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Mitral annular calcification (MAC) increases technical complexity for surgeons during mitral valve (MV) procedures. This study assesses the risks conferred by the presence of MAC in patients undergoing MV replacement (MVR) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database.A total of 52,816 MVR procedures were performed between 2011 and June 2017. Individuals with concomitant tricuspid procedures were included, but those from institutions that reported1 MAC case/y were excluded. Operative mortality and in-hospital complications in MAC patients were compared with controls from the same institution. The contribution of hospital MV procedure volume (stratified by mean procedures per year during) to adjusted operative mortality was also assessed.Overall, 9551 MVR cases were classified as MAC (18.1%). Observed operative mortality was 5.8% for MAC and 4.4% for non-MAC patients (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.19-1.38). Although postoperative stroke and reoperation rates were similar, MAC was associated with increased risk of acute kidney injury (relative risk, 1.15) and reintubation (relative risk, 1.26) (all P.001). After risk adjustment, MAC remained a risk factor for operative mortality (OR, 1.24; 95% CI, 1.08-1.42). Centers with less than 50 MV procedures/y were also associated with increased operative mortality (OR, 1.21; 95% CI, 1.08-1.37; observed-to-expected mortality among MAC patients 1.09 vs 0.82 in centers with ≥ 50 MV procedures; P = .001) CONCLUSIONS: The presence of MAC alone, regardless of severity, was independently associated with increased operative mortality and adverse postoperative outcomes. Even after adjusting for attendant cardiovascular and metabolic comorbidities, centers with low MV case volumes were found to have worse outcomes after MVR.

Background: We hypothesized that protein delivery during hospitalization in patients who survived critical care would be associated with outcomes following hospital discharge. Methods: We studied 801 patients, age &ge, 18 years, who received critical care between 2004 and 2012 and survived hospitalization. All patients underwent a registered dietitian formal assessment within 48 h of ICU admission. The exposure of interest, grams of protein per kilogram body weight delivered per day, was determined from all oral, enteral and parenteral sources for up to 28 days. Adjusted odds ratios for all cause 90-day post-discharge mortality were estimated by mixed- effects logistic regression models. Results: The 90-day post-discharge mortality was 13.9%. The mean nutrition delivery days recorded was 15. In a mixed-effect logistic regression model adjusted for age, gender, race, Deyo-Charlson comorbidity index, acute organ failures, sepsis and percent energy needs met, the 90-day post-discharge mortality rate was 17% (95% CI: 6&ndash, 26) lower for each 1 g/kg increase in daily protein delivery (OR = 0.83 (95% CI 0.74&ndash, 0.94, p = 0.002)). Conclusions: Adult medical ICU patients with improvements in daily protein intake during hospitalization who survive hospitalization have decreased odds of mortality in the 3 months following hospital discharge.

Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period.Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients.Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p = 0.018).This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.

Catalytic iron, the chemical form of iron capable of participating in redox cycling, is a key mediator of acute kidney injury (AKI) in multiple animal models, but its role in human AKI has not been studied. Here we tested in a prospective cohort of 250 patients undergoing cardiac surgery whether plasma catalytic iron levels are elevated and associated with the composite outcome of AKI requiring renal replacement therapy or in-hospital mortality. Plasma catalytic iron, free hemoglobin, and other iron parameters were measured preoperatively, at the end of cardiopulmonary bypass, and on postoperative days 1 and 3. Plasma catalytic iron levels, but not other iron parameters, rose significantly at the end of cardiopulmonary bypass and were directly associated with bypass time and number of packed red blood cell transfusions. In multivariate analyses adjusting for age and preoperative eGFR, patients in the highest compared with the lowest quartile of catalytic iron on postoperative day 1 had a 6.71 greater odds of experiencing the primary outcome, and also had greater odds of AKI, hospital mortality, and postoperative myocardial injury. Thus, our data are consistent with and expand on findings from animal models demonstrating a pathologic role of catalytic iron in mediating adverse postoperative outcomes. Interventions aimed at reducing plasma catalytic iron levels as a strategy for preventing AKI in humans are warranted.

Background The association between long-term survival and aortic atheroma in cardiac surgical patients has not been comprehensively investigated. In this study we determine the relation between grade of atheroma and the risk of long-term mortality in a retrospective cohort of more than 20,000 patients undergoing cardiac operation during a 20-year period. Methods We included 22,304 consecutive intraoperative transesophageal and epiaortic ultrasound examinations performed at Brigham and Women's Hospital between 1995 and 2014, with long-term follow-up. The extent of atheromatous disease recorded in each examination was used for analysis. Mortality data were obtained from our institution's data registry. Mortality analyses were done using Cox proportional hazard regression models with follow-up as a time scale. We repeated the analysis in a subgroup of 14,728 patients with more detailed demographic characteristics, including postoperative stroke, queried from the institutional Society of Thoracic Surgeons database. Results A total of 7,722 mortality events and 872 stroke events occurred. Patients with atheromatous disease demonstrated a significant increase in mortality across all grades of severity, both for the ascending and descending aorta. This relation remained unchanged after adjusting for additional covariates. Adjustments for postoperative stroke resulted in only minimal attenuation in the risk of postoperative mortality related to aortic atheroma. Conclusions Aortic atheromatous disease of any grade in the ascending and descending aorta is a significant long-term risk of long-term, all-cause mortality in cardiac operation patients. This association remains independent of other conventional risk factors and is not related to postoperative cerebrovascular accidents.

Beginning in 2002, all 14 Massachusetts nonfederal cardiac surgery programs submitted Society of Thoracic Surgeons (STS) National Database data to the Massachusetts Data Analysis Center for mandatory state-based analysis and reporting, and to STS for nationally benchmarked analyses. We sought to determine whether longitudinal prevalences and trends in risk factors and observed and expected mortality differed between Massachusetts and the nation.We analyzed 2003 to 2014 expected (STS predicted risk of operative [in-hospital + 30-day] mortality), observed, and risk-standardized isolated coronary artery bypass graft mortality using Massachusetts STS data (N = 39,400 cases) and national STS data (N = 1,815,234 cases). Analyses included percentage shares of total Massachusetts coronary artery bypass graft volume and expected mortality rates of 2 hospitals before and after outlier designation.Massachusetts patients had significantly higher odds of diabetes, peripheral vascular disease, low ejection fraction, and age ≥75 years relative to national data and lower odds of shock (odds ratio, 0.66; 99% confidence interval, 0.53-0.83), emergency (odds ratio, 0.57, 99% confidence interval, 0.52-0.61), reoperation, chronic lung disease, dialysis, obesity, and female sex. STS predicted risk of operative [in-hospital + 30-day] mortality for Massachusetts patients was higher than national rates during 2003 to 2007 (P .001) and no different during 2008 to 2014 (P = .135). Adjusting for STS predicted risk of operative [in-hospital + 30-day] mortality, Massachusetts patients had significantly lower odds (odds ratio, 0.79; 99% confidence interval, 0.66-0.96) of 30-day mortality relative to national data. Outlier programs experienced inconsistent, transient influences on expected mortality and their percentage shares of Massachusetts coronary artery bypass graft cases.During 12 years of mandatory public reporting, Massachusetts risk-standardized coronary artery bypass graft mortality was consistently and significantly lower than national rates, expected rates were comparable or higher, and evidence for risk aversion was conflicting and inconclusive.

Objectives Functional status prior to coronary artery bypass graft surgery may be a risk factor for post-operative adverse events. We sought to examine the association between functional status in the 3 months prior to coronary artery bypass graft surgery and subsequent 180 day mortality. Design, setting, and participants We performed a single center retrospective cohort study in 718 adults who received coronary artery bypass graft surgery from 2002 to 2014. Exposures The exposure of interest was functional status determined within the 3 months preceding coronary artery bypass graft surgery. Functional status was measured and rated by a licensed physical therapist based on qualitative categories adapted from the Functional Independence Measure. Main outcomes and measures The main outcome was 180-day all-cause mortality. A categorical risk prediction score was derived based on a logistic regression model of the function grades for each assessment. Results In a logistic regression model adjusted for age, gender, New York Heart Association Class III/IV, chronic lung disease, hypertension, diabetes, cerebrovascular disease, and the Society of Thoracic Surgeons score, the lowest quartile of functional status was associated with an increased odds of 180-day mortality compared to patients with highest quartile of functional status [OR = 4.45 (95%CI 1.35, 14.69; P = 0.014)]. Conclusions Lower functional status prior to coronary artery bypass graft surgery is associated with increased 180-day all-cause mortality.

ObjectivePostoperative hyperglycemia is associated with poor clinical outcomes in patients undergoing cardiac surgery. However, some experts consider hyperglycemia to be an epiphenomenon related to acute stress. We investigated whether preoperative patient characteristics can predict hyperglycemia after cardiac surgery in nondiabetic patients.MethodsThis is a retrospective study of nondiabetic patients undergoing cardiac surgery at a single center during the years 2004 to 2009. Hyperglycemia was defined as 2 consecutive blood glucose readings of 150 mg/dL or greater during the 72 hours after cardiac surgery.ResultsThis study included 1453 patients with hyperglycemia and 2205 patients without hyperglycemia. Hyperglycemic patients were older, were more likely to be men, had higher body mass index, were more likely to be hypertensive and hypercholesterolemic, and had lower left ventricular ejection fractions; in addition, a greater proportion had a history of cardiovascular disease and renal failure. Multivariate logistic regression analysis showed age, gender, body mass index, preoperative serum creatinine, left ventricular ejection fraction, previous cardiac surgery, and preoperative cardiogenic shock to be independently associated with hyperglycemia (P

BACKGROUND: We hypothesized that metabolic profiles would differ in critically ill patients with malnutrition relative to those without. MATERIALS AND METHODS: We performed a prospective cohort study on 85 adult patients with systemic inflammatory response syndrome or sepsis admitted to a 20-bed medical intensive care unit (ICU) in Boston. We generated metabolomic profiles using gas and liquid chromatography and mass spectroscopy. We followed this by logistic regression and partial least squares discriminant analysis to identify individual metabolites that were significant. We then interrogated the entire metabolomics profile using metabolite set enrichment analysis and network model construction of chemical-protein target interactions to identify groups of metabolites and pathways that were differentiates in patients with and without malnutrition. RESULTS: Of the cohort, 38% were malnourished at admission to the ICU. Metabolomic profiles differed in critically ill patients with malnutrition relative to those without. Ten metabolites were significantly associated with malnutrition (P < .05). A parsimonious model of 5 metabolites effectively differentiated patients with malnutrition (AUC = 0.76), including pyroglutamine and hypoxanthine. Using pathway enrichment analysis, we identified a critical role of glutathione and purine metabolism in predicting nutrition. Nutrition status was associated with 28-day mortality, even after adjustment for known phenotypic variables associated with ICU mortality. Importantly, 7 metabolites associated with nutrition status were also associated with 28-day mortality. CONCLUSION: Malnutrition is associated with differential metabolic profiles early in critical illness. Common to all of our metabolome analyses, glutathione and purine metabolism, which play principal roles in cellular redox regulation and accelerated tissue adenosine triphosphate degradation, respectively, were significantly altered with malnutrition.

Objective 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) have been shown to have pleiotropic effects in addition to their lipid-lowering properties. Some studies have shown the beneficial effect of preoperative statins on operative outcomes in coronary artery bypass grafting. However, the effect of preoperative statins in patients without coronary artery disease who undergo cardiac surgery remains poorly defined. Methods We performed a retrospective review of 1389 consecutive patients undergoing cardiac valve surgery between January of 2002 and December of 2005. Patients undergoing concomitant coronary artery bypass surgery and those with a history of myocardial infarction and coronary interventions were excluded. Of this cohort, 363 patients were receiving a statin preoperatively and 1026 patients were not. Propensity scores were constructed with patients' demographics, clinical data, and the year of procedure. Generalized estimating equations, including the propensity score as a covariate, were used to investigate whether preoperative statin use is associated with improved operative outcomes. Results The crude operative mortality rate was 0.8% and 2.3%, the incidence of stroke was 1.7% and 2.9%, and the incidence of perioperative myocardial infarction was 2.2% and 2.4% in the statin and non-statin groups, respectively. Generalized estimating equations showed that preoperative statin use is associated with lower mortality (odds ratio: 0.25, 95% confidential interval: 0.12–0.54). Preoperative statin use was not significantly associated with an incidence of stroke (odds ratio: 0.48, 95% confidential interval: 0.19–1.22) or perioperative myocardial infarction (odds ratio: 0.91, 95% confidential interval: 0.43–1.91) in this cohort. Conclusion Preoperative use of statins may improve operative outcomes in patients without coronary artery disease who undergo cardiac surgery.

With increasing prevalence of injected drug use in the United States, a growing number of intravenous drug users (IVDUs) are at risk for infective endocarditis (IE) that may require surgical intervention; however, few data exist about clinical outcomes of these individuals.We evaluated consecutive adult patients undergoing surgery for active IE between 2002 and 2014 pooled from 2 prospective institutional databases. Death and valve-related events, including reinfection or heart valve reoperation, thromboembolism, and anticoagulation-related hemorrhage were evaluated.Of the 436 patients identified, 78 (17.9%) were current IVDUs. The proportion of IVDUs increased from 14.8% in 2002 to 2004 to 26.1% in 2012 to 2014. IVDUs were younger (aged 35.9 ± 9.9 years vs 59.3 ± 14.1 years) and had fewer cardiovascular risk factors than non-IVDUs. During follow-up (median, 29.4 months; quartile 1-3, 4.7-72.6 months), adverse events among all patients included death in 92, reinfection in 42, valve-reoperation in 35, thromboembolism in 17, and hemorrhage in 16. Operative mortality was lower among IVDUs (odds ratio, 0.25; 95% confidence interval [CI], 0.06-0.71), but overall mortality was not significantly different (hazard ratio [HR], 0.78; 95% CI, 0.44-1.37). When baseline profiles were adjusted by propensity score, IVDUs had higher risk of valve-related complications (HR, 3.82; 95% CI, 1.95-7.49; P .001) principally attributable to higher rates of reinfection (HR, 6.20; 95% CI, 2.56-15.00; P .001).The proportion of IVDUs among surgically treated IE patients is increasing. Although IVDUs have lower operative risk, long-term outcomes are compromised by reinfection.

Background Surgical dogma suggests that homografts should be used preferentially, compared with conventional xenograft or mechanical prostheses, in the setting of infective endocarditis (IE), because they have greater resistance to infection. However, comparative data that support this notion are limited. Methods From the prospective databases of 2 tertiary academic centers, we identified 304 consecutive adult patients (age ≥17 years) who underwent surgery for active IE involving the aortic valve (AV), in the period 2002 to 2014. Short- and long-term outcomes were evaluated using propensity scores and inverse-probability weighting to adjust for selection bias. Results Homografts, and xenograft and mechanical prostheses, were used in 86 (28.3%), 139 (45.7%), and 79 (26.0%) patients, respectively. Homografts were more often used in the setting of prosthetic valve endocarditis (58.1% vs 28.8%, P = .002) and methicillin-resistant Staphylococcus (25.6% vs 12.1%, P = .002), compared with conventional prostheses. Early mortality occurred in 17 (19.8%) in the homograft group, and 20 (9.2%) in the conventional group ( P = .019). During follow-up (median: 29.4 months; interquartile-range: 4.7-72.6 months), 60 (19.7%) patients died, and 23 (7.7%) experienced reinfection, with no significant differences in survival ( P = .23) or freedom from reinfection rates ( P = .65) according to the types of prostheses implanted. After adjustments for baseline characteristics, using propensity-score analyses, use of a homograft did not significantly affect early death (odds ratio 1.61; 95% confidence interval [CI], 0.73-3.40, P = .23), overall death (hazard ratio 1.10; 95% CI, 0.62-1.94, P = .75), or reinfection (hazard ratio 1.04; 95% CI, 0.49-2.18, P = .93). Conclusions No significant benefit to use of homografts was demonstrable with regard to resistance to reinfection in the setting of IE. The choice among prosthetic options should be based on technical and patient-specific factors. Lack of availability of homografts should not impede appropriate surgical intervention.

Background. Choice of statistical methodology may significantly impact the results of provider profiling, including cardiac surgery report cards. Because of sample size and clustering issues, logistic regression may overestimate systematic interprovider variability, leading to false outlier classification. Theoretically, the use of hierarchical models should result in more accurate representation of provider performance. Methods. Extensively validated and audited data were available for all 4,603 isolated coronary artery bypass grafting procedures performed at 13 Massachusetts hospitals during 2002. To produce the official Massachusetts cardiac surgery report card, a 19-variable predictor set and a hierarchical generalized linear model were employed. For the current study, this same analysis was repeated with the 14 predictors used in the New York Cardiac Surgery Reporting System. Two additional analyses were conducted using each set of predictor variables and applying standard logistic regression. For each of the four combinations of predictors and models, the point estimates of risk-adjusted 30-day mortality, 95% confidence or probability intervals, and outlier status were determined for each hospital. Results. Overall unadjusted mortality for coronary bypass operations was 2.19%. For most hospitals, there was wide variability in the point estimates and confidence or probability intervals of risk-adjusted mortality depending on statistical model, but little variability relative to the choice of predictors. There were no hospital outliers using hierarchical models, but there was one outlier using logistic regression with either predictor set. Conclusions. When used to compare provider performance, logistic regression increases the possibility of false outlier classification. The use of hierarchical models is recommended.

We examined the impact of concomitant coronary artery bypass grafting (CABG) on hospital survival after aortic root replacement. We sought to determine whether CABG procedures that were not originally planned but rather added after the aortic root procedure was completed (CABG/bailout) skewed the results to shift patients with bad outcomes to the CABG group, making the non-CABG group appear undeservedly low risk.Between May 1992 and January 2001, 369 consecutive patients underwent aortic root replacement. Concomitant CABG was required in 95 patients (26%). Indications for CABG were significant coronary artery disease in 73 patients (20%), active endocarditis or acute aortic dissection involving the coronary orifices in 14 patients (4%), and difficulty weaning from bypass because of regional wall motion abnormality from presumed but unconfirmed coronary artery disease or technical error at coronary ostial reimplantation (CABG/bailout) in 8 patients (2%).Operative mortality for the entire cohort was 5.7% (21 patients). The operative mortality rate for the non-CABG group was 0.4% (1 of 274 patients), and for the CABG group, 21% (20 of 95 patients; p0.001). Independent predictors of operative mortality in the CABG group were New York Heart Association functional class III or IV (odds ratio, 3.9; 95% confidence interval, 1.07 to 14.5), active endocarditis (odds ratio, 9.2; 95% confidence interval, 2.06 to 41.5), acute aortic dissection (odds ratio, 7.6; 95% confidence interval, 1.81 to 32.0), and failure to use retrograde cardioplegia (odds ratio, 6.4; 95% confidence interval, 1.06 to 38.8). The use of CABG/bailout was not a predictor.Adding CABG at the end of an aortic root procedure is a rare event, and because it is rare, there is no significant shift of risk as a result of the CABG/bailout patients on the overall CABG group.

Objectives The goal of this study was to determine if a “hybrid” approach to the treatment of complex combined coronary and valve disease is superior to the results predicted by a Society of Thoracic Surgeons9 (STS) algorithm with conventional coronary artery bypass graft (CABG)/valve surgery in high-risk patients. Background With advancements in percutaneous coronary interventions (PCIs), some patients requiring coronary revascularization and valve surgery may benefit from a hybrid approach involving initial planned PCI followed by valve surgery, rather than conventional CABG/valve surgery. Methods We retrospectively analyzed 26 consecutive patients with coronary artery and valve disease who underwent planned initial PCI followed by valve surgery during the same hospital stay between September 1997 and August 2003. We calculated the predicted mortality at the time of PCIand compared it with the observed mortality. Results There were 12 male and 14 female patients with a median age of 72 years (range 53 to 91 years). Balloon angioplasty was performed in all patients, followed by stenting in 22 (85%) patients. Within a median of 5 days (range 0 to 14 days), 15 patients (58%) underwent primary and 11 patients (42%) underwent re-operative valve surgery. Operative mortality was 1 of 26 patients (3.8%), dramatically lower than the STS-predicted mortality of 22%. Median blood loss was 900 ml, and 22 patients (85%) required blood transfusions. Survival at 1, 3, and 5 years was 78%, 56%, and 44%, respectively. Conclusions Hybrid initial PCI followed by staged valve surgery represents an excellent alternative to conventional CABG/valve surgery in some high-risk patients, particularly those who present in shock after myocardial infarction. Lower mortality rates come at the cost of more bleeding and transfusion requirements.

Background With advances in percutaneous coronary interventions, many patients now referred for coronary artery bypass grafting have diffuse coronary artery disease. We undertook this retrospective study to determine whether left anterior descending (LAD) coronary endarterectomy is a safe and effective long-term adjunct to coronary artery bypass grafting in patients who cannot otherwise be completely revascularized. Methods Between January 1992 and March 2000, 196 of 7,633 (2.5%) consecutive patients underwent LAD coronary endarterectomy with coronary artery bypass grafting. Median age was 67 years (range, 33 to 97 years), 101 patients (52%) had unstable angina, and 182 (93%) were in New York Heart Association class III or IV. Thirty-three patients (17%) had ongoing myocardial infarction; another 17 (9%) had myocardial infarction less than 1 month. Thirty patients (15%) required intraaortic balloon pump preoperatively and 19 (10%) were reoperations. Results All patients underwent LAD endarterectomy with coronary artery bypass grafting to the LAD. The left internal mammary artery was grafted to the LAD in 151 patients (77%), and 46 of 151 (30%) of these required an additional vein patch to the endarterectomized bed. Concomitant valve procedures were performed in 8 (4%) patients. Overall hospital mortality was 3% (6 of 196). Perioperative myocardial infarction in the LAD territory was 3%. One-year survival was 94% (95% confidence interval, 90% to 97%), whereas 5-year survival was 74% (95% confidence interval, 66% to 80%). Freedom from cardiac events (angina, myocardial infarction, congestive heart failure, percutaneous coronary interventions) was 90% (95% confidence interval, 84% to 94%) at 1 year and 84% (95% confidence interval, 75% to 90%) at 5 years. Conclusions Despite the presence of diffuse coronary artery disease, coronary artery bypass grafting with LAD endarterectomy offers excellent results with very low hospital mortality and morbidity, and favorable long-term survival.

We hypothesized that preexisting malnutrition in patients who survived critical care would be associated with adverse outcomes following hospital discharge.We performed an observational cohort study in 1 academic medical center in Boston. We studied 23,575 patients, aged ≥18 years, who received critical care between 2004 and 2011 and survived hospitalization.The exposure of interest was malnutrition determined at intensive care unit (ICU) admission by a registered dietitian using clinical judgment and on data related to unintentional weight loss, inadequate nutrient intake, and wasting of muscle mass and/or subcutaneous fat. The primary outcome was 90-day postdischarge mortality. Secondary outcome was unplanned 30-day hospital readmission. Adjusted odds ratios were estimated by logistic regression models adjusted for age, race, sex, Deyo-Charlson Index, surgical ICU, sepsis, and acute organ failure. In the cohort, the absolute risk of 90-day postdischarge mortality was 5.9%, 11.7%, 15.8%, and 21.9% in patients without malnutrition, those at risk of malnutrition, nonspecific malnutrition, and protein-energy malnutrition, respectively. The odds of 90-day postdischarge mortality in patients at risk of malnutrition, nonspecific malnutrition, and protein-energy malnutrition fully adjusted were 1.77 (95% confidence interval [CI], 1.23-2.54), 2.51 (95% CI, 1.36-4.62), and 3.72 (95% CI, 2.16-6.39), respectively, relative to patients without malnutrition. Furthermore, the presence of malnutrition is a significant predictor of the odds of unplanned 30-day hospital readmission.In patients treated with critical care who survive hospitalization, preexisting malnutrition is a robust predictor of subsequent mortality and unplanned hospital readmission.

The systemic immune response is a dynamic process involving the trafficking of lymphocytes from the Ag-stimulated lymph node to the peripheral tissue. Studies in sheep have demonstrated several phases of cell output in the efferent lymph after Ag stimulation. When skin contact sensitizers are used as Ag, the efferent lymph cell output peaks ∼96 h after Ag stimulation and is temporally associated with the recruitment of cells into the skin. To investigate the relative contribution of this high-output phase of efferent lymphocytes to lymphocytic inflammation in the skin, we used a common contact sensitizer 2-phenyl-4-ethoxymethylene-5-oxazolone (oxazolone) to stimulate the skin and draining prescapular lymph node of adult sheep. The efferent lymph ducts draining the Ag-stimulated and contralateral control lymph nodes were cannulated throughout the experimental period. The lymphocytes leaving the lymph nodes during the 72-h period before maximum infiltration were differentially labeled with fluorescent tracers, reinjected into the arterial circulation, and tracked to the site of Ag stimulation. Quantitative tissue cytometry of the skin at the conclusion of the injection period (96 h after Ag stimulation) demonstrated more migratory cells derived from the Ag-stimulated lymph node than the contralateral control (median 18.5 vs 15.5 per field; p < 0.05). However, when corrected for total cell output of the lymph node, the Ag-stimulated migratory cells were 3.8-fold more prevalent in the skin than the contralateral control cells. These results suggest that the in situ immune response generally mirrors the frequency of recruitable lymphocytes in the peripheral blood.

To compare the short-term and long-term outcomes of mitral valve repair (MVP) versus mitral valve replacement (MVR) in elderly patients.All patients, age 70 years or greater, with mitral regurgitation who underwent MVP or MVR with or without coronary artery bypass graft (CABG), tricuspid valve surgery, or a maze procedure between 2002 and 2011 were retrospectively identified. Patients with a rheumatic cause or who underwent concomitant aortic valve or ventricular-assist device procedures were excluded.Overall, 556 patients underwent MVP and 102 patients underwent MVR. The mean age of the patients in the MVR group was 78 years versus 77 years for those in the MVP group (P.02). The patients in the MVR group had a better mean left ventricular ejection fraction than those in the MVP group (60% vs 55%, P=.04). The incidence of concomitant CABG, tricuspid valve operations, and atrial fibrillation ablation procedures was similar in both groups, but perfusion time was significantly longer for the MVR group (median 177 minutes vs 146 minutes for MVP, P=.001). Postoperatively, patients in the MVR group had a higher incidence of stroke (6% vs 2%, P.10) and significantly longer intensive care unit stay (median 86 hours vs 55 hours, P=.001) and hospital stay (9 days vs 8 days, P.01). Operative mortality of patients was significantly higher for the MVR group (8.8% vs 3.6%, P=.03) and remained significant long-term on Kaplan-Meier analysis. Cox regression analysis of all 658 patients and propensity-matched analysis of 96 patients also confirmed these results.Elderly patients with mitral regurgitation who undergo MVP have better postoperative outcomes, lower operative mortality, and improved long-term survival than those undergoing MVR. MVP is a safe and more effective option for the elderly with mitral regurgitation.

This case report illustrates the presentation, diagnosis, and surgical management of an anomalous origin of the right coronary artery from the left coronary sinus in a young adult in whom the right coronary artery was reimplanted directly onto the aorta, rather than bypassed, as is typically done.

We hypothesized that increased postgraduate surgical experience correlates with improved operative efficiency and long-term survival in standard cardiac surgery procedures.Utilizing a prospectively collected retrospective database, we identified patients who underwent isolated coronary artery bypass grafting (CABG) (n = 3726), aortic valve replacement (AVR) (n = 1626), mitral valve repair (n = 731), mitral valve replacement (MVR) (n = 324), and MVR + AVR (n = 184) from January 2002 through June 2012. After adjusting for patient risk and surgeon variability, we evaluated the influence of surgeon experience on cardiopulmonary bypass and crossclamp times, and long-term survival.Mean surgeon experience after fellowship graduation was 16.0 ± 11.7 years (range, 1.0-35.2 years). After adjusting for patient risk and surgeon-level fixed effects, learning curve analyses demonstrated improvements in cardiopulmonary bypass and crossclamp times with increased surgeon experience. There was marginal improvement in the predictability (R(2) value) of cardiopulmonary bypass and crossclamp time for CABG with the addition of surgeon experience; however, all other procedures had marked increases in the R(2) following addition of surgeon experience. Cox proportional hazard models revealed that increased surgeon experience was associated with improved long-term survival in AVR (hazard ratio [HR], 0.85; P .0001), mitral valve repair (HR, 0.73; P .0001), and MVR + AVR (HR, 0.95; P = .006) but not in CABG (HR, 0.80; P = .15), and a trend toward significance in MVR (HR, 0.87; P = .09).In cardiac surgery, not including CABG, surgeon experience is an important determinant of operative efficiency and of long-term survival.

Background. Improved understanding of the incidence and risk factors for operative complications and longterm mortality following coronary artery bypass grafting (CABG) is needed to better define the optimal role for CABG in patients with chronic kidney disease (CKD). Methods. We analysed 2438 patients who underwent CABG at a single centre between 2005 and 2008. Multivariable regression was used to analyse associations and to generate a CKD-specific predictive tool. Results. Operative mortality was 4.8% in individuals with stage 3 CKD, 7.1% in individuals with stage 4–5 CKD and 2.2% in those without significant CKD (P< 0.001). CKD was associated with post-operative blood transfusion, acute kidney injury, myocardial injury and cardiac arrest, and use of exogenous blood and acute kidney injury were strongly associated with in-hospital death in CKD patients. Patients with stage 3 (HR 1.64, 95% CI 1.30–45.94) and stage 4–5 CKD (HR 2.77, 95% CI 1.00–2.68) were more likely to die during follow-up than those without CKD, but mortality rates were low among patients who survived to discharge—stage 3 (0.006 deaths/year) and stage 4–5 CKD (0.009/year). A scoring system including urgent or emergent surgery (OR 2.30), prior cardiac surgery (OR 3.06), concurrent valve surgery (OR 2.06), preoperative shock (OR 6.18), and prior stroke (OR 1.98) had 96.4% percent specificity for the detection of in-hospital death in patients with CKD. Conclusions. Perioperative mortality and morbidity remain more frequent in patients with stage 3–5 CKD than patients with preserved renal function, but long-term outcomes in patients surviving hospitalization are favourable. We have developed a predictive tool that holds promise as a means of identifying CKD patients most likely to survive surgery and benefit from CABG.

Monoclonal antibodies are an important resource for defining molecular expression and probing molecular function. The characterization of monoclonal antibody reactivity patterns, however, can be costly and inefficient in nonhuman experimental systems. To develop a computational approach to the pattern analysis of monoclonal antibody reactivity, we analyzed a panel of 128 monoclonal antibodies recognizing sheep antigens. Quantitative single parameter flow cytometry histograms were obtained from five cell types isolated from normal animals. The resulting 640 histograms were smoothed using a Gaussian kernel over a range of bandwidths. Histogram features were selected by SiZer—an analytic tool that identifies statistically significant features. The extracted histogram features were compared and grouped using hierarchical clustering. The validity of the clustering was indicated by the accurate pairing of externally verified molecular reactivity. We conclude that our computational algorithm is a potentially useful tool for both monoclonal antibody classification and molecular taxonomy in nonhuman experimental systems.

We describe the patterns of utilization of arterial blood gas (ABG) tests in a large tertiary care hospital. To our knowledge, no hospital-wide analysis of ABG test utilization has been published. We analyzed 491 ABG tests performed during 24 two-hour intervals, representative of different staff shifts throughout the 7-day week. The clinician ordering each ABG test was asked to fill out a utilization survey. The most common reasons for requesting an ABG test were changes in ventilator settings (27.6%), respiratory events (26.4%), and routine (25.7%). Of the results, approximately 79% were expected, and a change in patient management (eg, a change in ventilator settings) occurred in 42% of cases. Many ABG tests were ordered as part of a clinical routine or to monitor parameters that can be assessed clinically or through less invasive testing. Implementation of practice guidelines may prove useful in controlling test utilization and in decreasing costs.

Objective: Valvular tissue and aorta calcify at different rates when placed as fresh homografts or cryopreserved allografts. Furthermore, differences between valvular endothelial cells and aortic endothelial cells are not well appreciated. We established primary cultures of valve and aortic endothelial cells derived from swine and tested transcriptional and proliferative differences on various extracellular matrices. Methods: Transcriptional profiling was performed on primary cultures of porcine valve and aortic endothelial cells. We extracted total RNA from both cell types and created cDNA libraries. We scored for 847 genes important in signal transduction pathways, and measured their expression on valve and aortic endothelial cells. To determine if there were functional differences between aortic and valvular cells, their growth rate was determined by cell counting on various extracellular matrices. Results: Of 847 genes investigated, 69 (8.1%) were transcriptionally active on aortic endothelial cells and 89 (10.5%) on valve endothelial cells. Common to both cell types were 55 genes, which represents 79.7% (55/69) of activated genes on aortic endothelial cells and 61.8% (55/89) of those in valve endothelial cells. Remarkable features of the analysis included Ephrin ligand and receptor specificity for cell type, a potential fibroblast growth factor autocrine loop in both cell types, as well as upregulation of the platelet-derived growth factor receptor in valvular cells. Aortic endothelial cells were noteworthy of upregulation of vascular endothelial cell growth factor-B and vascular cell adhesion molecule. Proliferation analysis revealed that valve endothelial cells grew more rapidly (12-fold over control) than aortic endothelial cells (3-fold over control). Furthermore, valve endothelial cells proliferated most rapidly on gelatin or collagen, whereas aortic endothelial cells were most proliferative on lysine or laminin. Conclusions: Valve and aortic endothelial cells have different transcriptional and proliferative profiles. The knowledge of these differences may be an exploitable strategy in the future rational design of artificially engineered valve surfaces and in the study of the valve antigenicity, immunogenicity and structural failure. q 2003 Elsevier B.V. All rights reserved.

Objectives: Although age and co-existing coronary disease are major determining factors when deciding valve choice (mechanical vs. biological) in simple aortic valve replacement, no studies have documented selection criterion for biological (BIO) vs. mechanical (MECH) aortic root prosthesis. Methods: Two hundred and twenty-one consecutive patients underwent elective aortic root replacement with either BIO (homograft, n ¼ 111, Freestyle w , n ¼ 25) or MECH composite grafts (n ¼ 85). Median age in BIO was 53 years and in MECH 54 years (P ¼ NS). Groups were similar in gender, NYHA class and ejection fraction (BIO, EF ¼ 59% vs. MECH, EF ¼ 55%), but the need for concomitant coronary artery bypass grafting (CABG) did differ between groups (MECH ¼ 35% vs. BIO ¼ 17%, P ¼ 0:003). Mean followup was 42 ^ 28 months for mortality and 39 ^ 28 months for morbidity. Results: Full root replacement was performed in 213 patients (96%) and hemi-root in eight (4%). The most common underlying etiologies were annulo-aortic ectasia (n ¼ 82, 37%), calcified-degenerative (n ¼ 73, 33%) and bicuspid/congenital aortic valve disease (n ¼ 39, 18%). Operative mortality was 1.5% for BIO and 2.4% for MECH (P ¼ 0:5). By univariate analysis there was a trend towards greater 5-year survival in BIO (92.4% vs. 88.2%, P ¼ 0:068). By multivariate analysis, increasing age (HR ¼ 2:4, P ¼ 0:003), previous valve replacement (HR ¼ 4:7, P ¼ 0:024), concomitant CABG (HR ¼ 3:7, P ¼ 0:032), and perioperative stroke (HR ¼ 9:9, P ¼ 0:0005) were all independent predictors of late death. The 5-year freedom from valve-related complications was similar in both groups (BIO ¼ 93% vs. MECH ¼ 86%, P ¼ 0:5). Conclusions: Elective aortic root replacement is an exceedingly safe operation. At mean follow-up of 4 years, there is no meaningful difference in early or mid term valve-related results between BIO and MECH aortic root replacement. Continued evaluation for late valve-related complications in this cohort will be necessary to determine the advantages, if any, of one prosthesis over the other. q 2002 Elsevier Science B.V. All rights reserved.

Mr Corazon is a 78-year-old man with insulin-dependent diabetes mellitus and an ejection fraction of 40% who is postoperative day 2 from coronary artery bypass grafting. He has been extubated and feels good, but he remains on a low-dose epinephrine infusion to support his blood pressure. His cardiac index is 2.2 L/m2, and he has a mixed venous oxygen saturation of 59%. He has low filling pressures and marginal urine output. His hematocrit is 24%. His surgeon and his cardiologist confer and agree to transfuse him with 1 unit of red blood cells. They explain to him that he needs the blood transfusion and that the major risk of transfusion is the very low risk of viral infection. After the transfusion, his mixed venous oxygen saturation and urine output improve, and his epinephrine infusion is weaned off. He is transferred out of the intensive care unit the following day. Article p 2544 The rationale for transfusing Mr Corazon is understandable. Historically, patients were thought to benefit from transfusions that boosted their hematocrit to ≥30%, particularly if they were older and sicker. Transfused blood is an excellent volume expander and remains in the intravascular space better than other resuscitation fluids. Transfused patients often “look better.” It is possible that Mr Corazon’s transfusion allowed his hemodynamics to improve sufficiently to wean him more quickly from his inotropic support. We might even expect that his recovery has been accelerated and his length of stay reduced. How should we evaluate this decision making in light of the available evidence? The article by Murphy …

Endothelial cells are intimately involved in a variety of biological processes such as inflammatory disorders, wound healing, and tumor invasion. The finding of endothelial heterogeneity in various tissues has led to major efforts to isolate and culture microvascular endothelial cells in human and animal tissue. In this report we have used phosphatidyl ethanolamine (PE)-labeled liposomes to fluorescently label the sheep lung microvasculature in situ. Using normotensive perfusion pressure, the PE-labeled liposomes did not extravasate into extravascular lung tissue. Mechanical and enzymatic digestion of the lung tissue demonstrated that the PE-labeled liposomes provided a stable label of the vascular lining cells during ex vivo processing. After digestion, the overwhelming majority of the fluorescent label appeared in cellular aggregates. Approximately 80% of these cells demonstrated an in vitro phenotype consistent with microvascular endothelium. A novel monoclonal antibody selective for sheep endothelial cells was developed to confirm the presence of lung endothelium in the fluorescently labeled cellular aggregates. We conclude that in situ fluorescence labeling of vascular lining cells provides an anatomic marker for relevant vascular lining cells and an opportunity to study these cells in vitro.

Introduction: Acute kidney injury (AKI) after cardiac surgery increases length of hospital stay and in-hospital mortality. A significant number of patients undergoing cardiac surgical procedures require perioperative intra-aortic balloon pump (IABP) support. Use of an IABP has been linked to an increased incidence of perioperative renal dysfunction and death. This might be due to dislodgement of atherosclerotic material in the descending thoracic aorta (DTA). Therefore, we retrospectively studied the correlation between DTA atheroma, AKI and in-hospital mortality. Methods: A total of 454 patients were retrospectively matched to one of four groups: -IABP/-DTA atheroma, +IABP/-DTA atheroma, -IABP/+DTA atheroma, +IABP/+DTA atheroma. Patients were then matched according to presence/absence of DTA atheroma, presence/absence of IABP, performed surgical procedure, age, gender and left ventricular ejection fraction (LVEF). DTA atheroma was assessed through standard transesophageal echocardiography (TEE) imaging studies of the descending thoracic aorta. Results: Basic patient characteristics, except for age and gender, did not differ between groups. Perioperative AKI in patients with -DTA atheroma/+IABP was 5.1% versus 1.7% in patients with -DTA atheroma/-IABP. In patients with +DTA atheroma/+IABP the incidence of AKI was 12.6% versus 5.1% in patients with +DTA atheroma/-IABP. In-hospital mortality in patients with +DTA atheroma/-IABP was 3.4% versus 8.4% with +DTA atheroma/+IABP. In patients with +DTA atheroma/+IABP in hospital mortality was 20.2% versus 6.4% with +DTA atheroma/-IABP. Multivariate logistic regression identified DTA atheroma > 1 mm (P = *0.002, odds ratio (OR) = 4.13, confidence interval (CI) = 1.66 to 10.30), as well as IABP support (P = *0.015, OR = 3.04, CI = 1.24 to 7.45) as independent predictors of perioperative AKI and increased in-hospital mortality. DTA atheroma in conjunction with IABP significantly increased the risk of developing acute kidney injury (P = 0.0016) and in-hospital mortality (P = 0.0001) when compared to control subjects without IABP and without DTA atheroma. Conclusions: Perioperative IABP and DTA atheroma are independent predictors of perioperative AKI and in-hospital mortality. Whether adding an IABP in patients with severe DTA calcification increases their risk of developing AKI and mortality postoperatively cannot be clearly answered in this study. Nevertheless, when IABP and DTA are combined, patients are more likely to develop AKI and to die postoperatively in comparison to patients without IABP and DTA atheroma.

Abstract 4351 INTRODUCTION: While recombinant activated Factor VII (rFVIIa) is increasingly used for management of uncontrolled hemorrhage in a variety of clinical settings, its efficacy appears mixed. Few studies have examined the association between coagulation studies and rFVIIa efficacy in cardiac surgery. DESIGN/METHODS: We performed a retrospective study of all patients at Brigham and Women’s Hospital (BWH) from February 2005 through March 2011 who received rFVIIa for uncontrolled hemorrhage during or after cardiac surgery. rFVIIa-mediated hemostasis was determined based on clinical descriptions in the medical record. Laboratory studies, clinical parameters, blood product transfusions, and chest tube output were compiled from the medical record. RESULTS AND DISCUSSION: Forty-seven patients were identified for this study. The median age was 65 years (range, 16–85). Thirty-one patients were male. Eleven had a perioperative left ventricular ejection fraction < 35%. Of 47 surgeries performed, 30 were emergent or urgent and 16 elective (data was missing in 1 case). Twelve required an intraaortic balloon pump, and 12 placement or removal of a ventricular assist device. Median cardiopulmonary bypass (CPB) time was 281.5 min (range, 104–744; n = 45). Over a median follow-up period of 52 days (range, 0–1673), 22 patients (46.8%) died, 10 within one day of receiving rFVIIa. Median survival was 443 days (90% confidence interval (CI) [30, not-yet-reached]). The median dose of rFVIIa was 40.2 mcg/Kg. rFVIIa-mediated hemostasis was achieved in 23 patients (48.9%), while continued bleeding was observed in 24 (51.1%). Thromboembolic complications attributed to rFVIIa developed in 9 patients (arterial, 5; venous, 4). Median transfusion requirements decreased after rFVIIa administration for the entire population, although the differences were not statistically significant. Survival status could not be reliably incorporated into models of transfusion requirements in this retrospective study, prohibiting further analysis. Mean coagulation studies before vs after rFVIIa were: PT, 24.9 sec +/− 18.3 (n = 44) vs 15.4 sec +/− 4.9 (n = 47); INR, 2.3 +/− 2.5 (n = 44) vs 1.2 +/− 0.5 (n = 47); and PTT, 57.3 sec +/− 27.2 (n = 40) vs 48.4 sec +/− 17.8 (n = 44), respectively. Plasma fibrinogen was excluded from the analysis, as levels were not measured in over one-third of cases. Univariate analyses identified several clinical or laboratory variables associated with rFVIIa-mediated hemostasis: PT after rFVIIa administration (p = 0.02 by Fisher’s exact test), INR before rFVIIa (p = 0.05), INR after rFVIIa (p = 0.05), PTT after rFVIIa (p = 0.008), pH after rFVIIa (p = 0.04), and survival status (p = 0.008). In stepwise multivariable logistic regression analyses, only normalization of PTT after rFVIIa was significantly associated with rFVIIa-mediated hemostasis (odds ratio (OR) = 0.169, 95% CI [0.041,0.694], p = 0.01). Stepwise multivariable regression models of PT, INR, and PTT after rFVIIa showed a strong association of PTT and only a marginal association of PT with rFVIIa-mediated hemostasis (PTT: OR = 0.181, 95% CI [0.047,0.722], p = 0.02; PT: OR = 0.10, 95% CI [0.01,0.98], p = 0.05). Chest tube output was recorded for 14 patients who received rFVIIa in the CSICU rather than in an operating room. Of these, 8 (57.1%) had a reduction in chest tube output of ≥ 25% and 5 (21.4%) a reduction of ≥ 50%. While none of the variables examined showed a significant association with reduced chest tube output, concordance with rFVIIa-mediated hemostasis among this small subset of patients was poor (for ≥ 25% reduction: concordance 64.3%, 90% CI [39,84.7], p = 1.0 by McNemar’s test; for ≥ 50% reduction: concordance 57.1%, 90% CI [32.5,79.4]), p = 0.2). CONCLUSION: In cardiac surgery patients who receive rFVIIa for uncontrolled hemorrhage, normalization of PTT after rFVIIa appears to be strongly correlated with rFVIIa-mediated hemostasis. This suggests that optimal hemostasis with rFVIIa occurs following concomitant repletion of other coagulation factors in both extrinsic and intrinsic pathways, although the possibility that normalization of coagulation studies in both pathways is a marker of rFVIIa-mediated hemostasis has not been ruled out. Prospective trials may help to determine whether correction of PTT and other coagulation parameters can improve rFVIIa efficacy in cardiac surgery. Disclosures: No relevant conflicts of interest to declare.

Abstract 2062 INTRODUCTION: Diagnosis of heparin-induced thrombocytopenia (HIT) is challenging in cardiac surgery patients, as nearly all develop postoperative thrombocytopenia, and 10–50% have platelet factor 4 (PF4) IgG antibodies after surgery. Pre-test probability scores for HIT have not been widely used by cardiac surgeons at our institution due to concerns regarding thromboembolic complications in untreated HIT, leading to overuse of direct thrombin inhibitors (DTIs) as empiric therapy for postoperative thrombocytopenia. DESIGN/METHODS: From August through September 2010, we incorporated a hematologist into work rounds in the Brigham and Women's Hospital (BWH) Cardiac Surgery Intensive Care Unit (CSICU). The hematologist collaborated with cardiac surgeons to create literature-based, multidisciplinary guidelines on hematology topics in CSICU patients. For postoperative thrombocytopenia, the guidelines (1) discouraged empiric use of DTIs on postoperative days (POD) 0–3, except in suspected catastrophic HIT; (2) allowed for empiric DTI use on POD ≥ 4 while awaiting PF4 antibody test results; and (3) suggested discontinuation of DTIs after two negative PF4 antibody tests drawn on POD ≥ 4. We performed a retrospective analysis of projected DTI use in BWH cardiac surgery patients based on the guidelines. RESULTS AND DISCUSSION: From February 2010 through February 2011, 80 cardiac surgery patients received DTIs for suspicion of HIT. The median age was 72 years (range, 30–90). Forty-two patients were male. The most common procedures were aortic valve replacement (n = 36), mitral valve replacement (n = 32), and coronary artery bypass grafting (n = 31). Six required an intraaortic balloon pump. Nine were reoperations. PF4 antibody tests, performed using polytypic (Diagnostica Stago) or IgG-specific (Gen-Probe GTI Diagnostics) PF4 antibody ELISA assays, were positive in 19/80 cases (23.75%). Among a subset of 20 patients for whom pre-test probability scores were calculated, correlation between 4 T's and Lillo-Le Louet scores was poor (high probability score, 45% and 15%, respectively; concordance, 50%; p = 0.109 (McNemar's test)). Initiation of DTIs was in disagreement with the guidelines in 17/80 cases (21.25%), of which PF4 antibody tests were negative in 15 and positive in 2. Of the 15 PF4 antibody-negative cases, 12 had no evidence of thrombosis; two developed superficial or deep venous thromboses but tolerated heparin reexposure, and one with multiple negative PF4 antibody tests developed a radial artery thrombosis on POD 9 and was treated with heparin and thrombectomy. Both of the PF4 antibody positive cases were unusual presentations of HIT; in one case, the guidelines would have supported delaying initiation of DTIs by one day, which would not have changed overall clinical course for this patient. Patients in whom DTIs were started on POD ≥ 4 were more likely to test positive for PF4 antibodies than patients in the POD 0–3 group (50% vs 11.1%, respectively; p = 0.0004 (Fisher's exact test)). Almost all cases in which initiation of DTIs disagreed with the guidelines occurred in the POD 0–3 group rather than the POD ≥ 4 group (16 vs 1, respectively; p = 0.008). Overall, the guidelines would have delayed DTI initiation by approximately 1–2 days in 20% of patients and shortened duration of DTI therapy in roughly 15%, leading to a 163-day reduction in total bivalirudin use, a 7-day reduction in argatroban use, and a projected yearly cost savings of $81,414.29–83,055.82 in DTI usage, with minimal impact on patient outcomes. Since launching of these guidelines and other coordinated hospital-wide efforts, overall DTI use at BWH has decreased markedly and stabilized. CONCLUSION: Our analysis suggests a potential role for multidisciplinary clinical care models incorporating hematologists into surgical and critical care units. Disclosures: Fanikos: Baxter: ran a symposium at American Society of Health-System Pharmacists.

Objective Management of a patent left internal thoracic artery graft during reoperation is controversial. The "no-dissection" technique avoids dissection and clamping of the left internal thoracic artery graft, and myocardial protection is achieved using adjunctive systemic hypothermia and hyperkalemia. We compared the postoperative outcomes after isolated reoperative aortic valve replacement in patients with previous coronary artery bypass grafting with a patent left internal thoracic artery graft using a no-dissection technique with the outcomes of patients with previous coronary artery bypass grafting without a left internal thoracic artery graft. Methods The outcomes were analyzed for patients who underwent isolated reoperative aortic valve replacement with previous coronary artery bypass grafting from January 1, 2002, to June, 30, 2011. Patency of the left internal thoracic artery was confirmed using either coronary angiography or computed tomography angiography. The patent left internal thoracic artery group did not undergo dissection or clamping of the left internal thoracic artery graft, and myocardial protection was obtained using systemic hypothermia and hyperkalemia. The no left internal thoracic artery group underwent isolated aortic valve replacement with previous coronary artery bypass grafting but had no left internal thoracic artery graft. Results A total 174 patients were identified for the patent left internal thoracic artery group and 26 for the no left internal thoracic artery group. The perfusion and crossclamp times were similar. No differences were seen between the 2 groups in operative mortality (6.9% vs 7.7%, P = 1.00). The complication rates were similar, and the peak creatine kinase-MB values within 24 hours of surgery were not significantly different between the 2 groups (median, 27.4 vs 29 μ/mL; P = .72). Conclusions Reoperative aortic valve replacement in patients with previous coronary artery bypass grafting and a patent left internal thoracic artery graft can be performed safely without dissection or clamping of the left internal thoracic artery using systemic hyperkalemia and hypothermia. We believe this method prevents unnecessary injury during dissection of the left internal thoracic artery graft.

Objectives This study retrospectively reviews an aggressive multidisciplinary approach to the treatment of massive pulmonary embolism, centering on rapid diagnosis with contrast-enhanced computed tomography of the chest to define the location and degree of clot burden and transthoracic echocardiography to document right ventricular strain followed by immediate surgical intervention when appropriate. Methods Between October 1999 through February 2004, 47 patients (30 men and 17 women; median age, 58 years; age range, 24–86 years) underwent emergency surgical embolectomy for massive central pulmonary embolism. The indications for surgical intervention were (1) contraindications to thrombolysis (21/47 [45%]), (2) failed medical treatment (5/47 [10%]), and (3) right ventricular dysfunction (15/47 [32%]). Preoperatively, 12 (26%) of 47 patients were in cardiogenic shock, and 6 (11%) of 47 were in cardiac arrest. Results There were 3 (6%) operative deaths, 2 with preoperative cardiac arrest; 2 of these 3 patients required a right ventricular assist device. In 38 (81%) patients a caval filter was placed intraoperatively. Median length of stay was 11 days (range, 3–75 days). Median follow-up was 27 months (range, 2–50 months); follow-up was 100% complete in surviving patients. There were 6 (12%) late deaths, 5 of which were from metastatic cancer. Actuarial survival at 1 and 3 years' follow-up was 86% and 83%, respectively. Conclusion An aggressive approach to large pulmonary embolus, including rapid diagnosis and prompt surgical intervention, has improved results with surgical embolectomy. We now perform surgical pulmonary embolectomy not only in patients with large central clot burden and hemodynamic compromise but also in hemodynamically stable patients with right ventricular dysfunction documented by means of echocardiography.

Severe Traumatic Brain Injury (TBI) is associated with hypermetabolism and increased protein catabolism. While studies suggest that nutritional support in TBI may be beneficial, to date, limited information exists regarding the association between existing malnutrition at ICU admission and patient outcomes.