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Introduction: Cardiac surgery demands effective teamwork for safe, high-quality care. The objective of this pilot study was to develop a comprehensive program to sharpen performance of experienced cardiac surgical teams in acute crisis management., Methods: We developed and implemented an educational program for cardiac surgery based on high realism acute crisis simulation scenarios and interactive whole-unit workshop. The impact of these interventions was assessed with postintervention questionnaires, preintervention and 6-month postintervention surveys, and structured interviews., Results: The realism of the acute crisis simulation scenarios gradually improved; most participants rated both the simulation and whole-unit workshop as very good or excellent. Repeat simulation training was recommended every 6 to 12 months by 82% of the participants. Participants of the interactive workshop identified 2 areas of highest priority: encouraging speaking up about critical information and interprofessional information sharing. They also stressed the importance of briefings, early communication of surgical plan, knowing members of the team, and continued simulation for practice. The pre/post survey response rates were 70% (55/79) and 66% (52/79), respectively. The concept of working as a team improved between surveys (P = .028), with a trend for improvement in gaining common understanding of the plan before a procedure (P = .075) and appropriate resolution of disagreements (P = .092). Interviewees reported that the training had a positive effect on their personal behaviors and patient care, including speaking up more readily and communicating more clearly., Conclusions: Comprehensive team training using simulation and a whole-unit interactive workshop can be successfully deployed for experienced cardiac surgery teams with demonstrable benefits in participant's perception of team performance., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: We sought to assess early and late survival and cardiovascular-specific mortality after surgical repair of acute ascending aortic dissection and the effect of differences in surgical technique, patient characteristics, and preoperative diagnostic testing., Methods: Between 1979 and 2003, 195 consecutive patients underwent repair for acute ascending aortic dissection within 2 weeks of the onset of symptoms. Mean follow-up was 7.0 +/- 5.9 years (range, 0-26 years) and was 100% complete., Results: Patients were aged 62 +/- 15 years on average and were mostly male (66%) and hypertensive (69%). Risk of death early and late after the operation decreased over the study period, with hospital mortality decreasing from 21% to 4% when comparing the first and most recent quartiles (P = .007, chi(2) test for trend). At 1, 5, 10, and 20 years postoperatively, survival was 84%, 69%, 55%, and 30%, respectively, and freedom from cardiovascular death was 86%, 80%, 71%, and 51%, respectively. Additional independent risk factors for death were older age (P < .001), renal dysfunction (P < .003), syncope (P = .007), and peripheral vascular disease (P = .006). During the study period, echocardiographic and computed tomographic diagnostic imaging replaced routine aortic angiographic analysis, and operative techniques involved more frequent use of open distal anastomoses, retrograde cerebral perfusion, earlier restoration of antegrade perfusion, and a conservative approach to aortic arch repair. Freedom from reoperation on the aorta or aortic valve was 93% and 84% at 5 and 10 years, respectively., Conclusions: Early and late survival after repair of acute ascending aortic dissection has improved progressively over 25 years in association with noticeable changes in preoperative and intraoperative management. Aortic reoperations were infrequent during follow-up.

Background: Few studies of learning in the health care sector have analyzed measures of process, as opposed to outcomes. We assessed the learning curve for a new cardiac surgical center using precursor events (incidents or circumstances required for the occurrence of adverse outcomes)., Methods: Intraoperative precursor events were recorded prospectively during major adult cardiac operations, categorized by blinded adjudicators, and counted for each case (overall and according to these categories). Trends in the number of precursor events were analyzed by hospital and by defining 10 equal-sized groups across time, as were trends in outcomes obtained from institutional databases. Results from the first 101 cases performed at a new cardiac surgical site (hospital A) were compared with 2 established centers., Results: A steep reduction in the total number of precursor events over time was observed in the early experience of hospital A (9.2 +/- 4.9 to 2.0 +/- 1.2 events per case, from first to last decile of time, P(trend) < .0001) compared with qualitatively stable levels in the other hospitals; this reduction was driven largely by decreases in the minor severity (P(trend) < .0001), compensated (P(trend) < .0001), and environment (P(trend) < .0001) categories of precursor events. No detectable changes over time were observed in postoperative mortality and complications. No significant improvement was observed in patient comorbid conditions or medical status over time to explain the trend in hospital A., Conclusion: Analyzing and targeting specific kinds of process-related failures (precursor events) may provide a novel and sensitive means of tracking, deconstructing, and optimizing organizational learning in medicine.

Background: Although extensive study has been directed at the influence of patient factors and comorbidities on cardiac surgical outcomes, less attention has been focused on process. We sought to examine the relationship between intraoperative precursor events (those events that precede and are requisite for the occurrence of an adverse event) and adverse outcomes themselves., Methods: Anonymous, prospectively collected intraoperative data was merged with database outcomes for 450 patients undergoing major adult cardiac operations. Precursor events were categorized by type, person most affected, severity, and compensation. Number and categories of precursor events were analyzed as predictors of a composite outcome combining death or near miss complications (DNM), using logistic regression., Results: Precursor events occurred more frequently in cases with a DNM outcome than in those with no adverse event (2.7 +/- 2.4 vs 2.0 +/- 2.3/procedure, P = .005). After adjustment for other patient characteristics, the number of precursor events remained an independent predictor of DNM (RR, 1.14 per event [1.04 to 1.24]). Of 990 events, 35.6% related to management, 28.8% were technical, and 22.8% were environment-related. The surgeon was most affected in 40.8%, and 16.5% were of major severity. When categories of precursor events were analyzed, major severity events and those most affecting the surgeon were independent predictors of DNM., Conclusions: More detailed study of process in complex operations may lead to improved quality of care and patient safety. Special attention must be paid particularly to high risk patients and high risk precursor events.

Over a 7-year period, 5.8% (n = 210) of patients who underwent coronary artery bypass grafting at our institution had severely impaired global left ventricular function with an ejection fraction of 20% or less. Mean age at operation was 66 years (+/- 0.7; standard error), and 76% of patients were male. Primary indications for operation were unstable angina (73 patients, 35%), return of symptoms with previous bypass grafting (41 patients, 20%), congestive heart failure with reversible ischemia (55 patients, 26%), and recurrent ventricular arrhythmias (41 patients, 20%). Overall, actuarial survival (n = 210) was 82%, 79%, and 73% at 1, 2, and 5 years. Risk of death was highest early after the operation, and then declined rapidly to a constant level. Patients who did not receive retrograde coronary sinus cardioplegia (p = 0.05), older patients (p = 0.004), and those with preoperative ventricular arrhythmias (p = 0.003) or renal failure (p < 0.0001) had an increased risk of death early after operation. Patients with congestive symptoms and those requiring extensive or redo bypass grafting (p = 0.02) were found to be at an increased risk of death throughout the follow-up period. When the number of distal anastomoses performed increased, survival was found to decrease (p < 0.003), and to a greater extent in women than in men (p = 0.02). Of the four primary indications for operation, unstable angina yielded the highest risk-adjusted survival. Successful results after surgical revascularization in patients with severe impairment of ventricular function can be achieved by careful patient selection and management.

Replacement valve endocarditis occurred in 3.7% of 2443 patients who underwent primary or redo aortic valve replacements at The Prince Charles Hospital between December 31, 1969 and January 1, 1992, based on a cross-sectional follow-up in 1992 which was 98.8% complete. Because some patients had re-replacements during the study period, a total of 2686 operations were considered for analysis. A variety of replacement devices were used, including 571 allografts (21%), 1152 xenografts (43%), and 880 mechanical valves (36%). Insertion of an allograft valve resulted in a constant risk of endocarditis which, by multivariable hazard function analysis, negated the effect of any early-phase factors (p < 0.0001). With other replacement devices, the risk of infection peaked early after operation (9 weeks) and then gave way to a constant risk. Compared with the risk associated with allograft valves, constant risk was higher when the replacement device was a Carpentier-Edwards xenograft (n = 1021, p = 0.02) and lower when a St. Jude Medical mechanical valve was used (n = 505, p = 0.05). In nonallograft recipients, the presence of active preoperative endocarditis (p < 0.0001) or a concomitant synthetic synthetic aortic root replacement (p = 0.0006) increased the magnitude of the early peaking risk. Regardless of replacement device, constant risk was increased in patients with renal dysfunction (p = 0.01), in younger patients 0.04). When preoperative endocarditis was caused by Staphylococcus aureus, culture-positive postoperative wound infection was associated with increased risk of replacement valve infection (p < 0.001) and when it occurred, the same organism was usually responsible (86%). Identification of patients at increased risk for replacement valve infection may lead to reduced morbidity through strategies such as selective use of replacement devices and antimicrobial prophylaxis.