients was 0.72, for African American patients was 0.28, and for Asian patients was 3.20. Between 2008-2012 and 2013-2017, the CABG PPR decreased for female patients (0.67→0.50) and African American patients (0.37→0.17) but increased for Hispanic patients (0.38→1.32) and Asian patients (3.51→4.57). Conclusions Participation in cardiovascular trials by female patients and minorities (except Asian patients) remains low. Given that inherent differences among the previously mentioned groups could affect outcomes, balance is clearly needed. The engagement of our surgical leadership, community, and industry to address these disparities is vitally important.

Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. Using administrative coding, we evaluated the impact of frailty on in-hospital death, complications, and resource use in a nationally representative cohort of patients undergoing isolated coronary artery bypass grafting (CABG).Patients aged 18 years and older who underwent isolated CABG across the United States were identified using the 2005 to 2016 National Inpatient Sample. Frailty was defined using a derivative of the validated Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Mortality, length of stay, inflation-adjusted costs, and postoperative complications were evaluated using multilevel multivariable regression.Of an estimated 2,137,618 patients undergoing isolated CABG, 85,879 (4.0%) were considered frail. The proportion of frail patients increased over the study period (nonparametric test for trend P = .002), while annual mortality rates declined (nonparametric test for trend P.001). Frail patients were older (68.9 ± 10.7 years vs 65.0 ± 10.6 years, P.001), and more commonly female (32.8% vs 26.2%, P.001). After adjustment, frailty was associated with increased odds of in-hospital death (adjusted odds ratio [AOR], 2.49; 95% confidence interval [CI], 2.30-2.70; P.001), major complications (AOR, 2.55; 95% CI, 2.39-2.71; P.001), increased length of stay (AOR, 1.40; 95% CI, 1.09-2.11; P.001), and costs (AOR, 1.03; 95% CI, 1.02-1.07; P.001).Frailty, as identified by administrative coding, serves as a strong independent predictor of death and complications after CABG. Incorporation of frailty into risk models may aid in counseling patients about operative risk and benchmarking outcomes.

The efficacy of coronary artery bypass grafting for pregnancy-related spontaneous coronary artery dissection (SCAD) is controversial, as graft occlusion due to SCAD lesion healing has been reported. Only 24 grafts in 14 cases of coronary artery bypass grafting for SCAD have been reported: 8 of the 9 arterial grafts were occluded, but 9 of the 15 vein grafts were patent. We encountered a case of coronary artery bypass grafting with left internal thoracic artery to the left antero-descending branch due to pregnancy-related SCAD. The patient’s graft revealed good patency immediately postoperatively but string signs 7 months later due to healing of SCAD lesions.

Background The role of simulation-based training in coronary artery bypass grafting remains undefined. Barriers to simulator use include clinical and personal obligations, insufficient materials, and lack of mentorship. The purpose of this study was to implement a longitudinal, residency-wide coronary anastomosis simulation curriculum. Methods A prospective observational study was conducted from 2018 to 2019 at a single academic center. All residents of the Thoracic Surgery training program participated. Each participant was provided a low-fidelity coronary anastomosis simulator, high-quality instruments, and faculty mentor. Formal assessments were held quarterly, and residents were encouraged to practice alone and with their mentor. Baseline and follow-up metrics were compared with simple descriptive statistics. Results Seventeen residents and 12 faculty participated in the study. Residents demonstrated increased use of the simulator, with 21% participating in independent practice at baseline and 82% in the fourth quarter (P = .02). The median score on the Thoracic Surgery Directors Association Vessel Anastomosis Assessment improved from 42 out of 65 at baseline to 54 out of 65 in the fourth quarter (P = .04), and mean anastomosis time was reduced by 5 minutes 6 seconds (P = .02). Over 12 months, junior residents demonstrated a mean reduction in anastomosis time of 6 minutes 36 seconds, and senior residents decreased anastomosis time by 3 minutes 6 seconds (P = .02). Conclusions Providing residents with a low-fidelity coronary anastomosis trainer with high-quality instruments and a faculty mentor improved rates of independent practice, Thoracic Surgery Directors Association assessment scores, and anastomosis time. Our next step is validating the coronary simulator curriculum by measuring improvement of resident performance in the operating room.

The use of the bilateral internal mammary artery (BIMA) in coronary artery bypass grafting remains controversial. The objective of this study was to investigate the long-term outcomes using the BIMA vs the single internal mammary artery (SIMA) in the United States.Medicare beneficiaries who underwent primary isolated coronary artery bypass surgery using the SIMA or BIMA from 1999 to 2010 were included in this retrospective study, with follow-up through 2014. Greedy matching algorithms were used for 1:4 matching on propensity score based on age, gender, year of surgery, and comorbidities. Kaplan-Meier survival analyses were performed. The primary outcome was death from any cause.A total of 1,156,339 and 25,005 patients who were 72 ± 7.6 years of age and 70.3 ± 7.9 years of age underwent primary isolated coronary artery bypass surgery using SIMA and BIMA, respectively. Matching created comparable groups with 95,780 SIMA and 24,160 BIMA patients. Matched median survival using SIMA vs BIMA was 11.8 vs 12.4 years (P.001) and 9.6 vs 10 years in diabetic patients (P = .006), respectively. At 10 years of follow-up, the respective survival rates of using SIMA vs BIMA were 58.3% vs 61.1%, respectively. The stratified matched median survival using SIMA vs BIMA with 1, 2, 3, and 4 or more aortocoronary bypasses were 11.8 vs 12.3 years (P = .005), 11.7 vs 12.5 years (P.001), 11.9 vs 12.3 years (P = .01), and 11.4 vs 12 years (P = .02), respectively.Primary isolated coronary artery bypass surgery using the BIMA rather than the SIMA was associated with improved long-term survival. This survival advantage was independent of aortocoronary bypass grafts or patient diabetes status.

Social determinants of health, including neighborhood socioeconomic status (NSES), are increasingly being associated with disparate outcomes in those undergoing cardiac procedures. The objective of this study was to determine the effect of NSES on outcomes after coronary artery bypass grafting (CABG).Adults undergoing isolated CABG between July 2011 and December 2017 were retrospectively reviewed. Neighborhood median household income (NMI) and neighborhood high school graduation rate (NHS) were obtained by individual patient ZIP code from the American FactFinder Database. Primary outcome was 5-year all-cause mortality stratified by NMI quartile. Secondary end points included mortality risk by NHS, freedom and frequency of readmission, and mortality and readmission predictors.During the study period, 5243 patients underwent CABG. Increasing NMI quartile was associated with increasing age, male sex, white race, decreased diabetes prevalence, decreased active smoker status, and decreased lung disease (all P.05). Although no difference in 30-day mortality was observed, lower NMI quartiles were associated with increased longitudinal mortality through 5 years (log-rank P.01). Lower NMI quartile was associated with increased blood transfusions and sternal wound infections. Multivariable modeling demonstrated multiple complex associations between socioeconomic status variables (race, sex, age, NMI, and NHS) for mortality and readmission.NSES affects longer-term outcomes after CABG. Patient-focused NSES interventions and incorporation of NSES variables into prediction models may improve prediction and outcomes after CABG.

Reoperative coronary artery bypass grafting (CABG) surgery has an established increased operative risk with worse perioperative morbidity and mortality. However, contemporary propensity-matched outcomes are limited in the existing literature.All patients who underwent CABG from 2011 to 2017 at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania were included. Propensity matching yielded risk-adjusted patient populations. Cox regression analysis was performed to identify independent predictors of 30-day, 1-year, and 5-year mortality and readmission.The total population consisted of 7615 patients who underwent CABG; 7265 of these patients had first-time CABG, and 350 patients had reoperative CABG. After propensity score matching, blood product transfusion (45.5% vs 56.4%; P = .002) and delayed sternal closure (0.2% vs 2.5%; P.001) remained significantly higher for reoperative CABG. There was no difference in 30-day (5.3% vs 7.5%; P = .19) or 1-year (12.1% vs 14.8%; P = .23) mortality for first-time vs reoperative CABG. Five-year mortality was significantly higher for the reoperative cohort (28.5% vs 38.3%; P = .03). There was no difference in 30-day, 1-year, or 5-year hospital readmissions. On Cox multivariable regression analysis, reoperative CABG was not a predictor of mortality or readmission at 30 days, 1 year, or 5 years.After propensity score matching, there was no difference in postoperative mortality or readmission for reoperative CABG up to 1-year. This trend continued for 5-year readmissions; however, 5-year mortality was higher for the reoperative cohort. Risk adjustment did not identify reoperative CABG as a risk factor for long-term mortality.

Tricuspid regurgitation (TR) is associated with poor outcomes after cardiac surgery. Guidelines recommend correction of severe TR in patients undergoing left-sided valve surgery but not coronary artery bypass graft surgery (CABG). We sought to evaluate impact of TR on outcomes after CABG.All patients (n = 28,027) undergoing CABG in The Society of Thoracic Surgeons (STS) regional database (2011 to 2018) were stratified by TR severity. Primary outcomes included major morbidity or mortality, which were compared using univariate analysis.Of patients undergoing CABG, 4837 (17%) had mild, 800 (3%) had moderate, and 81 (0.29%) had severe TR. Increased severity was associated with higher rate of preoperative heart failure (none 5162 [23.4%] vs mild 1697 [35%] vs moderate 427 [53%] vs severe 54 [67%], P.001] and STS predicted risk of mortality (1.0 [0.6 to 1.9) vs 1.4 [0.8 to 2.9] vs 2.8 [1.4 to 5.4] vs 6.2 [2.2 to 11.4], P.001). Increasing severity was associated with higher postoperative rate of renal failure (426 [1.9%] vs 145 [3%] vs 58 [7.3%] vs 7 [8.6%], P.001), prolonged ventilation (1652 [7.5%] vs 495 [10.2%] vs 153 [19.1%] vs 22 [27.2%], P.001), and mortality (344 [1.6%] vs 132 [2.7%] vs 58 [7.3%] vs 9 [11.1%], P.001). After risk adjustment, mild, moderate, and severe TR remained associated with increased morbidity and mortality (all P.05).Increasing TR severity, although independently associated with higher surgical risk, is not accounted for entirely by STS risk calculator. This highlights the importance of TR on operative risk and supports consideration of concurrent tricuspid intervention for patients with significant TR undergoing CABG.

In patients with myocardial bridges (MBs) and insufficient medical management, the optimal surgical strategy remains undetermined. Based on computer simulations we developed a novel procedure, MB bypass grafting, that showed better hemodynamics compared with coronary artery bypass grafting in a simulation study. In this novel procedure the left internal mammary artery was used to connect the proximal and distal ends of the MB. For the first time we used MB bypass grafting to treat a patient with extensive MB. The patient recovered well after surgery, and the left internal mammary artery graft remained patent 3 months postoperatively.

Background Learning curves and skill attrition with aging have been reported to impair outcomes in select surgical subspecialties, but their role in complex cardiac surgery remains unknown. Methods From 1986 to 2019, 2314 patients underwent reoperative cardiac surgery: coronary artery bypass grafting (n = 543), valve (n = 1527), or combined coronary artery bypass grafting and valve (n = 244). Thirty-four different surgeons in practice between 1 and 39 years were included. Standardized mortality ratio (observed-to-expected) was determined for all surgeons in each post-training year of experience. Results Risk-adjusted cumulative sum change-point analysis was used to define five distinct career phases: 0 to 4 years, 5 to 8 years, 9 to 17 years, 18 to 28 years, and 29 to 39 years. With 5 to 8 years and 18 to 28 years of experience, standardized mortality ratio was near unity (0.95 and 1.05, respectively) and lowest with 9 to 17 years of experience (0.78, P = .03). In the youngest experience group (0 to 4 years), observed and expected mortality were both highest, and standardized mortality ratio was elevated at 1.29, which approached statistical significance (P = .059). In the oldest experience group (29 to 39 years), expected mortality was low compared with most other groups but observed mortality increased, yielding a significantly elevated standardized mortality ratio at 1.53 (P = .032). Conclusions Standardized mortality ratios with reoperative cardiac surgery were highest early and late in a surgeon’s career and lowest in mid career. As surgeons gain experience, outcomes improve through the first two career decades, then stabilize in the third decade before declining in the fourth decade.

Purpose We developed a heart positioner, the Tentacles NEO, specifically designed for minimally invasive coronary artery bypass grafting (MICS-CABG). Description The device has 3 flexible suction tubes, with a suction cup at the tip of each tube. The suction tubes can be detached from the device body, allowing them to be manipulated in any direction through a small incision around the small thoracotomy. When the device displaces the heart, the suction cup moves behind the chest wall and does not crowd the operative field. Evaluation Although the sideways suction force of the new device was as strong as that of the original device, Tentacles, the longitudinal and perpendicular force exerted was approximately 80% of the original device. Nevertheless, the new device could safely and favorably displace the heart in a pig model and even during off-pump CABG via sternotomy. During MICS-CABG, the device was able to displace the heart without crowding the operative field. Conclusions The new heart positioner, Tentacles NEO, is a useful and practical heart positioner suitable for MICS-CABG.

Various devices are available for endoscopic radial artery harvesting during coronary artery bypass grafting. Thermal spread and graft damage, however, are common concerns. The aim of this study was to compare the MiFusion TLS2 system (Endotrust, Nettetal Germany) with direct heat technique and the LigaSure Maryland system (Medtronic, Dublin, Ireland) using advanced bipolar technique in a prospective randomized study.One hundred consecutive patients undergoing coronary artery bypass grafting with endoscopic radial artery harvesting were prospectively included and randomized 1:1. The proximal (brachial) ends of the grafts were analyzed using fluorescence microscopy with focus on graft integrity. In addition, harvesting time, graft sealing, residual bleeding, and incidence of neurological disorders were compared.Patient age was 67 ± 8 years. Mean harvesting time was 26.5 ± 9 minutes for the TLS2 and 23.2 ± 8 minutes for the LigaSure (P = .049). Overall graft integrity was good in both groups. A significantly better graft integrity was observed in the LigaSure group (scale 0 to 3; 3 = best) with 2.5 ± 0.6 for TLS2 and 2.8 ± 0.4 for LigaSure (P = .031). LigaSure provided significantly better graft sealing (scale 0 to 2; 0 = best) with 0.6 ± 0.7 vs 1.0 ± 0.6 (TLS2) (P = .006) and less residual bleeding (scale 1 to 5; 1 = best) with 1.4 ± 0.6 vs 2.0 ± 0.9 (TLS2) (P.001). Transient sensibility disorders were less frequently observed with LigaSure (2% vs 16%, P = .015).Endoscopic radial artery harvesting can be performed with excellent results and good graft integrity using both devices. Compared with the MiFusion TLS2, the LigaSure device led to faster procedural times and resulted in better graft integrity. Along with providing a better seal, LigaSure was associated with less sensibility disorders.

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

Continuation of dual antiplatelet therapy (DAPT) after coronary artery bypass grafting (CABG) after acute myocardial infarction is recommended by current guidelines. We sought to evaluate guideline adherence over time and factors associated with postoperative DAPT within a regional consortium.Isolated CABG patients from 2011 to 2017 who had a myocardial infarction within 21 days prior to surgery were included. Patients were stratified by DAPT prescription at discharge and by time period, early (2011-2014) vs late (2015-2017). Hierarchical regressions were then performed to evaluate factors influencing DAPT use after CABG.A total of 7314 patients were included with an overall rate of DAPT utilization of 31.2% that increased from 29.6% in the early to 33.4% in the late era (P.01). There was considerable variability in hospital rates of DAPT (range 9.5%-92.1%) and hospital level changes over time (26% increased, 11% decreased, and 63% remained stable). After adjustment for clinical factors, era was not associated with DAPT use but treating hospital remained significantly associated with DAPT use. Other clinical factors associated with increased DAPT utilization included off-pump surgery (odds ratio [OR] 4.48, P.01) and prior percutaneous coronary intervention (OR 2.02, P.01), and atrial fibrillation (OR 0.39, P.01) was associated with decreased utilization.Dual antiplatelet use has increased between 2011 and 2017, driven primarily by evolving patient demographics. Significant hospital-level variability drives inconsistency in DAPT utilization. Efforts to promote DAPT use for patients treated with CABG after myocardial infarction in concordance with current guidelines should be targeted at the hospital level.

Background The "weekend effect" is a purported phenomenon whereby patients admitted for time-sensitive medical and surgical conditions on a weekend suffer worse outcomes than those admitted on a weekday. There are limited data on the weekend effect for nonelective coronary artery bypass grafting (CABG). Methods We studied outcomes for weekend vs weekday operations for all adult patients in the 2013 to 2014 National Inpatient Sample (NIS) undergoing nonelective CABG. Results Of 101,510 patients undergoing nonelective CABG, 12,795 patients (12.6%) underwent CABG on the day of admission (n = 1230 for weekend and 11,565 for weekday admission, respectively). Patients undergoing surgical procedures on a weekend were more likely to have a diagnosis of ST-elevation acute coronary syndrome (47.2% vs 20.2%, P Conclusions Patients undergoing CABG on a weekend had higher crude mortality but similar risk-adjusted mortality compared with their weekday counterparts. Some of the excess mortality observed for weekend operations is likely attributable to a sicker cohort of patients undergoing CABG on the weekend.

Background Although the safety and feasibility of combined coronary artery bypass grafting (CABG) and bone marrow stem cell (BMSC) transplantation have been proven, the efficacy of this approach remains controversial. Therefore, we conducted an updated meta-analysis of randomized controlled trials to evaluate the efficacy of this procedure. Methods Electronic databases were systematically searched for randomized trials comparing 4-month to 6-month follow-up outcomes in patients who underwent isolated CABG (CABG group) and patients who received BMSC transplantation with CABG (BMSC group). A random-effects meta-analysis was conducted across eligible studies. Meta-regression and subgroup analyses were utilized to identify sources of data heterogeneity. Results Thirteen trials were eligible, with a total number of 292 patients in the BMSC group and 247 patients in the CABG group. Compared with the CABG group, the BMSC group showed significant improvement of follow-up left ventricular ejection fraction (n = 539, 4.8%; 95% confidence interval [CI], 2.3%-7.3%; P = .001). The analyzed data showed significant heterogeneity (I2 = 74.2%, P Conclusions The present evidence suggests that combined CABG and BMSC transplantation is associated with improvement of left ventricular ejection fraction. However, the heterogeneity in the data suggests variations in patient response to this therapy. Further studies are required to understand these variations.

Anomalous aortic origin of the left main coronary artery arising from the right coronary sinus with a trans-septal course are rare and pose surgical challenges not addressed by current techniques. Coronary artery bypass grafting, although a plausible solution, has an unacceptably high incidence of graft failure due to competitive flow. We describe a novel transconal approach to effectively unroof the trans-septal left main coronary artery.

Female patients with coronary artery disease have inferior outcomes compared with male patients, including higher mortality after coronary artery bypass graft surgery (CABG). We aimed to evaluate the association of female sex with the use of guideline-concordant CABG revascularization techniques.The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for adult patients who underwent first-time isolated CABG in the United States from 2011 to 2019. The association between female sex and the odds of (1) receiving a left internal mammary artery graft for revascularization of the left anterior descending artery, (2) undergoing complete revascularization, and (3) undergoing multiarterial grafting was assessed, adjusting for procedural anatomy.Among 1,212,487 patients meeting inclusion criteria, 75% were male (n = 911,178) and 25% were female (n = 301,309). Female sex was associated with lower unadjusted rates of revascularization with an internal mammary artery graft (93.9% vs 95.9%, P.001), bilateral internal mammary artery graft (2.9% vs 5.6%, P.001), or radial artery graft (3.2% vs 5.6%, P.001). After adjustment, female patients had lower odds than males of receiving a left internal mammary artery graft to the left anterior descending artery (adjusted odds ratio 0.79; 95% confidence interval, 0.75 to 0.83; P.001), undergoing complete revascularization (adjusted odds ratio 0.86; 95% confidence interval, 0.83 to 0.90; P.001), and undergoing multiarterial grafting (adjusted odds ratio 0.78; 95% confidence interval, 0.75 to 0.81; P.001).Female sex was associated with 14% to 22% lower odds of undergoing guideline-concordant revascularization including left internal mammary artery to left anterior descending artery grafting, multiarterial grafting, and complete revascularization. Further investigation is necessary to determine why revascularization approaches differ by sex and to what degree sex disparities in coronary artery disease outcomes are due to surgical approach.

Proper positioning of the heart through a small left thoracotomy is the main challenge during off-pump minimally invasive cardiac coronary artery bypass grafting. Here we report a novel technique for target vessel exposure using the Tentacles NEO (Sumitomo Bakelite, Co Ltd, Tokyo, Japan) multisuction heart positioner, a device with 3 independent small suction cups that can be applied to various surfaces of the heart and pulled toward any direction using attached traction cords. The armless design of the device enables the use of flexible exposure techniques and contributes to the safety and feasibility of minimally invasive coronary artery bypass grafting.

Background Although coronary artery bypass grafting (CABG) is the preferred choice for advanced Kawasaki disease (KD)-associated coronary artery disease, graft design such as number of grafts or type of conduits has not been fully established. We reviewed a series of patients who underwent single or multiple CABG for coronary artery disease of KD sequelae to investigate the optimum revascularization strategy. Methods We enrolled a consecutive series of 102 CABG surgeries in 92 patients during the last 36 years. Mean patient age at CABG was 14.9 ± 10.4 years. Internal thoracic artery, radial artery, and gastroepiploic artery were used in 100 (98%), 18 (15%), and 4 (4%) cases, respectively. Patients were divided into 2 groups by single (n = 53) or multiple (n = 49) CABG. Results Actuarial survival was 93% in single CABG and 91% in multiple CABG at 30 years (P = .71). There was no in-hospital mortality, but 6 deaths occurred long term, with no significant difference between the groups. Freedom from cardiac events was 45.2% in single CABG and 68.5% in multiple CABG at 25 years (P = .228), and reintervention to the left anterior descending (LAD) artery territory was the most common event. Graft patency of the internal thoracic artery–LAD artery graft was 81% in single CABG and 85% in multiple CABG at 25 years. Patency of the radial artery in the non-LAD artery territories was significantly greater than that of the saphenous vein graft at 10 years (91% vs 46%, P = .013). Conclusions Multiple CABG using arterial conduits is feasible, safe, and therapeutically effective long term for patients with advanced KD-associated coronary artery disease.

Background Phase of care mortality analysis (POCMA) is a quality improvement tool categorizing triggers for mortality into phases of patient care. However, the relationship between a patient's risk profile and the triggers for mortality is incompletely understood. Methods POCMA was implemented for cases with available Society of Thoracic Surgeons (STS) risk models. Risk-adjusted rates were obtained from the STS database. Mortality triggers were categorized by the phase of occurrence (preoperative, intraoperative, intensive care unit [ICU], postoperative floor, and discharge). Patients were then stratified by STS risk score: low risk ( 8%). Results A total of 3,919 isolated coronary artery bypass grafting (CABG), 901 isolated valve, and 321 CABG plus single-valve procedures were performed from 2012 to 2018, with 4.6% crude mortality and a median STS risk score of 5.8%. POCMA was performed on 67 patient mortalities, with triggers occurring in the following phases of care: 49.3% preoperative, 13.4% intraoperative, 23.9% ICU, 3.0% postoperative floor, and 10.4% discharge phase. Mortality distribution was bimodal, occurring mostly in low-risk (37.3%) and high-risk (38.8%) patients. For low-risk patients, the trigger for mortality most frequently occurred during the postoperative ICU phase, while for high-risk patients, the trigger for mortality most frequently occurred during the preoperative phase. Conclusions Mortality had a bimodal distribution with respect to patient risk profile. Phase-of-care triggers for mortality differed according to patient risk profile: low-risk triggers during the postoperative ICU phase versus high-risk triggers typically during the preoperative phase. Specific focus on phases according to the patient's risk profile represents an opportunity to improve quality and outcomes.

Background Frailty measurement in cardiac surgery is poorly studied. The study purposes were to identify a simple but accurate frailty tool by comparing the simplified frailty index, Study of Osteoporotic Fractures (SOF), to a more complex frailty index, the Cardiovascular Health Study (CHS), and outcomes of frail patients to nonfrail patients. Methods Patients aged 65 years or older admitted for elective coronary artery bypass grafting (CABG), valvular surgery (valve), or a combination of CABG/valve were recruited and administered the SOF and CHS indexes. Surgical outcomes were defined by The Society of Thoracic Surgeons. A hand-held dynamometer assessed grip strength. Health-related quality of life was assessed by the 12-Item Short Form Health Survey. Results Patients (n = 167) were primarily male (75%), white (88%), and CABG (23%), valve (50%), or CABG/valve (25%). Frailty agreement between the CHS (frail, n = 47) and SOF (frail, n = 15) was poor (κ = 0.185). SOF frail patients had poorer health, were men (67% vs 61%), had a decreased ejection fraction (0.467 vs 0.537), an increased Society of Thoracic Surgeons Risk (5.0 vs 3.5), and increased European System for Cardiac Operative Risk Evaluation score (8.2 vs 5.2). All SOF frail patients reported lack of energy vs 8.7% CHS frail patients, and 80% vs 23.9% reported an unintentional weight loss of 5% or more. SOF frail patients were significantly more likely to experience prolonged ventilation (20% vs 6.5%), pneumonia (20% vs 6.5%), prolonged intensive care unit hours (158.6 vs 85.01), and readmission within 30 days (20% vs 8.7%). All frail patients reported a significantly lower physical health-related quality of life. Conclusions The SOF tool better identified patients considered "frail." Frail patients had more adverse outcomes and poorer health-related quality of life.

Background The St. Jude Medical Trifecta bioprosthesis (St. Jude Medical, St. Paul, MN) is a bovine pericardial valve mounted on a titanium stent. The objective of this study was to report a single-center experience with the Trifecta aortic valve. Methods Patients undergoing aortic valve replacement (AVR) with the Trifecta valve between 2011 and 2017 at a single center were included. The primary outcome was overall survival. Secondary outcomes included operative mortality and morbidity, aortic valve reoperations, and reoperation for structural valve deterioration. Echocardiographic outcomes were evaluated. Multivariable logistic regression models were created to identify predictors of death. Results The study included 1,953 Trifecta valve implants. Operations included isolated AVR (45% [n = 869]), AVR plus coronary artery bypass grafting (40% [n = 771]), and AVR plus mitral valve operation (13% [n = 254]). Overall survival at 30 days, 1 year, and 5 years was 94.9%, 89.7%, and 69.8%, respectively. Overall freedom from aortic valve reintervention was 96.4% at 5 years, with an overall freedom from reoperation for structural valve deterioration of 98.7% at 5 years. For elective isolated AVRs, survival was 98.6%, 94.1%, and 77.5% at 30 days, 1 year, and 5 years, respectively. The 5-year freedom from aortic valve reintervention and reoperation for structural valve deterioration for elective isolated AVRs was 97.6% and 99.1%, respectively. Overall mean gradients were 6.8 ± 5.3 mm Hg postoperatively and remained low at 10.1 ± 6.2 mm Hg at 1 year. Conclusions This is the largest series reporting on outcomes of the Trifecta valve. Our results demonstrate that this valve can be safely implanted in the aortic position with excellent midterm durability and hemodynamics.

We report our 10-year experience of a multicenter hemoglobin optimization program with the aim to reduce red blood cell transfusion in patients undergoing coronary artery bypass grafting (CABG).From 2006 to 2016, patients undergoing CABG at 10 centers in Ontario were referred to the Ontario Transfusion Coordinators (ONTraC) program. Of these, we present data on the first 60 consecutive patients per center, per year (n = 6,145).Overall, 45.7% patients were assessed14 days preoperatively, 16.4% were assessed ≥14 days preoperatively, and 37.9% were not assessed by ONTraC preoperatively. Transfusion rates fell from 40.1% in 2006 to 26.2% in 2016 (p0.01). Patients undergoing assessment were more likely to be older (p0.01), female (p 0.01), and anemic (p0.01) versus nonassessed patients. Those patients assessed were more likely to be treated with iron (p0.01) and erythropoietin (p0.01) preoperatively versus nonassessed patients. Transfusion rates were 26%, 28%, and 28% for patients undergoing assessment ≥14 days prior to operation,14 days prior to operation, or not at all. After baseline covariate adjustment, patients assessed ≥14 days preoperatively had shorter length of stay (effect -0.83, 95% confidence interval [CI] -1.41 to -0.25; p0.01) and a trend towards lower risk of red blood cell transfusion (odds ratio [OR] 0.83, 95% CI 0.68 to 1.00; p = 0.06). Blood transfusion was independently associated with an increased risk of death (OR 1.49, 95% CI 1.37 to 1.60; p0.01), infection (OR 1.24, 95% CI 1.18 to 1.30; p0.01), and longer hospital length of stay (effect 1.49, 95% CI 1.35 to 1.62; p0.01).The results of this study suggest that preoperative hemoglobin optimization may be effective in reducing red blood cell transfusion after CABG, particularly for patients assessed ≥14 days preoperatively.

Aortic root replacement (ROOT) has been an established therapy, yet the impact of adding coronary artery bypass grafting (CABG) to ROOT (CABG-R) is unknown. The purpose of this research was to investigate the impact of CABG on the outcomes of ROOT.A retrospective review from 2004 to 2016 of patients undergoing nonemergent ROOT surgical procedure was performed. Cohorts were established based on the presence or absence of added CABG. A propensity-score weighted comparison of outcomes was then conducted.A total of 867 patients met inclusion criteria and were analyzed (711 ROOT [72.0%], 156 CABG-R [18.0%]). CABG-R patients were older and had higher proportions of previous valve operation, hypertension, endocarditis, immunosuppressive therapy, renal insufficiency, and redo operation (all p0.01). Indications for CABG included anatomy (n = 48, 30.8%), coronary artery disease (80, 51.3%), and ventricular failure (28, 17.9%). The permanent stroke rate was not significantly increased with the addition of CABG-R (p = 0.06). Thirty-day mortality was 5.5% for the entire cohort but was substantially higher in patients who underwent concomitant CABG (3.4% ROOT, 15.4% CABG-R). Mortality rates were highest among patients with acute ventricular failure and CABG (28.8%) compared with patients who underwent CABG for coronary artery disease (6.3%) or patients for anatomy (22.9%; p = 0.003).CABG-R results in increased postoperative morbidity or mortality compared with isolated ROOT. Outcomes, however, are influenced by the specific clinical indication. CABG for coronary artery disease was associated with similar outcomes compared with isolated ROOT. Patients undergoing unplanned CABG for acute ventricular failure had the worst outcomes, thus underscoring the importance of technical success during coronary reimplantation.

Chylothorax after coronary artery bypass grafting is a rare complication. The treatment protocol is not well described because of its rarity. The current treatment options for chylothorax include conservative medical treatment or an interventional approach (ie, thoracic duct embolization or surgical ligation of the thoracic duct). With high chest tube output, medical treatment has a high failure rate, and early embolization or surgical ligation of the thoracic duct should be considered to reduce hospital stay cost and morbidity. This report presents 2 cases of chylothorax after coronary artery bypass grafting with different treatment approaches.

Female patients experience worse outcomes after coronary artery bypass grafting (CABG). We investigated whether rates of failure-to-rescue (FTR), a systems-based quality indicator, were greater in women who underwent CABG.A retrospective review was conducted on 20 045 patients who underwent isolated, nonemergent CABG between January 2002 and August 2019 at a single academic center. FTR was defined as postoperative death within 30 days after stroke, renal failure, reoperation, and prolonged ventilation. Propensity score matching was performed utilizing preoperative variables, excluding sex.A total of 4980 propensity score-matched pairs were identified. In the matched analysis, women experienced higher rates of postoperative stroke (1.9% vs 1.2%; P = .008), prolonged ventilation (13.3% vs 10.0%, P.001), and 30-day mortality (2.6% vs 1.8%; P = .01). Rates of FTR after stroke (P = .36), renal failure (P = .11), reoperation (P = .86), and prolonged ventilation (P = .48) were not statistically significant between female and male patients.Women who underwent isolated, nonemergent CABG had statistically similar frequencies of FTR compared with their male counterparts despite experiencing greater rates of morbidity and mortality. Further efforts to narrow the sex outcome gap after CABG should focus on preoperative and intraoperative phases of care instead of postoperative management.

Background Suitable autologous conduits may be lacking when performing coronary artery bypass grafting. The aim of this review is to determine the status of nonautologous grafts in coronary artery bypass grafting. Methods We conducted a literature search on MEDLINE All, Embase Classic, and Embase through Ovid from 1960 to April 2020. Results Of the 1579 records identified, 21 studies were included in the review. The following grafts were assessed for patency: 109 homologous saphenous veins (patency rates ranged from 66.7% at a median follow-up of 8.5 months to 0% at 6-12 months and 7-18 months, respectively), 29 expanded polytetrafluoroethylene grafts (from 80% at a median follow-up of 5 months to 14.3% at 45 months), 12 human umbilical veins (50% at a median follow-up of 6 months), 50 Bioflow bovine internal mammary arteries (from 15.8% to 0% at a mean follow-up of 9.5 months and 19 months, respectively), 39 Perma-Flow grafts (80% and 76.9% at 1-3 months and 12 months, respectively), 20 No-React bovine internal mammary arteries (57.1% at a median follow-up of 28 months and 23.1% at a mean follow-up of 7 months), 40 autologous venous endothelial cell–seeded expanded polytetrafluoroethylene grafts (94.7% and 81% at a mean follow-up of 27 months and 60 months, respectively), and 12 autologous venous endothelial cell–seeded cryopreserved homologous veins (83.3% at a mean follow-up of 8.5 months). Conclusions The goal of an alternative conduit with patency and attributes that match those of autografts remains elusive. Autologous endothelial cell–seeded synthetic grafts have demonstrated promising results but require further investigation.

A statewide database identified prolonged ventilation (PV) and acute renal failure (RF) as the biggest cost drivers after isolated coronary artery bypass grafting. Reducing these complications through regional collaboration should improve outcomes and lower health care costs.A total of 27,978 patients who underwent isolated coronary artery bypass grafting were divided into pre- and post-quality improvement initiative groups (early era: 2008 to 2011, n = 15,176; later era: 2012 to 2015, n = 12,802). Focused learning sessions on PV and postoperative RF were undertaken in the earlier era. Incidence of death, PV, and RF in the two groups was analyzed using one-way analysis of variance and Fisher exact tests.The Society of Thoracic Surgeons (STS) predicted risk of mortality and predicted risk of mortality/morbidity were significantly higher in the later era (p 0.01), as were STS predicted PV (10.1% vs 11.3%) and RF (3.4% vs 3.8%). Despite these increased risks, STS observed-to-expected ratios for mortality and mortality/morbidity fell. Observed rates for PV (10.5% vs 8.8%, p 0.01) and RF (3.6% vs 2.3%, p0.01) were associated with STS observed-to-expected ratios of PV (1.04 vs 0.78) and RF (1.03 vs 0.60). Adjusting for case volume in the two eras, 271 cases of PV and 170 of RF were avoided, with estimated cost savings of $10,212,637 and $8,519,630, respectively.A regional collaboration using a statewide STS and an all-payor database with focused quality improvement is a powerful tool for change. Despite rising risks for mortality and morbidity, outcomes for PV and RF improved and produced significant cost savings. Applying these efforts nationally can enormously affect patient care and health care costs.

Background We evaluated the long-term outcomes of coronary artery bypass grafting (CABG) according to β-blocker therapy using landmark analysis. Although β-blockers have been shown to improve outcomes for ischemic heart disease, the long-term effects and optimal treatment duration of use after CABG remain unknown. Methods From January 2001 to December 2014, 5382 CABG patients were stratified into 2 groups according to β-blocker therapy at discharge (β-blocker group: 3677 [68.3%], no β-blocker group: 1705 [31.7%]). Results The primary outcome was all-cause death during 48 months of follow-up. Using propensity score-matched analysis, β-blocker therapy was associated with all-cause death during the 48-month follow-up (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.41-0.95; P = .03). The landmark analysis demonstrated that the effect of β-blockers on all-cause death was particularly significant within the first 12 months of therapy (HR, 0.37; 95% CI, 0.19-0.80; P = .01) but not after 12 months (HR, 0.92; 95% CI, 0.56-1.53; P = .77). Conclusions The benefits of postdischarge β-blockers may be limited to 1 year after CABG, but further studies are required to confirm this finding.

More than 90% of coronary artery bypass grafting (CABG) is performed with a single-arterial bypass graft (SABG), based on the left internal thoracic artery (ITA) with supplemental vein grafts. This practice, often justified by safety concerns with multiple-arterial grafting (MABG), defies evidence of improved late survival achieved with bilateral ITA (BITA-MABG) or left ITA plus radial artery (RA-MABG). We hypothesized that MABG and SABG are equally safe.We analyzed The Society of Thoracic Surgeons National Database (2004 to 2015) to assess the operative safety of BITA-MABG (n = 73,054) and RA-MABG (n = 97,623) vs SABG (n = 1,334,511). Primary end points were operative (30-day or same hospitalization) mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were derived from by logistic regression with sensitivity analyses in multiple subcohorts including MABG use rate.SABG (73.8% men; median age, 66 years), BITA-MABG (85.1% men; median age, 59 years), and RA-MABG (82.5% men; median age, 61 years) showed distinctly different patient characteristics. Compared with SABG (1.91% OM; 0.73% DSWI), observed OM was lower for BITA-MABG (1.19%, p0.001) and RA-MABG (1.19%, p0.001). DSWI was higher among BITA-MABG (1.08%, p0.001) and similar for RA-MABG (0.71%, p = 0.55). BITA-MABG showed marginally increased, likely not clinically significant, OM (AOR, 1.14; 95% CI, 1.00 to 1.30; p = 0.05) and doubled DSWI (AOR, 2.09; 95% CI, 1.80 to 2.43; p0.001). RA-MABG had similar OM (AOR, 1.01; 95% CI, 0.89 to 1.15; p = 0.85) and DSWI (AOR, 0.97; 95% CI, 0.83 to 1.13; p = 0.70). Results were consistent across multiple subcohorts. A U-shaped OM vs BITA use relation was documented, with worse OM at hospitals with low (5%: AOR, 1.38; 95% CI, 1.18 to 1.61; p0.001) and high (≥40%: AOR, 1.31; 95% CI, 1.00 to 1.70; p = 0.049) BITA use.MABG in the United States is associated with OM comparable to SABG and increased DSWI risk with BITA-MABG. Our findings highlight the importance of surgeon and institutional experience and careful patient selection for BITA-MABG. Our short-term results should not in any way dissuade the use of MABG, given its well-established long-term survival advantage.

Background Debate persists over the association between blood transfusions, especially those considered discretionary, and outcomes after cardiac operations. Using data from the Maryland Cardiac Surgery Quality Initiative, we sought to determine whether outcomes differed among coronary artery bypass grafting (CABG) patients receiving 1 U of red blood cells (RBCs) vs none. Methods We used a statewide database to review patients who underwent isolated CABG from July 1, 2011, to June 30, 2016, across 10 Maryland cardiac surgery centers. We included patients who received 1 U or fewer of RBCs from the time of the operation through discharge. Propensity scoring, using 20 variables to control for treatment effect, was performed among patients who did and did not receive a transfusion. These two groups were matched 1:1 to assess for differences in our primary outcomes: operative death, prolonged postoperative length of stay (>14 days), and a composite postoperative respiratory complication of pneumonia or reintubation, or both. Results Of 10,877 patients who underwent CABG, 6,124 (56%) received no RBCs (group 1) during their operative hospitalization, and 981 (9.0%) received 1 U of RBCs (group 2), including 345 of 981 patients (35%) who received a transfusion intraoperatively. Propensity score matching generated 937 well-matched pairs. Compared with group 2, propensity-matched analysis revealed significantly greater 30-day survival in group 1 (99% vs 98%, p = 0.02) and reduced incidence of prolonged length of stay (3.7% vs 4.0%, p Conclusions Our collaborative statewide analysis demonstrated that even 1 unit of blood was associated with significantly worse survival and longer length of stay after CABG. Multiinstitutional quality initiatives may seek to address discretionary transfusions and possess the potential to improve patient outcomes.

In the past, minimally invasive cardiac surgery (MICS)- coronary artery bypass graft surgery (CABG) alternatives have been introduced that dramatically reduce the invasiveness of standard operative procedures while still showing excellent clinical outcomes. However, in patients with high morbidity, reduced lung function impeding single-lung ventilation is one of the major concerns for MICS-CABG procedures, although those patients might reap the largest benefit from a procedure of reduced invasiveness.Here, we describe a simple surgical technique-the fan technique-that allows for continuous full-lung ventilation with unimpeded surgical view during common MICS-CABG procedures. To evaluate the procedural feasibility of this technique, we analyzed intraoperative ventilation measurements of 22 consecutive MICS-CABG patients in whom the fan technique was used.This study demonstrates a significant improvement of standard respiratory measurements during procedural full-lung ventilation using the fan technique as compared with conventional single-lung ventilation (ventilation pressure 21.4 ± 3.2 versus 26.6 ± 3 mbar, p0.001; respiratory rate 13.1 ± 1.4 versus 14.4 ± 2.2 breaths per minute, p0.001; minute volume 7.4 ± 1.1 versus 6.2 ± 1 L/min, p0.0001; PaoThe presented technique may not only enable us to perform MICS-CABG procedures in patients not suitable for single-lung ventilation owing to reduced pulmonary function, but also may soon also become a standard procedure for MICS-CABG surgery, especially with regard to procedures involving complex and time-consuming multivessel revascularizations. However, further studies are strongly warranted to assess whether the fan technique may also decrease postoperative pulmonary complications and benefit clinical outcome indicators.

Background Off-pump coronary artery bypass grafting (OPCAB) has been shown to be an effective strategy for surgical revascularization. The purpose of this study was to define the incidence of intraoperative conversion from OPCAB to on-pump coronary artery bypass grafting (ONCAB) and report outcomes based on the reason for conversion. Methods Starting in July 2007, the Society of Thoracic Surgeons database captured patients that were planned OPCAB but then were converted to ONCAB. A total of 196,576 patients undergoing planned OPCAB within the Society of Thoracic Surgeons National Database from July 2007 to June 2014 were evaluated. Patients were grouped according to their intraoperative conversion to cardiopulmonary bypass: (1) planned conversion, (2) unplanned conversion for visualization, (3) unplanned conversion for hemodynamic instability, and (4) no conversion (OPCAB). Multiple logistic regression analysis was used to determine risk factors for conversion. Results The overall rate of conversion from OPCAB to ONCAB was 5.5%, with 49.6% of the conversions being planned. When compared with those not undergoing conversion (OPCAB, 30-day mortality observed to expected ratio [O/E], 0.8), those undergoing conversion to ONCAB experienced greater 30-day mortality regardless of etiology of conversion (planned conversion O/E, 1.4; unplanned conversion for visualization O/E, 1.6; and unplanned conversion for hemodynamic instability O/E, 2.7). Similar O/E ratios were observed for renal failure and prolonged ventilation following conversion. Logistic regression analysis showed advanced age, ejection fraction less than 35%, preoperative intraaortic balloon pump placement, increasing number of diseased coronary arteries, preoperative heart failure within 2 weeks, and urgent procedural status were all independent predictors for conversion to ONCAB ( p ≤ 0.01). Conclusions Intraoperative conversion from OPCAB to ONCAB remains a morbid event with a risk of mortality much higher than expected. Surgeons should consider elective ONCAB in those with a high risk for conversion during OPCAB.

A better prediction of postoperative acute kidney injury (AKI) is worthwhile in patients undergoing coronary artery bypass grafting (CABG) because AKI is associated with high rates of morbidity and mortality. The present study was performed to investigate whether preoperative C-reactive protein (CRP) predicted AKI and the long-term rate of mortality in CABG.This retrospective cohort study included 1,656 patients whose high-sensitivity CRPs were measured before CABG at two tertiary referral centers from 2004 to 2010. The odds ratios and hazard ratios for AKI and all-cause mortality were measured according to the tertiles of CRP levels after the adjustment of multiple covariates. The net reclassification improvement and integrated discrimination improvement were calculated to determine whether the addition of CRP to the risk model improves predictive capacity. Patients were followed for 12 years.The prevalence of AKI was increased in the third tertile group (42.7%) compared with in the first tertile group (25.6%). The corresponding odds ratio of AKI and p values were 1.86 (95% confidence interval: 1.39 to 2.49) and0.001, respectively. Compared with the existing risk model, the addition of CRP improved the predictability with 0.135 of net reclassification improvement (p = 0.005) and 0.084 of integrated discrimination improvement (p0.001). There were 474 deaths (28.6%) during follow-up. The third tertile group exhibited a higher hazard ratio for mortality (1.63, 95% confidence interval: 1.27 to 2.08) than the first tertile group. This predictability for mortality remained consistent regardless of the presence of AKI.Preoperative CRP level is a predictor of postoperative AKI and mortality in patients undergoing CABG.

Background There is concern about graduating thoracic trainees' independent operative skills due to limited autonomy in training. This study compared faculty and trainee expected levels of autonomy with intraoperative measurements of autonomy for common cardiothoracic operations. Methods Participants underwent frame-of-reference training on the 4-point Zwisch scale of operative autonomy (show and tell → active help → passive help → supervision only) and evaluated autonomy in actual cases using the Zwisch Me!! mobile application. A separate "expected autonomy" survey elicited faculty and resident perceptions of how much autonomy a resident should have for six common operations: decortication, wedge resection, thoracoscopic lobectomy, coronary artery bypass grafting, aortic valve replacement, and mitral valve repair. Results Thirty-three trainees from 7 institutions submitted evaluations of 596 cases over 18 months (March 2015 to September 2016). Thirty attendings subsequently provided their evaluation of 476 of those cases (79.9% response rate). Expected autonomy surveys were completed by 21 attendings and 19 trainees from 5 institutions. The six operations included in the survey constituted 47% (226 of 476) of the cases evaluated. Trainee and attending expectations did not differ significantly for senior trainees. Both groups expected significantly higher levels of autonomy than observed in the operating room for all six types of cases. Conclusions Although faculty and trainees both expect similar levels of autonomy in the operating room, real-time measurements of autonomy show a gap between expectations and reality. Decreasing this gap will require a concerted effort by both faculty and residents to focus on the development of independent operative skills.

Background Cardiopulmonary bypass (CPB) elicits a systemic inflammatory response that may impair blood–brain barrier (BBB) integrity. BBB disruption can currently be detected by dynamic contrast enhancement magnetic resonance imaging (MRI), reflected by an increase in the permeability constant ( K t r a n s ). We aimed to determine (1) whether CPB induces BBB disruption, (2) duration until BBB disruption resolution, and (3) the obtainable correlation between BBB injury (location and intensity) and neurocognitive dysfunction. Methods Seven patients undergoing CPB with coronary artery bypass grafting (CABG) were assigned to serial cerebral designated MRI evaluations, preoperatively and on postoperative day (POD) 1 and 5. Examinations were analyzed for BBB disruption and microemboli using dynamic contrast enhancement MRI and diffusion-weighted imaging methods, respectively. Neuropsychologic tests were performed 1 day preoperatively and on POD 5. Results A significant local K t r a n s increase (0.03 min –1 vs 0.07 min –1 , p = 0.033) compatible with BBB disruption was evident in 5 patients (71%) on POD 1. Resolution was observed by POD 5 (mean, 0.012 min –1 ). The location of the disruption was most prominent in the frontal lobes (400% vs 150% K t r a n s levels upsurge, p = 0.05). MRI evidence of microembolization was demonstrated in only 1 patient (14%). The postoperative global cognitive score was reduced in all patients (98.2 ± 12 vs 95.1 ± 11, p = 0.032), predominantly in executive and attention (frontal lobe–related) functions (91.8 ± 13 vs 86.9 ± 12, p = 0.042). The intensity of the dynamic contrast enhancement MRI BBB impairment correlated with the magnitude of cognition reduction ( r = 0.69, p = 0.04). Conclusions BBB disruption was evident in most patients, primarily in the frontal lobes. The location and intensity of the BBB disruption, rather than the microembolic load, correlated with postoperative neurocognitive dysfunction.

Background Whether delaying coronary artery bypass grafting (CABG) after myocardial infarction (MI) is associated with better outcomes or is an unnecessary use of health care resources is unclear. This study investigated the relationship between MI-to-CABG timing on in-hospital death. Methods From the Northern New England Cardiovascular Disease Study Group (NNE) Cardiac Surgery Registry we identified 3,060 isolated CABG patients with prior MI from 2008 to 2014. We compared in-hospital death by MI-to-CABG timing of less than 1 day, 1 to 2 days, 3 to 7 days, and 8 to 21 days. We adjusted for patient characteristics using logistic regression. Results Among patients with prior MI, CABG was performed within 1 day for 99 (3.2%), 1 to 2 days for 369 (12.1%), 3 to 7 days for 1,966 (64.3%), and 8 to 21 days for 626 (20.5%) patients. NNE-predicted mortality was similar for patients operated on within 1 day (1.8%), 1 to 2 days (1.8%), and 3 to 7 days (1.9%), but was higher for 8 to 21 days (2.4%) of MI. Crude in-hospital mortality was higher for those with MI-to-CABG time of less than 1 day (5.1%) compared with 1 to 2 days (1.6%), 3 to 7 days (1.6%), and 8 to 21 days (2.7%, p = 0.044). Adjusted in-hospital mortality remained high for less than 1 day (5.4%; 95% CI, 1.5% to 9.4%), and similar for 1 to 2 days (1.8%; 95% CI, 0.4% to 3.1%), 3 to 7 days (1.7%; 95% CI, 1.1% to 2.3%), and 8 to 21 days (2.3%; 95% CI, 1.2% to 3.3%) between MI and CABG. Conclusions Patients operated on 1 to 2 days and 3 to 7 days after MI had a similar mortality rate, suggesting it may be possible to reduce the MI-to-CABG interval for some patients without sacrificing outcomes. Patients operated on within 1 day after MI had a higher mortality rate.

The left internal mammary artery is the most accepted and widely used conduit in coronary artery bypass grafting. This report presents a rare case of very early bifurcation of the left internal mammary artery at the level of the third intercostal space.

The optimum antithrombotic strategy before open heart surgery in patients with recently implanted coronary stents has not been clearly established because of lack of clinical evidence. This report describes a case of stent thrombosis in a patient who discontinued a P2Y12 inhibitor (ticagrelor) for 3 days before coronary artery bypass grafting. The period of withdrawal of antiplatelet drugs before coronary artery bypass grafting should be minimized in patients with recently implanted drug-eluting coronary stents to prevent stent thrombosis.

Background We compared 10-year graft patency rates and long-term clinical outcomes after off-pump coronary artery bypass grafting using bilateral internal thoracic arteries (ITAs) as in situ grafts with those using bilateral ITAs as Y-composite grafts. Methods Of 509 patients who underwent off-pump coronary artery bypass grafting using bilateral ITAs, bilateral ITAs were used as in situ grafts in 172 patients (group I) and as Y-composite grafts in 337 patients (group Y). A propensity score–matched analysis was used to match group I patients (n = 153) with group Y patients (n = 153). Ten-year angiographic patency rates and long-term clinical outcomes were compared. The follow-up data were complete in 99.2% of patients (505/509) with a median follow-up duration of 175 months. Results Ten-year overall patency rates and patency rates for distal anastomoses using bilateral ITAs were 87.5% (356/407) and 89.2% (297/333), respectively, in the propensity score–matched groups. No differences in overall patency rates (groups I vs Y, 84.9% vs 89.5%, P = .277) and bilateral ITA patency rates (groups I vs Y, 86.5% vs 91.1%, P = .282) were found between the propensity score–matched groups. There were no differences in the overall survival and cumulative incidence of cardiac death between the propensity score–matched groups (P = .312 and P = .812, respectively) up to 15 years after surgery. Cumulative incidences of target vessel revascularization (P = .606), reintervention (P = .849), and major adverse cardiac events (P = .672) were also similar between the propensity score–matched groups up to 15 years after surgery. Conclusions Off-pump coronary artery bypass grafting using bilateral ITAs as in situ versus Y-composite grafts demonstrated no differences in terms of 10-year patency rates and long-term clinical outcomes between the groups.