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Background. Venous thromboembolism (VTE) is the third leading cause of cardiovascular death in patients undergoing surgery. However, VTE prophylaxis practices in cardiac surgery are based on noncardiac surgical literature. The objective of our study was to extract current patterns of VTE prophylaxis practices in cardiac surgery patients. We also aimed to identify health care professionals knowledge of available evidence supporting VTE prophylaxis in adult cardiac surgery patients. Methods. A web-based survey was developed and sent to all Canadian cardiac surgery centers with the intent to have the survey distributed to all personnel involved in the perioperative care of adult cardiac surgery patients. Participation in the questionnaire was voluntary and anonymized. Results. Thirty-five responses were obtained. Sixty-nine percent reported having an established protocol for VTE prophylaxis. However, 83% reported using VTE prophylaxis in their daily practice despite lack of protocol. The majority (60%) believed that the class of recommendation was high despite the lack of evidence. Conclusions. Our survey demonstrated the following. (a) Majority of Canadian centers employ VTE prophylaxis, with considerable variability. (b) There is a misconception among health care professionals about the strength of evidence supporting VTE prophylaxis in cardiac surgery. Our findings highlight the need for appropriately designed studies to fill this knowledge gap. [ABSTRACT FROM AUTHOR]

Objective To date only a few randomized controlled studies have compared grafting strategies in patients with multi-vessel coronary disease. This study represents a pilot RCT designed to test the feasibility of a trial comparing conventional CABG performed with a LIMA-LAD plus saphenous vein grafts (LIMA+SVG) and CABG performed with total arterial grafting (TAG). Methods Consenting patients undergoing non-redo isolated CABG surgery at a single institution were randomized to TAG or LIMA+SVG groups. Exclusion criteria included prior CABG, emergent procedure, concomitant procedure, varicose veins and renal dysfunction. The primary endpoints were: enrolment >20% and completion of CT coronary angiography at 6 months >80%. Statistical investigation was performed on an intention to treat analysis. Results Of 421 eligible patients, 60 were enrolled and 2 withdrew (n = 30 in TAG, n = 28 LIMA+SVG) for 14% enrolment rate. Patient characteristics were similar in each group. No patients died in hospital and adverse events such as MI, stroke and deep sternal wound infection were not significantly different between groups. Clinical follow-up was complete in 100% of patients, with 44/58 (76%) undergoing CT coronary angio at 6 months. Graft occlusion occurred in 2 patients in each group for patency rates of 89% (TAG) and 91% (LIMA+SVG). Conclusions We provide evidence that an RCT comparing grafting strategy is possible but also show that achieving recruitment or follow-up CT may be difficult. Given the excellent patency results and little difference between groups, our findings suggest that the sample size required may make it infeasible to compare graft patency at 6 months as a study end-point. Trial registration Randomized Controlled Trial number: ISRCTN80270323. Ultra-mini abstract Few RCT's exist comparing conventional CABG performed with a LIMA-LAD plus saphenous vein grafts (LIMA+SVG) compared to CABG performed with total arterial grafting (TAG). This study is a pilot RCT designed to test the feasibility of such a trial and identify pitfalls. [ABSTRACT FROM AUTHOR]

Background: Quality improvement initiatives in cardiac surgery largely rely on risk prediction models. Most often, these models include isolated populations and describe isolated end-points. However, with the changing clinical profile of the cardiac surgical patients, mixed populations models are required to accurately represent the majority of the surgical population. Also, composite model end-points of morbidity and mortality, better reflect outcomes experienced by patients. Methods: The model development cohort included 4,270 patients who underwent aortic or mitral valve replacement, or mitral valve repair with/without coronary artery bypass grafting, or isolated coronary artery bypass grafting. A composite end-point of infection, stroke, acute renal failure, or death was evaluated. Age, sex, surgical priority, and procedure were forced, a priori, into the model and then stepwise selection of candidate variables was utilized. Model performance was evaluated by concordance statistic, Hosmer-Lemeshow Goodness of Fit, and calibration plots. Bootstrap technique was employed to validate the model. Results: The model included 16 variables. Several variables were significant such as, emergent surgical priority (OR 4.3; 95% CI 2.9-7.4), CABG + Valve procedure (OR 2.3; 95% CI 1.8-3.0), and frailty (OR 1.7; 95% CI 1.2-2.5), among others. The concordance statistic for the major adverse cardiac events model in a mixed population was 0.764 (95% CL; 0.75-0.79) and had excellent calibration. Conclusions: Development of predictive models with composite end-points and mixed procedure population can yield robust statistical and clinical validity. As they more accurately reflect current cardiac surgical profile, models such as this, are an essential tool in quality improvement efforts [ABSTRACT FROM AUTHOR]

A 58-year-old male with a history of left pneumonectomy and radiation for pulmonary sarcomatoid carcinoma 8 years prior presented with significant shortness of breath, tachycardia, and a murmur. Solitary cardiac metastases have been successfully resected in small case series.[1] Palliative debulking cardiac operations for metastatic cancer are rare, with one series including a single case.[2] This palliative debulking operation resulted in 4 months with minimal symptoms. [Extracted from the article]

Background: The purpose of this study was to assess the use of arterial revascularization and to compare the in-hospital mortality with other CABG grafting strategies. Methods: A total of 71,470 CABG patients (1992–2001) in 27 centers in the United Kingdom were studied. The proportion of patients with arterial revascularization was compared. In-hospital mortality was compared for various grafting strategies: all-arterial (n = 5,401), all non-all-arterial patients (n = 66,069), one artery any number of veins (n = 49,801). The groups were compared for in-hospital mortality using multivariate logistic regression to assess the independent effect of the grafting strategies on mortality; logistic EuroSCORE-predicted mortality was compared to actual mortality, and all arterial and one artery and veins patients were compared with propensity score analysis. Results: There was a significant increase in the proportion of all-arterial patients over time (3.2% to 11.7%, p< 0.001) with evidence of variability across centers. Crude mortality for all-arterial patients was 2% vs 3% for all non-all-arterial patients (p < 0.001). In multivariate analysis, all-arterial was associated with a slight but insignificant increase in in-hospital mortality (odds ratio [OR] 1.13; [95% confidence interval {CI} 0.86–1.48], p = 0.36). There was a trend toward higher mortality in the all-arterial group when compared with the one artery and veins group (OR 1.19 [95% CI 0.91–1.56], p = 0.10). The one artery and veins group was the only group where actual mortality was significantly lower than predicted by EuroSCORE (p < 0.001). In propensity analysis the mortality was 1.51% for one artery and veins and 1.74% of all-arterial patients (p = 0.56). Conclusions: The use of arterial grafting has increased over time, varies by center, and appears to be safe in terms of in-hospital mortality. [Copyright &y& Elsevier]

Background: The safety of training residents in complex procedures has not been elucidated. In particular, the impact of resident-performed mitral valve surgery on patient outcomes is unknown.Methods: All mitral valve procedures performed by residents between 1998 and 2003 were compared with those performed by staff surgeons. Operative mortality and a composite morbidity (reoperation for bleeding, myocardial infarction, infection, stroke, or ventilation > 24 hours) were compared using multivariate analysis. Individual outcomes were compared with the use of propensity scores.Results: There were 1020 cardiac surgeries performed by residents, including 165 mitral valve procedures (86 replacements, 79 repairs). In the same period, the staff surgeons performed 261 mitral procedures. Crude operative mortality for isolated mitral procedures was 5.4% and 4.7% (resident and staff, respectively, p = 1.00). Mitral valve repair including combined procedures had an operative mortality of 3.8% and 4.3% (resident and staff, respectively, p = 1.00). The composite morbidity outcome was 29.7% and 35.3% for resident and staff-performed cases, respectively (p = 0.24). In multivariate analysis, resident was not associated with the adverse outcomes examined (OR 0.80, 95% CI, 0.47, 1.37). The incidence of major adverse outcomes for propensity score-matched mitral valve cases, including combined procedures, were similar between residents and staff, respectively: mortality, 7.4% versus 8.7% (p = 0.67), stroke, 4.0% versus 6.7% (p = 0.30), and reoperation for bleeding, 4.7% versus 9.4% (p = 0.11).Conclusions: There were no significant differences in morbidity and mortality in patients undergoing mitral valve surgery between resident and staff surgeons. It is possible to train residents to perform complex cardiac cases without adversely affecting outcomes. [Copyright &y& Elsevier]

: BackgroundSingle-center studies suggest substantial variation in intraaortic balloon pump (IABP) utilization. Our purpose is to examine IABP utilization over time and across medical centers.: MethodsThis was a prospective cohort of 29,961 consecutive patients undergoing isolated coronary artery bypass graft surgery, between 1995 and 2000, at 10 centers (eight in northern New England and two in Canada).: ResultsA total of 2,678 (8.9%) patients received an IABP. The rate of preoperative IABP insertion was 6.3%, and that of intra- or postoperative insertion was 2.6%. During the 6 years, IABP use increased from 7.0% to 10.3% (ptrend <0.001). Preoperative IABP insertion increased from 5.4% to 7.8% (ptrend < 0.001). There was no significant increase in intra-/postoperative IABP insertion 1.7% to 3.4% (ptrend = 0.34). Adjustment for changes in patient and disease characteristics did not substantially alter these results. The rate of IABP use varied substantially by center, from 5.9% to 16.4% (p < 0.001). Adjustment for patient and disease characteristics resulted in variation from 4.8% to 12.8% across the 10 centers (p < 0.001). The adjusted rates of preoperative IABP insertion varied from 3.6% to 13.7% (p < 0.001), and the rates of intra-/postoperative IABP insertion ranged from 1.0% to 5.2% (p < 0.001). There was no significant correlation between the rates of preoperative and intra-/postoperative IABP use (rs = 0.085, p = 0.815).: ConclusionsDuring the 6 years, there was a 47% increase in the rate of IABP utilization. Even after adjustment, there was almost threefold variation in IABP use across centers. This variation likely reflects lack of consensus on the appropriate use of the IABP in CABG patients. [Copyright &y& Elsevier]

The intraaortic balloon pump (IABP) has been used in cardiac operations since the late 1960s. Over the years, with refinements in technology, its use has expanded; the IABP is now the most commonly used mechanical assist device in cardiac operative procedures. This review provides an evaluation of evidence for the efficacy of IABP use in different clinical scenarios, using the American College of Cardiology/American Heart Association classification of evidence where appropriate. We evaluated complications and outcomes associated with IABP use, and attempted to draw conclusions regarding the use of the IABP in different clinical situations. We examined the trends and variation in utilization over time and across centers. We discussed the IABP in light of new cardiac assist devices and the changing patient population and management strategies. Lastly, we identified areas of future research. [Copyright &y& Elsevier]

Background. The impact of surgical training on patient outcomes in cardiac surgery is unknown.Methods. All cases performed by residents from 1998 to 2001 were compared to staff surgeon cases using prospectively collected data. Operative mortality and a composite morbidity of: reoperation for bleeding, perioperative myocardial infarction, infection, stroke, or ventilation more than 24 hours were compared using multivariate analysis.Results. Four residents performed 584 cases. The cases were as follows: coronary artery bypass grafting (CABG), 366 cases; aortic valve replacement (AVR) with or without CABG (AVR ± CABG), 86 cases; mitral valve replacement, 31 cases; mitral valve repair, 25 cases; thoracic aneurysm/dissection, 22 cases; aortic root, 20 cases; transplantations, 14 cases; and adult congenital defect repairs, 20 cases. There were 2,638 CABGs and 363 AVR ± CABG performed by the staff during the same period. Crude operative mortality in CABG patients was 2.5% (resident) and 2.9% (staff) (p = 0.62). In multivariate analysis, resident was not associated with operative mortality odds ratio (OR) of 0.59 (p = 0.19). Resident cases had a higher incidence of the composite morbidity outcome for CABG cases (19.4% vs 13.6% for staff; p = 0.003). However, in multivariate analysis, resident was not associated with increased morbidity (OR = 1.23, p = 0.16). The AVR ± CABG crude mortality was 3.6% (resident) and 2.8% (staff) (p = 0.69). Because of the small number of cases (n = 447), operative mortality was combined with the composite morbidity outcome for the AVR ± CABG model. In all, 16.7% of resident cases and 19.8% of staff cases had the composite outcome or died (p = 0.51). In multivariate analysis resident was not associated with this outcome (OR = 0.74, p = 0.35).Conclusions. In this analysis of our experience with residency training, the operative morbidity and mortality in CABG and AVR patients was similar for residents and staff. Training residents to perform cardiac surgery appears to be safe. [Copyright &y& Elsevier]

We present the case of a 62-year-old man with infectious endocarditis in a Chiari network. Chiari networks are present in 1.5% to 3% of the population. Although Chiari networks are usually clinically insignificant, they are associated with a number of conditions, including patent foramen ovale, thromboembolism, atrial aneurysm, and cardiac arrhythmias. Although there are rare reports of patients with a Chiari network who had endocarditis develop, this is the first report of a patient who had endocarditis develop solely within a Chiari network. [Copyright &y& Elsevier]

Streptococcal endocarditis in an infant is rare. We report a case of acute aortic valve endocarditis with abscess and aorta-to-right atrial fistula formation. This 4-month-old infant with a structurally normal heart had been previously well. The child was successfully treated with the Ross procedure and remains well 13 months postoperatively. [Copyright &y& Elsevier]

Abstract: Objectives: Sequential anastomoses in coronary artery bypass grafting (CABG) offer theoretical advantages including increased graft flow and more complete revascularisation. However, published studies concerning the safety and efficacy of this technique are not definitive. The objective of this study was to assess the effect of sequential anastomoses on outcomes following CABG. Methods: Perioperative data were prospectively collected on all patients with triple-vessel disease who underwent first-time, isolated, on-pump CABG between 1995 and 2005 at a single centre. Patients with a left internal mammary artery graft to the anterior wall and saphenous vein grafts to the lateral and posterior walls were included. Results: Compared to patients without sequential anastomoses (n =1108), patients with sequential anastomoses (n =1246) were more likely to have an ejection fraction (EF)<40% (14.9% vs 10.8%, p =0.004), a recent myocardial infarction (19.3% vs 14.3%, p =0.001) and an urgent/emergent operative status (19.6% vs 14.4%, p =0.0008). Median follow-up was 78 months. After adjusting for clinical covariates, sequential grafting was not an independent predictor of in-hospital adverse events (odds ratio (OR) 1.15, 95% confidence interval (CI) 0.88–1.50, p =0.31) or long-term mortality and/or readmission to hospital (hazard ratio (HR) 0.98, 95% CI 0.86–1.12, p =0.74). Sequential grafting was an independent predictor of receiving greater than three distal anastomoses (OR 9.26, 95% CI; 6.27–13.67, p <0.0001). Conclusions: Patients undergoing sequential grafting presented with greater acuity and worse systolic function. After adjusting for baseline differences, sequential grafting was not found to be an independent predictor of adverse events. These results support the safety of sequential anastomoses in patients undergoing CABG. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Diffuse coronary artery disease jeopardizes myocardium, increasing surgical mortality in primary coronary artery bypass grafting (CABG). We sought to determine the impact of diffuseness on pre- and post-discharge outcomes for both primary and reoperative CABG (REOP). Methods: Using a validated system for measuring diffuseness of coronary disease, preoperative angiograms were scored for primary CABG (n =792) and REOP cases (n =268) performed 1997–2004. A diffuseness score (DS)>18 was defined as elevated. In-hospital mortality, intermediate-term survival, and in-hospital composite outcome (COMP) (one or more of: mortality, stroke, MI, deep sternal infection, sepsis, IABP insertion, or return to OR) were examined. Results: In-hospital mortality and COMP for patients with DS>18 were significantly higher (7.9% vs 2.4%, p <0.0001), (17.8% vs 9.2%, p <0.0001). DS (mean±SD) was higher in REOP cases than primary CABG (18.9±7.1 vs 14.4±6.0, p <0.0001). By multivariate analysis, DS>18 (OR 2.00, 95%CI, 1.20–3.32, p =0.008) and REOP (OR 2.40, 95%CI, 1.53–3.77, p <0.0001) were independently associated with COMP. Using propensity scores 82% of cases with DS>18 (n =289) were matched 1:1 to cases with DS≤18. In-hospital mortality and COMP were significantly higher for cases with DS>18 (6.9% vs 2.8%, p =0.02), (16.6% vs 10.4%, p =0.03). Comparing cases with DS≤18 versus DS>18 and primary CABG versus REOP, survival at 2 years was 92.1% versus 84.5% (p =0.001) and 92.7% versus 82.7% (p <0.0001), respectively. Conclusions: Diffuse coronary artery disease is an important predictor of morbidity and mortality in primary and REOP CABG patients, and should be considered in both individual patient assessment and risk adjustment. [Copyright &y& Elsevier]

Mechanical complications of ventricular assist devices (VADs) are rare but serious. The authors describe two cases of different mechanical complications of VADs that can affect the mitral valve. Attention should be paid to the position of the inflow/outflow cannula after off-loading of the ventricle, especially in acute heart failure and normal atrial dimensions. Complete off-loading of the left ventricle in the presence of a bioprosthetic mitral valve might cause fusion of the valve leaflets leading to mitral stenosis, which will call for another intervention.

There have been significant advances in mechanical circulatory support during the past several years. Older pulsatile models of left ventricular assist devices (LVADs) (also known as VADs) have shown improved outcomes compared with medical therapy but have had limited durability and significant morbidity associated with their use. For this reason, Canadian Cardiovascular Society 2003 guidelines recommended permanent cessation of driving in these patients (for both private and commercial vehicle operation). However, recent advances with newer, continuous-flow devices have resulted in much lower rates of device-related complications and greater use of these devices for destination therapy. The majority of patients now are discharged home and lead active lives subsequently. Based on new evidence applied to the Society's "Risk of Harm" formula, it has been determined that patients with continuous-flow devices who are doing well 2 months post implantation are fit to hold noncommercial class drivers' licenses., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Delirium is the most common neurological complication following cardiac surgery. Much research has focused on potential causes of delirium; however, the sequelae of delirium have not been well investigated. The objective of this study was to investigate the relationship between delirium and sepsis post coronary artery bypass grafting (CABG) and to determine if delirium is a predictor of sepsis., Methods: Peri-operative data were collected prospectively on all patients. Subjects were identified as having agitated delirium if they experienced a short-term mental disturbance marked by confusion, illusions and cerebral excitement. Patient characteristics were compared between those who became delirious and those who did not. The primary outcome of interest was post-operative sepsis. The association of delirium with sepsis was assessed by logistic regression, adjusting for differences in age, acuity, and co-morbidities., Results: Among 14,301 patients, 981 became delirious and 227 developed sepsis post-operatively. Rates of delirium increased over the years of the study from 4.8 to 8.0% (P = 0.0003). A total of 70 patients of the 227 with sepsis, were delirious. In 30.8% of patients delirium preceded the development of overt sepsis by at least 48 hours. Multivariate analysis identified several factors associated with sepsis, (receiver operating characteristic (ROC) 79.3%): delirium (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.6 to 3.4), emergent surgery (OR 3.3, CI 2.2 to 5.1), age (OR 1.2, CI 1.0 to 1.3), pre-operative length of stay (LOS) more than seven days (OR 1.6, CI 1.1 to 2.3), pre-operative renal insufficiency (OR 1.9, CI 1.2 to 2.9) and complex coronary disease (OR 3.1, CI 1.8 to 5.3)., Conclusions: These data demonstrate an association between delirium and post-operative sepsis in the CABG population. Delirium emerged as an independent predictor of sepsis, along with traditional risk factors including age, pre-operative renal failure and peripheral vascular disease. Given the advancing age and increasing rates of delirium in the CABG population, the prevention and management of delirium need to be addressed.

Background: We investigated the association between trainees performing supervised operations and late outcomes of patients undergoing cardiac surgery., Methods and Results: Data were prospectively collected on patients who underwent coronary artery bypass graft surgery, aortic valve replacement, or a combination of these between 1998 and 2005 at the Maritime Heart Center, Halifax, Canada. In-hospital mortality and a composite outcome of in-hospital mortality, stroke, bleeding, intra-aortic balloon pump insertion, renal failure, and sternal infection was compared between teaching (n=1054) and nonteaching cases (n=5877). Late survival and cardiovascular hospital readmissions were also examined. To adjust for baseline risk disparities, we used logistic regression for dichotomous in-hospital outcomes and Cox proportional hazards regression for survival data. Resident cases were significantly more likely to have high-risk features such as depressed ventricular function, redo operation, and urgent or emergent procedure. Resident as primary operator was not independently associated with in-hospital mortality (OR, 1.09; 95% CI, 0.75 to 1.58; P=0.66) or with the composite outcome (OR, 1.01; 95%, CI 0.82 to 1.26; P=0.90). The Kaplan-Meier event-free survival of the 2 groups was equivalent at 1, 3, and 5 years (log-rank P=0.06). By Cox regression, resident cases were not associated with late death or cardiovascular rehospitalization (hazard ratio, 1.05; 95% CI, 0.94 to 1.17; P=0.42)., Conclusions: Cases performed by senior-level cardiac surgery residents were more likely to have greater acuity and complexity than staff surgeon-performed cases. However, clinical outcomes were similar in the short- and long-term. Allowing residents to perform cardiac surgery is not associated with adverse patient outcomes.

Selective serotonin reuptake inhibitors (SSRIs) are widely used to treat depression. We report a case of serotonin syndrome following cardiac surgery. This syndrome is rare in the cardiac literature. The clinical features, diagnosis and management of this unusual syndrome are described. In patients with polypharmacy, it is important to take cognisance of serotonergic antidepressants and anticipate their potential interactions with drugs used peri-operatively. Early recognition and treatment is important as this condition is potentially fatal.

A variety of extracorporeal techniques have been described in surgery of the descending thoracic and thoracoabdominal aorta. We describe an operative approach involving the cannulation of the pulmonary artery for venous drainage in 12 patients undergoing descending thoracic aortic surgery. In-hospital mortality was 17%; there were no in-hospital deaths for elective cases. There were no cases of post-operative paraplegia. Cannulation of the pulmonary artery is a safe and technically simple means of providing venous drainage during cardiopulmonary bypass in aortic surgery. This is an effective approach to distal perfusion in aortic surgery that is associated with excellent flows and avoids cannulating the left side of the heart.

Background: After coronary artery bypass graft (CABG) patients are at high risk for disease progression and future cardiac events. Risk factor control can reduce subsequent clinical events and mortality. The appropriateness of cardiovascular risk factor management in CABG patients is largely unknown., Objectives: To evaluate the presence of cardiovascular risk factors, their treatment and the adequacy of that treatment in patients just before elective CABG PATIENTS AND METHODS: Over a six-month period in 1999, 120 patients who underwent elective CABG at a single centre were assessed. All patients were assessed for the presence of important, known, modifiable cardiovascular risk factors (smoking, hypertension, hypercholesterolemia, obesity and diabetes), and the adequacy of the control of these risk factors, as determined by published consensus conference guidelines., Results: Ninety-five per cent of patients were receiving treatment for their risk factors. Twenty of 86 patients had their hyperlipidemia controlled, only 10 of 36 patients with diabetes had their glucose well controlled, 56 of 82 patients had adequate control of their hypertension, 21 of 120 patients were current smokers, 78 of 120 patients were obese and only 13 of 120 patients had all risk factors under control., Conclusions: As expected, the prevalence of all the risk factors was very high. Despite a high level of medical treatment, risk factor management was very poor. More effort needs to go into active, long term management, and patient education and motivation, if any substantial progress is to be made in reducing future cardiac events in patients after CABG.