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Objective We evaluated whether interhospital variation in mortality rates for coronary artery bypass grafting was driven by complications and failure to rescue. Methods An observational study was conducted among 83,747 patients undergoing isolated coronary artery bypass grafting between July 2011 and June 2017 across 90 hospitals. Failure to rescue was defined as operative mortality among patients developing complications. Complications included the Society of Thoracic Surgeons 5 major complications (stroke, surgical reexploration, deep sternal wound infection, renal failure, prolonged intubation) and a broader set of 19 overall complications. After creating terciles of hospital performance (based on observed:expected mortality), each tercile was compared on the basis of crude rates of (1) major and overall complications, (2) operative mortality, and (3) failure to rescue (among major and overall complications). The correlation between hospital observed and expected (to address confounding) failure to rescue rates was assessed. Results Median Society of Thoracic Surgeons predicted mortality risk was similar across hospital observed:expected mortality terciles (P = .831). Mortality rates significantly increased across terciles (low tercile: 1.4%, high tercile: 2.8%). Although small in magnitude, rates of major (low tercile: 11.1%, high tercile: 12.2%) and overall (low tercile: 36.6%, high tercile: 35.3%) complications significantly differed across terciles. Nonetheless, failure to rescue rates increased substantially across terciles among patients with major (low tercile: 9.1%, high tercile: 14.3%) and overall (low tercile: 3.3%, high tercile: 6.8%) complications. Hospital observed and expected failure to rescue rates were positively correlated among patients with major (R2 = 0.14) and overall (R2 = 0.51) complications. Conclusions The reported interhospital variability in successful rescue after coronary artery bypass grafting supports the importance of identifying best practices at high-performing hospitals, including early recognition and management of complications.

OBJECTIVE: To identify to what extent distinguishing patient and procedural characteristics can explain center-level transfusion variation during coronary artery bypass grafting (CABG) surgery. METHODS: Observational cohort study using the Perfusion Measures and Outcomes Registry (PERForm) from 43 adult cardiac surgical programs from July 1, 2011 to July 1, 2017. Iterative multilevel logistic regression models were constructed using patient demographic, preoperative risk factors, and intraoperative conservation strategies to progressively explain center-level transfusion variation. RESULTS: Of the 22,272 adult patients undergoing isolated coronary artery bypass (CABG) surgery using cardiopulmonary bypass, 7,241 (32.5%) received at least one unit of allogeneic RBCs (10.9% to 59.9%). When compared to subjects who were not transfused, patients that received at least one unit of RBCs were older (68 versus 64 years, p

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

Objectives Publicly reported postoperative 30-day mortality rates are commonly used to compare hospital quality after coronary artery bypass grafting. We sought to determine whether 90-day mortality rates, which are not publicly reported but better capture postdischarge mortality, are a better determinant of hospital performance. Methods We performed a retrospective cohort analysis of 30- versus 90-day risk-standardized mortality rates at adult cardiac surgical centers in New York State from 2008 to 2014. Hospitals were classified as good or poor performing outliers at each time point based on the bounds of the 95% confidence interval around each hospital's predicted risk-standardized mortality rates determined via hierarchical models. The primary outcome was change in institutional performance via outlier classification from 30 to 90 days. Results During the study period, 72,398 adults underwent a coronary artery bypass grafting procedure at 1 of 42 institutions. The risk-standardized mortality rates increased from 30 to 90 days at all institutions, with a median 30-day risk-standardized mortality rate of 2.16% (interquartile range, 0.69%) and median 90-day risk-standardized mortality rate of 3.69% (interquartile range, 1.00%). In using a 90-day instead of a 30-day metric, 3 hospitals changed outlier status. One hospital improved to a good from as expected performer, and 2 worsened to as expected from good performers. Conclusions In a cohort of patients who underwent coronary artery bypass grafting surgery from 2008 to 2014 in New York State, use of a 90-day mortality metric resulted in a change in hospital quality assessment for a minority of hospitals. The use of 90-day mortality may not provide additional value when evaluating institutional performance for this population.

Objective The aim was to show that total arterial revascularization via a left minithoracotomy using bilateral internal thoracic arteries was not only feasible but also a safe and reproducible procedure with excellent midterm outcomes. Methods From August 2011 to August 2016, 819 patients underwent off-pump minimally invasive multivessel coronary artery bypass grafting using bilateral internal thoracic arteries harvested through a 2-inch left minithoracotomy incision, and complete revascularization of the myocardium was performed using the left internal thoracic artery-right internal thoracic artery Y composite conduit. Results A total of 819 patients underwent minimally invasive total arterial myocardial revascularization using bilateral internal thoracic arteries (left internal thoracic artery-right internal thoracic artery Y composite conduit) via a left minithoracotomy. The average number of grafts was 3.1. A total of 171 patients (21%) had 4 grafts, and 557 patients (68%) had 3 grafts. There were 6 mortalities (0.7%), and 4 patients (0.4%) had an elective conversion to sternotomy because of hemodynamic instability. The average hospital stay was 3.1 days. Coronary angiograms were performed in 195 patients (23%), and computed tomography angiograms were performed in 172 patients (21%) at 12 months; the grafts were patent. Four patients (0.4%) required reintervention with angioplasty. Conclusions Multivessel total arterial revascularization was performed using the left internal thoracic artery-right internal thoracic artery Y composite conduit via a left minithoracotomy and showed that it was safe and reproducible. The midterm outcomes have been good, and coronary angiograms showed widely patent grafts. This novel technique may help optimize minimally invasive coronary surgery and the use of bilateral internal thoracic arteries. Further, this technique has the potential for decreased morbidity, shorter hospital stay, cosmesis, and earlier return to active life.

Objective Inconsistent definitions of atrial fibrillation after coronary artery bypass grafting have caused uncertainty about its incidence and risk. We examined the extent to which limiting the definition to post–coronary artery bypass grafting atrial fibrillation events requiring treatment underestimates its incidence and impact on 30-day mortality. Methods We assessed in-hospital atrial fibrillation and 30-day mortality in 9268 consecutive patients without preoperative atrial fibrillation who underwent isolated coronary artery bypass grafting at 5 US hospitals (2004-2010). Patients who experienced 1 or more episode of post–coronary artery bypass grafting atrial fibrillation detected via continuous in-hospital electrocardiogram/telemetry monitoring were divided into those for whom Society of Thoracic Surgeons data (applying the definition "atrial fibrillation/flutter requiring treatment") also indicated atrial fibrillation versus those for whom it did not. Risk-adjusted 30-day mortality was compared between these 2 groups and with patients without post–coronary artery bypass grafting atrial fibrillation. Results Risk-adjusted incidence of post–coronary artery bypass grafting atrial fibrillation incidence was 33.4% (27.0% recorded in Society of Thoracic Surgeons data, 6.4% missed). Patients with post–coronary artery bypass grafting atrial fibrillation missed by Society of Thoracic Surgeons data had a significantly greater risk of 30-day mortality (odds ratio, 2.08, 95% confidence interval, 1.17-3.69) than those captured. By applying the significant underestimation of post–coronary artery bypass grafting atrial fibrillation incidence we observed (odds ratio [Society of Thoracic Surgeons vs missed], 0.78; 95% confidence interval, 0.72-0.83) to the approximately 150,000 patients undergoing isolated coronary artery bypass grafting in the United States each year estimates this increased risk of mortality is carried by 9600 patients (95% confidence interval, 9420-9780) annually. Conclusions Defining post–coronary artery bypass grafting atrial fibrillation as episodes requiring treatment significantly underestimates incidence and misses patients at a significantly increased risk for mortality. Further research is needed to determine whether this increased risk carries over into long-term outcomes and whether it is mediated by differences in treatment and management.

Reply : No-touch saphenous veins and radial arteries should qualify for the same coronary artery bypass grafting team