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Background: Numerous studies have identified the associations of socioeconomic factors with outcomes of cardiac procedures. The majority have focused on easily measured factors like sex, race, and insurance status, or on socioeconomic characteristics of patients' 5-digit zip codes. The impact of more granular census-derived socioeconomic information on outcomes has rarely been studied., Methods: The independent impact of the Area Deprivation Index (ADI) on short-term mortality and readmissions was tested on patients undergoing isolated coronary artery bypass grafting (CABG) surgery in New York by using it in logistic regression models in conjunction with patient risk factors and typical disparities measures (race, ethnicity, payer). Changes in hospitals' risk-adjusted outcomes and outlier status with the addition of socioeconomic measures were also tested., Results: After adjusting for numerous patient characteristics, patients in the fourth and fifth highest ADI quintiles (most deprived) were more likely to experience in-hospital/30-day mortality after CABG surgery (adjusted odds ratio [AOR] 1.54, 95% confidence interval [CI] 1.08, 2.20; and AOR 1.50, 95% CI 1.02, 2.21), respectively. ADI was not associated with readmissions, but African Americans (AOR 1.49, 95% CI 1.18, 1.87), Hispanics (AOR 1.33, 95% CI 1.06, 1.65) and Medicaid patients (AOR 1.34, 95% CI 1.09, 1.64) were more likely to be readmitted., Conclusions: Patients with high ADIs are more likely to experience short-term mortality after CABG surgery. African Americans, Hispanics, and Medicaid patients are more likely to experience 30-day readmissions. This information should be taken into account when monitoring patients to reduce adverse events following surgery, and more studies related to ADI are needed to fully understand its implications., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Most studies of patients with isolated proximal left anterior descending (PLAD) coronary artery disease do not include all 3 procedural options: percutaneous coronary intervention (PCI), conventional coronary artery bypass graft (CABG) surgery, or minimally invasive CABG., Methods: New York's cardiac registries were used to identify patients who underwent revascularization for isolated PLAD disease between January 1, 2010, and November 30, 2016, in New York State. After exclusions, 14,327 patients, of whom 13,115 received PCI, 1001 of whom underwent CABG surgery, and 211 of whom underwent minimally invasive CABG were monitored through the end of 2017 to compare outcomes. Registry data were matched to vital statistics data to obtain deaths occurring after discharge and matched to claims data to obtain subsequent admissions for myocardial infarction and stroke., Results: There were no significant differences in mortality or in mortality/myocardial infarction/stroke after 7 years (with median follow-up times in excess of 4 years) among the 3 procedures after adjusting for differences in patient risk factors. However, conventional CABG surgery was associated with a lower subsequent revascularization rate than PCI (adjusted hazard ratio, 0.45; 95% confidence interval, 0.35-0.58) and minimally invasive CABG surgery (adjusted hazard ratio, 0.46; 95% confidence interval, 0.32-0.66)., Conclusions: Among patients with isolated PLAD disease undergoing any of 3 revascularization options (PCI, conventional CABG surgery, or minimally invasive CABG surgery), conventional CABG surgery was associated with lower subsequent revascularization rates, but there were no differences in mortality or mortality/myocardial infarction/stroke rates., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P., Methods: Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics., Results: In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)]., Conclusions: In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Hybrid coronary revascularization (HCR) treats multivessel coronary artery disease by combining a minimally invasive surgical approach to the left anterior descending artery with percutaneous coronary intervention for non-left anterior descending diseased coronary arteries. The objective of this study is to compare HCR and conventional coronary artery bypass graft (CABG) surgery medium-term outcomes., Methods: Data from multivessel disease patients in New York's cardiac surgery and percutaneous coronary intervention registries in 2010 to 2016 were used to compare mortality and repeat revascularization rates for HCR and conventional CABG after using propensity matching to reduce selection bias., Results: There was a total of 303 HCR (0.80%) patients and 37 556 conventional CABG patients after exclusions. After propensity matching, the respective median follow-up times were 3.72 years and 3.76 years. There was no difference between HCR and conventional CABG in survival at 6 years (80.9% versus 85.8%%, adjusted hazard ratio, 1.44 [0.90-2.31]), but HCR had higher mortality excluding deaths during the first year (adjusted hazard ratio, 1.88 [1.10-3.23]). Conventional CABG patients were more likely to be free from repeat revascularization at 6 years than HCR patients (88.2% versus 76.6%; hazard ratio, 2.22 [1.44-3.42])., Conclusions: HCR is rarely performed for patients with multivessel coronary artery disease. HCR and conventional CABG had no different 6-year mortality rates, but HCR had higher mortality after 1 year and higher rates of subsequent revascularization that were caused by both the need for repeat revascularization in the left anterior descending artery where minimally invasive CABG was performed, and in the coronary arteries where percutaneous coronary intervention was performed. Graphic Abstract: A graphic abstract is available for this article.

Introduction: Intra-Aortic Balloon Pumps (IABPs) can be utilized to provide hemodynamic support in high risk patients awaiting coronary artery bypass grafting (CABG). There are many indications for IABP and institutional practice patterns regarding the placement of IABPs is variable. As a result, the preoperative placement of an IABP in a patient awaiting CABG is not standardized and may vary according to non-clinical factors. We hypothesize that the rate of IABP placement varies by day of the week., Methods: A retrospective cohort analysis of the Office of Statewide Health Planning and Development database from 2006 to 2010 was performed. All patients admitted for CABG were included. Patients who died within 24 h of admission and those who had absolute contraindications to IABP placement were excluded. The primary outcome was preoperative IABP placement versus non-placement. A multivariable logistic regression analysis to identify predictors of IABP placement was performed, adjusting for patient demographics, clinical factors, and system variables., Results: A total of 46,347 patients underwent CABG, of which 7695 (16.60%) had an IABP placed preoperatively. On unadjusted analysis, IABP rates were significantly higher on weekends versus weekdays (20.83% vs. 15.70%, p < 0.001). On adjusted analysis, patients awaiting CABG were 1.30 times more likely to have an IABP placed on weekends than on weekdays (OR: 1.30, 95% CI 1.20-1.40, p < 0.001)., Conclusion: The odds of preoperative IABP placement prior to CABG is significantly increased on weekends compared to weekdays, even when controlling for clinical factors. Further exploration of this phenomenon and its associations are warranted.

Objective: The timing of operative revascularization for patients with concomitant carotid artery stenosis and coronary artery disease remains controversial. We examined the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database to evaluate the association of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) with postoperative outcomes., Methods: All patients undergoing CABG with known carotid stenosis of >80% were identified from 2011 to 2016. Individuals were stratified by use of cardiopulmonary bypass and whether a concomitant CEA was performed at the time of CABG. Multivariate logistic regression was used to model the probability of combined CABG and CEA. The resulting propensity scores were used to match individuals on the basis of clinical and operative characteristics to evaluate primary (30-day mortality and in-hospital transient ischemic attack and stroke) and secondary (STS morbidity composite events and length of stay) end points, with P < .05 required to declare statistical significance., Results: After propensity score matching, 994 off-pump CABG patients (497 CABG only and 497 CABG-CEA) and 5952 on-pump CABG patients (2976 CABG only and 2976 CABG-CEA) were identified. For patients who received on-pump operations, those undergoing CABG-CEA had no observed difference in rate of in-hospital stroke (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.72-1.21; P = .6), higher incidence of STS morbidity composite events (OR, 1.15, 95% CI, 1.01-1.31; P = .03), longer length of stay (7.0 [interquartile range, 5.0-9.0] days vs 6.0 [interquartile range, 5.0-9.0] days; P < .005), and no observed difference in 30-day mortality (OR, 1.28; 95% CI, 0.97-1.69; P = .08) compared with those undergoing CABG only. For off-pump procedures, CABG-CEA patients had no observed difference in rate of in-hospital stroke (OR, 0.80; 95% CI, 0.37-1.69; P = .56) compared with those undergoing CABG only., Conclusions: Whereas the differences are relatively small, these data suggest that a combined CABG-CEA approach is unlikely to provide significant stroke reduction benefit compared with CABG only. However, comparison with staged approaches merits further investigation., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: There is growing concern over the impact of fatigue and long work hours on patient safety. Our objective was to determine the perioperative outcomes and hospital costs associated with starting nonemergent cardiac surgical cases after 3 pm., Methods: A retrospective analysis was performed on adult patients who underwent elective coronary artery bypass or valve surgery at our institution between July 2011 and March 2018. Cases were defined as "late start" if the incision time was after 3 pm. Postoperative outcomes, 30-day mortality, and total hospital costs were compared between propensity-matched samples of early-starting and late-starting cases., Results: Of 2463 elective cases, 352 (14%) started after 3 pm. In propensity-matched samples, patients who had a late start demonstrated no difference in 30-day mortality (1% vs <1%; P = .10) or postoperative complications, such as prolonged ventilation (5% vs 7%; P = .37), renal failure (2% vs 1%), or stroke (2% vs 1%; P = .23) compared with patients who had an early start. A late start did not impact the median duration of ventilation (4 vs 5 hours; P = .72), intensive care unit (ICU) length of stay (26 vs 22 hours; P = .28), or postoperative length of stay (6 vs 7 days; P = .37). In addition, there were no significant differences in total hospital cost (P = .09), operating room cost (P = .22), or ICU cost (P = .05)., Conclusions: We report no differences in perioperative outcomes, operative mortality, length of stay, or total hospital cost for elective cases that start after 3 pm. This may be attributable to the resources available at a large quaternary center regardless of time of day., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background The Heart Team approach is ascribed a Class I recommendation in contemporary guidelines for revascularization of complex coronary artery disease. However, limited data are available regarding the decision-making and outcomes of patients based on this strategy. Methods and Results One hundred sixty-six high-risk coronary artery disease patients underwent Heart Team evaluation at a single institution between January 2015 and November 2018. We prospectively collected data on demographics, symptoms, Society of Thoracic Surgeons Predicted Risk of Mortality/Synergy Between PCI with Taxus and Cardiac Surgery (STS-PROM/SYNTAX) scores, mode of revascularization, and outcomes. Mean age was 70.0 years; 122 (73.5%) patients were male. Prevalent comorbidities included diabetes mellitus (51.8%), peripheral artery disease (38.6%), atrial fibrillation (27.1%), end-stage renal disease on dialysis (13.3%), and chronic obstructive pulmonary disease (21.7%). Eighty-seven (52.4%) patients had New York Heart Association III-IV and 112 (67.5%) had Canadian Cardiovascular Society III-IV symptomatology. Sixty-seven (40.4%) patients had left main and 118 (71.1%) had 3-vessel coronary artery disease. The median STS-PROM was 3.6% (interquartile range 1.9, 8.0) and SYNTAX score was 26 (interquartile range 20, 34). The median number of physicians per Heart Team meeting was 6 (interquartile range 5, 8). Seventy-nine (47.6%) and 49 (29.5%) patients underwent percutaneous coronary intervention and coronary artery bypass grafting, respectively. With increasing STS-PROM (low, intermediate, high operative risk), coronary artery bypass graft was performed less often (47.9%, 18.5%, 15.2%) and optimal medical therapy was recommended more often (11.3%, 18.5%, 30.3%). There were no trends in recommendation for coronary artery bypass graft, percutaneous coronary intervention, or optimal medical therapy by SYNTAX score tertiles. In-hospital and 30-day mortality was 3.9% and 4.8%, respectively. Conclusions Integrating a multidisciplinary Heart Team into institutional practice is feasible and provides a formalized approach to evaluating complex coronary artery disease patients. The comprehensive assessment of surgical, anatomical, and other risk scores using a decision aid may guide appropriate, evidence-based management within this team-based construct.

Background: Despite recent guideline statements, there is still wide practice variation in the use of multiple arterial grafts (MAGs) versus single arterial grafts (SAGs) for patients with multivessel disease undergoing coronary artery bypass graft surgery. This may be related to differences in findings between observational and randomized controlled studies., Objectives: This study sought to compare intermediate-term MAG and SAG outcomes with enhanced matching to reduce selection bias., Methods: New York's cardiac registry identified 63,402 multivessel disease patients undergoing coronary artery bypass graft surgery between January 1, 2005, and December 31, 2014, to compare outcomes (median follow-up 6.5 years) for patients receiving SAGs and MAGs. SAG and MAG patients were propensity matched using 38 baseline characteristics to reduce selection bias. The primary endpoint was mortality, and secondary endpoints included repeat revascularization and a composite endpoint of mortality, acute myocardial infarction, and stroke., Results: Before matching, 20% of procedures employed MAG. At 1 year, there was no mortality difference between matched MAG and SAG patients (2.4% vs. 2.2%, adjusted hazard ratio [AHR]: 1.11; 95% confidence interval [CI]: 0.93 to 1.32). At 7 years, MAG patients had lower mortality (12.7% vs. 14.3%, AHR: 0.86; 95% CI: 0.79 to 0.93), a lower composite outcome (20.2% vs. 22.8%, AHR: 0.88; 95% CI: 0.83 to 0.93), and a lower repeat revascularization rate (11.7% vs. 14.6%, AHR: 0.80; 95% CI: 0.74 to 0.87). At 7 years, the subgroups for which MAG did not have a lower mortality rate included patients with off-pump surgery, 2-vessel disease with right coronary artery disease, recent acute myocardial infarction, renal dysfunction, and patient ≥70 years of age., Conclusions: Mortality and the composite outcome were similar between MAG and SAG patients at 1 year, but lower for MAG after 7 years. Patients of higher volume MAG surgeons experienced lower MAG mortality., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: 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., Methods: 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., Results: 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., Conclusions: 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., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Mechanical complications following acute myocardial infarction are associated with high mortality. We present the first reported case of a new post myocardial infarction ventricular septal defect (VSD) within six months of coronary artery bypass grafting. The patient underwent successful surgical correction of the VSD with the assistance of mechanical circulatory support (MCS). This case highlights the importance of mechanical circulatory support in the management of cardiogenic shock associated with rare complications of myocardial infarction, even after surgical revascularization.

Objective: The treatment of patients with ischemic cardiomyopathy and concomitant mitral regurgitation can be challenging and is associated with reduced long-term survival. It is unclear how mitral valve repair versus replacement affects subsequent outcome. Therefore, we conducted this study to understand the predictors of mortality and to delineate the role of mitral valve repair versus replacement in this high-risk population., Methods: From 1993 to 2007, 431 patients (mean age, 70 ± 9 years) with ischemic cardiomyopathy (left ventricular ejection fraction ≤ 45%) and significant ischemic mitral regurgitation (>2) were identified. Patients (44) with concomitant mitral stenosis were excluded from the analysis. A homogeneous group of 387 patients underwent combined coronary artery bypass grafting and mitral valve surgery, mitral valve repair in 302 (78%) and mitral valve replacement in 85 (22%). Uni- and multivariate analyses were performed on the entire cohort, and the predictors of mortality were identified in 2 distinct risk phases. Furthermore, we specifically examined the impact of mitral valve repair versus replacement by comparing 2 propensity-matched subgroups., Results: Follow-up was 100% complete (median, 3.6 years; range, 0-15 years). Overall 1-, 5-, and 10-year survivals were 82.7%, 55.2%, and 24.3%, respectively, for the entire group. The risk factors for an increased mortality within the first year of surgery included previous coronary artery bypass grafting (hazard ratio = 3.39; P < .001), emergency/urgent status (hazard ratio = 2.08; P = .007), age (hazard ratio = 1.5; P = .03), and low left ventricular ejection fraction (hazard ratio = 1.31; P = .026). Thereafter, only age (hazard ratio = 1.58; P < .001), diabetes (hazard ratio = 2.5; P = .001), and preoperative renal insufficiency (hazard ratio = 1.72; P = .025) were predictive. The status of mitral valve repair versus replacement did not influence survival, and this was confirmed by comparable survival in propensity-matched analyses., Conclusions: Survival after combined coronary artery bypass grafting and mitral valve surgery in patients with ischemic cardiomyopathy (left ventricular ejection fraction ≤ 45%) and mitral regurgitation is compromised and mostly influenced by factors related to the patient's condition at the time of surgery. The specifics of mitral valve repair versus replacement did not seem to affect survival., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: A variety of protective strategies during repeat sternotomy been proposed; however, it remains unclear for which patients they are warranted., Methods: We identified adults undergoing repeat median sternotomy for routine cardiac surgery at our institution between January 1, 1996, and December 31, 2007. The operative notes and perioperative outcomes were reviewed., Results: Of the 2555 patients, 1537 (60%) had undergone previous coronary artery bypass grafting, 700 (27%) previous mitral valve surgery, and 643 (25%) previous aortic valve replacement (AVR). Sixty-one patients (2%) had prior mediastinal radiotherapy, and 424 (17%) had more than one previous sternotomy. In 231 patients, 267 injuries (9.0%) occurred. Injury occurred during sternotomy in 87 patients (33%) and during prepump dissection in 135 (51%). The hospital mortality rate was 6.5% among those without injury and 18.5% among those with injury (P < .001); when injury occurred during sternal division, the mortality rate was 25%. Injuries were more common after previous coronary artery bypass grafting (11% with previous coronary artery bypass grafting vs 7% without, P = .0012) but not previous AVR, mitral valve surgery, or aortic surgery. Injury was also more common when the current operation was AVR (10% with AVR vs 8% without, P = .04) or aortic surgery (14% vs 8%, P = .004). On multivariate analysis, previous radiotherapy (odds ratio, 4.9), a greater number of previous sternotomies (odds ratio 1.7), and a patent internal thoracic artery (odds ratio, 1.8) predicted injury. Injury was an independent risk factor of hospital death (odds ratio, 2.6)., Conclusions: Particular attention to protective strategies should be considered during reoperative sternotomy among patients with multiple previous sternotomies, previous mediastinal radiotherapy, and those with patent internal thoracic artery grafts., (Copyright © 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Saphenous vein graft (SVG) aneurysms (SVGAs) after coronary artery bypass grafting (CABG) occur rarely. Most reports are anecdotal. To determine early and late outcomes of surgical treatment, we reviewed our experience with management of this rare complication of surgical revascularization., Methods: From July 1975 to October 2007, 16 patients (15 men), mean age, 60.9 +/- 14.6 years, underwent repair of aortocoronary SVGAs., Results: Chest pain was present in 11 of 16 patients. The rest were asymptomatic. The average maximum diameter of the SVGA was 64 +/- 30 mm. The concern of SVGA rupture was the primary indication for operation in 9 patients (56%). Repair in the remaining patients occurred during other cardiac operations. A pseudoaneurysm (75%) at the body or anastomotic sites of the SVG was the most common cause of SVGA. In 8 patients (50%), the aneurysm involved SVG anastomotic sites. Thirteen patients (81%) had intraluminal thrombi. Vein grafts with aneurysm were patent in 9 patients (56%). Surgical procedures included excision of the aneurysm and direct distal coronary target vessel revascularization in 10 (63%), excision and interposition vein graft in 5 (31%), and exclusion by ligation in 1 (6%). Median follow-up was 7 years (maximum, 20 years). Survival was 83% at 5 years and 72% at 10 years after SVGA repair., Conclusions: Ischemic symptoms often accompany SVGA, and operation is indicated to prevent rupture. Ligation or excision of SVGA with simultaneous revascularization appears to be the optimal therapy, with satisfactory midterm and long-term results.

Background: General consensus favors aortic valve replacement (AVR) for patients with moderate aortic stenosis (AS) undergoing coronary artery bypass graft surgery (CABG); however, the management of similar patients with mild AS is controversial. We therefore investigated such patients to determine incremental risk of concomitant AVR, progression of AS among those undergoing CABG alone, and operative risk of AVR after prior CABG., Methods: Between January 1993 and December 2003, 316 consecutive patients with mild AS (mean gradient >15, <30 mm Hg) underwent CABG only (107) or CABG plus AVR (209). Follow-up was obtained by review of the medical record, the Social Security Death Index, and postal questionnaire., Results: The operative mortality was 3.7% for CABG only and 4.3% for CABG plus AVR (p = 1). Survival at a mean of 5.4 +/- 3.6 years was similar. Multivariate predictors of late mortality included comorbid illnesses (Charlson comorbidity score and age-weighted summary of diseases; p = 0.001), small body surface area (p = 0.001), low ejection fraction (p = 0.007), preoperative permanent pacemaker (p = 0.04), and congestive heart failure (p = 0.046), but not AVR. Twenty-three CABG-only patients (21%) underwent subsequent AVR (mean 5.6 +/- 1.8 years) without mortality. Aortic valve replacement at the time of initial CABG (p <0.001) and older age (p = 0.02) were multivariate predictors of freedom from reoperation., Conclusions: Prophylactic AVR for mild AS at CABG does not confer a survival benefit, and the likelihood of requiring AVR after CABG alone is low in the first 5 years. The decision to intervene on the valve is critically dependent upon the incremental operative risk imposed by concomitant AVR and late survival.

Background: Anomalous aortic origin of a coronary artery (AAOCA) from the opposite sinus traveling between the aorta and pulmonary artery is associated with ischemia and sudden death., Methods: A retrospective review of 36 patients (23 male) who underwent operation between October 1992 and August 2008 for AAOCA was performed. Median age was 47 years (range, 13 to 82 years). Angina, shortness of breath, or syncope was present in 29 (81%), and 9 of 21 (43%) had an abnormal stress test. Coronary or computed tomographic angiography demonstrated an anomalous left main coronary artery arising from the right sinus in 13 (36%), right coronary artery arising from the left sinus in 21 (58%), and left anterior descending artery arising from the right sinus traveling between the aorta and pulmonary artery in 2 (5%). An intramural course was identified on preoperative imaging in 34 (94%). Although no patients had significant associated atherosclerotic coronary artery disease, 5 (14%) had previous acute myocardial infarction related to the AAOCA., Results: Operation included coronary artery bypass grafting in 14 patients and unroofing in 22; 6 patients had associated cardiac procedures performed. There were no early deaths. There was one late death secondary to a subdural bleed. At follow-up (mean 1.1 years; maximum 14 years), chest pain recurred in 1 patient who had coronary artery bypass grafting. No recurrent symptoms were noted in the unroofing group., Conclusions: Unroofing of an anomalous coronary artery can be performed safely with excellent results in the majority of patients. When concomitant atherosclerotic coronary artery disease is present, coronary artery bypass grafting is an appropriate alternative.

Background: Elderly patients are the fastest growing population in the US healthcare system and more patients aged 80 years and older require CABG or percutaneous coronary intervention (PCI) for coronary revascularization than ever before. Because octogenarian patients have not been adequately represented in randomized trials comparing CABG and PCI, the most appropriate method of revascularization for this group of patients has not been determined., Methods: We performed a systematic review and a meta-analysis of 66 studies of coronary revascularization in patients aged over 80 years. The primary endpoints included 30 day mortality and long-term survival. Subgroup analyses stratified by revascularization type (PCI versus CABG) were also performed., Results: Pooled estimate of 30 day mortality was 6.3% (95% CI 5.3%-7.5%), and for survival at 1, 3 and 5 years, 86% (84%-88%), 78% (74%-81%) and 67% (61%-72%), respectively. A greater number of men (P <0.001) and patients with multivessel disease (P = 0.004) were treated with CABG than with PCI. Pooled estimates, based on type of revascularization, of 30 day mortality and 1 year survival were similar (7.3% [6.3%-8.2%] for CABG vs 5.4% [4.4%-6.4%] for PCI and 86% [83%-88%] for CABG vs 87% [84%-91%] for PCI, respectively)., Conclusions: Available data indicate that revascularization can be performed in octogenarians with acceptable short-term and long-term outcomes; most of the evidence is, however, low level. Furthermore, it is unclear whether octogenarians derive greater survival benefit from CABG or from PCI because preprocedural risk profiles differ between intervention types. Periprocedural and long-term outcomes are, however, equivalent, and randomized, controlled trials of high-risk octogenarians are needed.

Objective: Patients who have undergone prior mediastinal radiation might require coronary artery bypass grafting. However, there is some concern regarding potential radiation damage to the internal thoracic artery. Our objective was to assess the late patency of the internal thoracic artery and venous grafts in patients with prior mediastinal radiation., Methods: Patients undergoing coronary artery bypass grafting at our clinic after prior mediastinal radiation were identified, and medical records, including operative reports, clinical notes, and coronary angiography, were reviewed., Results: Between 1985 and 2005, 138 patients had coronary artery bypass grafting after mediastinal radiation. Of these, 25 underwent clinically indicated postoperative angiography. The mean patient age was 56.1 +/- 13.8 years, and 24% were female. All patients received between 3000 and 6000 rads in fractionated doses. Seventy-two percent of patients had 3-vessel coronary artery disease. At late angiography (mean, 2.2 years), 6 (32%) of 19 internal thoracic arteries and 13 (27%) of 48 venous or radial arterial conduits showed stenosis of 70% or greater (P = .72). Assessing only grafts that were anastomosed to the left anterior descending coronary artery, 35% (6 of 17) of internal thoracic artery grafts and 60% (3 of 5) of non-internal thoracic artery grafts showed narrowing of 70% or greater (P = .61). Among patients who received a graft to the left anterior descending coronary artery (n = 113), however, age-adjusted survival at 5 years was superior among those receiving an internal thoracic artery graft to the left anterior descending coronary artery., Conclusions: Internal thoracic artery graft patency among patients with prior radiation was less than expected and similar to that for venous grafts, although the effect of conduit disease versus distal target vessel runoff is unknown. Despite this, late survival was superior among those receiving an internal thoracic artery graft to the left anterior descending coronary artery. These data support use of an internal thoracic artery graft to the left anterior descending coronary artery when it appears grossly to be an acceptable conduit.

Objectives: Accurate prediction of recovery of dysfunctional myocardium would optimize risk/benefit analysis among patients with coronary artery disease and decreased ventricular function. Tissue-tagged magnetic resonance imaging permits quantitative assessment of changes in ventricular function and may improve the prediction of myocardial recovery after coronary artery bypass grafting., Methods: Thirteen patients underwent preoperative and postoperative stress magnetic resonance imaging with strain analysis at rest with 5 and 10 microg x kg(-1) x min(-1) dobutamine. Two-dimensional strain analysis was performed on a single midventricular short-axis image divided into 6 regions for each patient (n = 78). Regional minimum principal, circumferential, and radial strain values were calculated at each stress level. Regional changes in postoperative strain were correlated with changes in preoperative dobutamine stress by means of logistic regression. Receiver operating characteristic curves were created to determine the accuracy of preoperative dobutamine stress for the prediction of postoperative myocardial recoverability., Results: Minimum principal, circumferential, and radial strain values at 5 and 10 microg of dobutamine differed significantly from baseline strains (P < .05). Receiver operator characteristic curves found minimum principal strain to be 75% accurate for prediction of recoverability at both stress levels. Circumferential strain was 72% and 70% accurate at 5 and 10 microg, respectively, whereas radial strain was 77% and 64% accurate at 5 and 10 microg, respectively., Conclusions: Dobutamine-stressed tissue-tagged magnetic resonance imaging with strain analysis is feasible to quantitatively predict myocardial recoverability after coronary artery bypass grafting. Further study is required to determine the optimal strain parameter for predicting myocardial recoverability after surgical revascularization.

Objective: The study objective was to describe the independent effect of preoperative atrial fibrillation on the outcome of coronary artery bypass grafting, including the causes of death (cardiac vs noncardiac)., Methods: We analyzed the outcome of patients with preoperative atrial fibrillation who underwent on-pump coronary artery bypass grafting between 1993 and 2002 and compared them with matched controls in sinus rhythm; matching variables were age, gender, ejection fraction, and numbers of diseased coronary arteries and distal anastomoses. Direct patient follow-up focused on late complications and reinterventions, and we investigated causes for all deaths., Results: Operative mortality (1.6% vs 1.9%, P = .79) was similar in patients with preoperative atrial fibrillation (n = 257) compared with patients in sinus rhythm (n = 269). The patients with atrial fibrillation had longer hospital stays (9 +/- 6 days vs 8 +/- 6 days, P = .0008) and a trend to more frequent early readmissions (13% vs 9%, P = .08). During follow-up (median 6.7 years, maximum 12 years), late hospital admission was more frequent in patients with atrial fibrillation (59% vs 31%, P < .0001). Risk of late mortality (all causes) in patients with atrial fibrillation was increased by 40% compared with patients in sinus rhythm (P = 0.02), and the late cardiac death rate in the atrial fibrillation group was 2.8 times that of the sinus rhythm group (P = .0004). Major adverse cardiac events occurred in 70% of patients with preoperative atrial fibrillation compared with 52% of patients in preoperative sinus rhythm (P < .0001). Subsequent rhythm-related intervention, including pacemaker implantations, was more common in the atrial fibrillation group (relative risk = 2.1, P = .0027)., Conclusions: Uncorrected preoperative atrial fibrillation in patients undergoing coronary artery bypass grafting is associated with increased late cardiac morbidity and mortality and poor long-term survival. These data support consideration of atrial fibrillation surgery at the time of coronary artery bypass grafting.

Background: Cardiac conduction defects occur after cardiac surgery. We hypothesized that population aging and increased use of beta-blockers would increase the incidence of new conduction defects after coronary surgery., Methods: We examined the medical records of 800 coronary artery bypass grafting (CABG) patients (400 from 1991 and 400 from 2001). Exclusion criteria included the following: preexisting conduction defect, permanent pacemaker, and perioperative atrial fibrillation, leaving 303 and 269 patients, respectively, included in the two study years. The incidence, type, and persistence of new conduction defects were determined from the preoperative, postoperative, and the predischarge electrocardiogram. Multivariate analysis identified predictors of new defects., Results: Study populations were well-matched. There was a marked decrease in the incidence of new postoperative conduction defects from 1991 (19%) to 2001 (6%). There was also a change in the most frequently occurring block, from a right-bundle-branch-block in 1991 (10%) to first-degree atrioventricular block (3%) in 2001. Finally, conduction defects in 1991 were more transient. While 19% of 1991 patients showed a conduction defect early postoperatively, only 9% were persistent. In 2001, the incidence of conduction defects at discharge (7%), was equivalent to that early postoperatively (6%). Predictors of new conduction defects included year of operation, age, intraaortic balloon counterpulsation, number of vessels bypassed, and crystalloid cardioplegia., Conclusions: Our results were the opposite of those predicted. Our report identifies a changing incidence, type, and natural history of conduction defects after CABG. Our comparison demonstrated a decrease in the incidence of new conduction defects, as well as a qualitative change in the defects identified. Multivariate analysis provided predictors of new conduction defects after CABG.

Coronary artery bypass grafting has proven a remarkably effective treatment for occlusive coronary artery disease, with demonstrable impact on both symptoms and survival. As conducted traditionally, cardiopulmonary bypass is required, and a global myocardial ischemic insult imposed with aortic occlusion under the protection of cardioplegic arrest. Despite the remarkable success of this approach, concerns over the systemic effects of bypass, including neurologic sequelae as well as ischemic myocardial injury, have stimulated development of techniques and technology to perform coronary bypass 'off-pump'. This technique obviates the need for the bypass machine and imposes only brief regional ischemia during construction of each individual anastomosis. Despite enthusiastic support by a devoted cohort of surgeons, and a host of nonrandomized retrospective studies demonstrating an apparent benefit to the off-pump technique, the technique has not been universally adopted. How can there be such controversy over what appears to be a superior approach? In part, many surgeons are concerned that the greater technical difficulty of the technique will impact long-term results adversely. There is also uncertainty with regard to the actual advantage of off-pump coronary artery bypass over the tried-and-true methods. Surgeons recognize that the results of any surgical series are particularly subject to the influence of subtle selection biases. Accordingly, prospective randomized studies add particular value to the debate. It is the aim of this review to examine the evidence for off-pump coronary artery bypass critically, from a surgeon's perspective, with particular emphasis on knowledge derived from a representative selection of published prospective randomized studies.

Background: Previous studies have shown that intraoperative transesophageal echocardiography provides important preoperative and postoperative information in various cardiac and noncardiac surgeries that may alter patient management and outcome. The role of intraoperative transesophageal echocardiography in patients in whom isolated coronary artery bypass graft surgery is anticipated has been reported only in small selected groups. This study was designed to prospectively evaluate the role of intraoperative transesophageal echocardiography in a large, nonselected group of patients undergoing primarily coronary artery bypass graft surgery., Methods: From January 2001 to December 2003, 474 consecutive patients (76% men, 24% women) aged 30 to 89 years (mean age of 70 +/- 10 years) who were undergoing coronary artery bypass graft surgery had prebypass and postbypass intraoperative transesophageal echocardiography. New findings and alterations in the surgical plan were documented prospectively., Results: New prebypass findings were found in 10% of patients, and the surgical plan was altered in 3.4% of patients. New postbypass findings were found in 3.2% of patients, altering the surgical plan in 2% of patients., Conclusions: This large consecutive, nonselected, prospective study reveals the significant impact of intraoperative transesophageal echocardiography in patients having coronary artery bypass graft surgery as a primary procedure. New findings (prebypass and postbypass) were found in 13% of patients overall, and the surgical plan was altered in 5.5% of patients. This study supports the use of intraoperative transesophageal echocardiography in patients undergoing primarily coronary artery bypass graft surgery.

Objective: Magnetic resonance imaging with radiofrequency tissue tagging permits quantitative assessment of regional systolic myocardial strain. We sought to investigate the utility of this imaging modality to quantitatively determine preoperative impairment and postoperative improvement in ventricular function in patients with ischemic heart disease., Methods: Magnetic resonance imaging with radiofrequency tissue tagging was performed on 6 patients (average age 60.2 +/- 13.7 years) with coronary artery disease and 32 control subjects with no known heart disease. Patients with coronary artery disease underwent imaging before and 3 months after coronary artery bypass grafting. The ventricle was divided into 6 segments within a midventricular plane. Regional 2-dimensional left ventricular circumferential strain was calculated from tagged magnetic resonance images throughout systole. Circumferential strain results were compared in patients before and after and 3 months after coronary artery bypass grafting and also in control subjects., Results: Before the operation circumferential strain identified 100% (10/10) of all regional wall motion abnormalities seen by preoperative ventriculography. Postoperatively, improvements were demonstrated in 56% (20/36) of the regions, and these improvements agreed with viability testing by single-photon emission computed tomography when available. Additionally, preoperative global circumferential strain for the ischemic group was significantly depressed relative to that in control subjects (0.11 +/- 0.05 vs 0.20 +/- 0.03, P <.001). Global circumferential strain correlated with ejection fraction by ventriculography (r = 0.84, P <.01) and improved after coronary artery bypass grafting (0.14 +/- 0.05 vs 0.11 +/- 0.05, P <.01)., Conclusions: Magnetic resonance imaging with radiofrequency tissue tagging permitted circumferential strain calculation. This technology quantitatively demonstrated improvements in left ventricular wall motion after coronary artery bypass grafting for both individual regions and the entire ventricle. This noninvasive method may prove useful in preoperative evaluation and postoperative serial assessment of left ventricular wall motion.

Background: For the last decade, the Cox maze III procedure has been available for the treatment of atrial fibrillation. It is unknown whether the operation has similar efficacy in patients with lone atrial fibrillation compared with that in patients with atrial fibrillation associated with coronary, valve, or congenital heart disease. This study examined the long-term outcome of patients who underwent this procedure either as a lone operation or as a concomitant procedure., Methods: From 1988 to 2001, 198 patients underwent a Cox maze III procedure; 112 were lone operations, and 86 were concomitant procedures. Major complications included renal failure, reoperation for bleeding, mediastinitis, stroke, and balloon pump insertion. Follow-up was performed by means of mail and telephone questionnaires with both the patients and their cardiologists. All patients who had any history of arrhythmia or who were taking medication had their rhythm documented by means of electrocardiography., Results: The lone operation group was significantly younger (51.3 +/- 10.5 vs 58.8 +/- 9.9 years) and had a higher male/female ratio (4:1 vs 2:1). There was no difference in operative mortality between groups (1.8% vs 1.2%). At a follow-up of 5.4 +/- 2.9 years, 96.6% (172/178) of all patients were free of atrial fibrillation. There was no difference between the lone operation and concomitant procedure groups (95.9% vs 97.5%)., Conclusion: The Cox maze III procedure has equivalent operative risk and long-term efficacy in patients undergoing both lone operations and concomitant procedures. The Cox maze III procedure remains the standard against which alternative procedures for atrial fibrillation must be judged.

Objective: Harvest site infections are more common than chest surgical infections after coronary artery bypass surgery, yet few studies detail risk factors for these infections. We sought to determine independent risk factors for leg surgical site infections using our institutional Society of Thoracic Surgeons database., Methods: We retrospectively analyzed data collected from 1980 coronary artery bypass patients undergoing surgery at our institution from January 1, 1996, through June 30, 1999, using The Society of Thoracic Surgeons database. Independent risk factors for leg harvest site infection were identified by multivariate logistic regression., Results: Seventy-six patients (4.5%) were coded as having had a leg harvest site infection, of which 67 were confirmed by infection control. The length of hospital stay after surgery was significantly longer in patients with leg harvest site infection (mean 10.1 days) compared with that of patients without infection (mean 7.1 days, P <.001), and infected patients were more likely to be readmitted to the hospital within 30 days of surgery. Independent risk factors for leg harvest site infection included previous cerebrovascular accident (odds ratio, 2.9), postoperative transfusion of 5 units or more of red blood cells (odds ratio, 2.8), obesity (odds ratio, 2.5), age 75 years or older (odds ratio, 1.9), and female gender (odds ratio, 1.8)., Conclusions: Consistent with previous studies, female gender and obesity were identified as independent risk factors for leg harvest site infection, while previous cerebrovascular accident, postoperative transfusion, and older age are newly described risk factors. The Society of Thoracic Surgeons database is a useful tool for identification of predictors of leg harvest site infections.

Background: Ischemic mitral regurgitation is known to be associated with poor long-term outcome after coronary artery bypass grafting; however, our ability to alter that outcome with intervention on the valve is unclear. The decision to address the valve is most challenging for patients with only moderate mitral regurgitation, particularly with the popularization of off-pump surgery. We therefore reviewed early and late outcomes of patients undergoing revascularization with or without mitral valve surgery., Methods: Patients with moderate mitral regurgitation undergoing revascularization with and without mitral surgery between January 1991 and September 1996 were identified retrospectively. Operative notes were reviewed and patients with structural valve disease excluded. Perioperative events and late outcomes as determined by telephone contact and search of the social security death index (survival data 97% complete) were compared., Results: One hundred seventy-six patients with moderate mitral regurgitation underwent revascularization alone (n = 142) or with mitral repair or replacement (n = 34). Those undergoing revascularization alone had a higher serum creatinine, somewhat less mitral regurgitation, and lower New York Heart Association functional class preoperatively. Operative mortality was greater with valve surgery (21% vs 9%, p = 0.047). Actuarial survival of both groups at 5 years was similar (52% vs 58%, p = NS); however, when stratified by preoperative functional class, those with more advanced heart failure preoperatively had superior late survival if their mitral valve was intervened upon., Conclusions: The late survival of patients with ischemic mitral regurgitation undergoing coronary revascularization remains poor; however, intervention on the mitral valve appears to benefit those with symptomatic heart failure.

Objective: We sought to determine risk factors for deep and superficial chest wound infections after coronary artery bypass graft surgery to develop predictive models., Methods: We retrospectively analyzed data collected on 1980 consecutive patients undergoing coronary artery bypass surgery at our institution between January 1, 1996, and June 30, 1999, by using the Society of Thoracic Surgery database. Independent risk factors for surgical-site infection were identified with multivariate logistic regression., Results: There were 37 (1.9%) deep chest and 46 (2.3%) superficial chest surgical-site infections. Obese diabetic patients had a 7.7-fold increased risk of deep chest infections after controlling for intra-aortic balloon pump use (odds ratio, 3.1) and postoperative transfusion (odds ratio, 2.3). Independent risk factors for superficial surgical-site infections included obesity (odds ratio, 3.1), diabetes in persons 65 years of age or older (odds ratio, 2.7), and current smoking (odds ratio, 2.5). Use of antiplatelet drugs was associated with a lower risk of superficial infections (odds ratio, 0.4). Predicted operative mortality as a marker of severity of illness was not clearly predictive of deep or superficial surgical-site infection. Mortality in the year after the operation was increased in patients with deep chest infections compared with that seen in uninfected control subjects (8/37 [21.6%] vs 114/1612 [7.1%], P =.004) but not in patients with superficial chest infections (7/47 [15.2%] vs 114/1612 [7.1%], P =.075)., Conclusions: Risk factors for deep and superficial chest surgical-site infections after coronary artery bypass surgery differ, suggesting different mechanisms of pathogenesis. Appropriate risk stratification models specific to these important outcomes must be developed.

Objective: The purpose of this study was to evaluate the effect of target vessel characteristics on radial artery patency when used as a composite T graft., Methods: Between October 1993 and March 2001, 1022 patients underwent coronary bypass with the internal thoracic artery-radial artery composite T graft. Of these, angiography has been performed on 109 patients at a mean 27.1 months (range, 2-70 months) postoperatively for symptoms of ischemia. By means of Cox proportional hazard models, the relationships between anastomotic patency and target vessel location, proximal stenosis, target diameter, and quality were assessed., Results: A total of 231 radial artery anastomoses were evaluated. The mean stenosis for patent anastomoses was 82% compared with 71% for occluded anastomoses (P <.001). Anastomotic patency for targets with moderate stenosis (< or = 70%) was worse than that for vessels with critical stenosis (> or = 90%; relative risk, 1.7; 95% confidence interval, 1.3-2.2; P <.001). Patency for targets of the right coronary artery was statistically inferior to that for targets of the left anterior descending artery (relative risk, 1.8; 95% confidence interval, 1.2-2.9; P =.01) and bordered on significance versus that for the circumflex artery distribution (relative risk, 1.6; 95% confidence interval, 1.0-2.8; P =.06). When directed toward critically stenosed targets of the left anterior descending or circumflex arteries, radial artery patency was not statistically different that that of the internal thoracic artery (P =.19)., Conclusion: Radial artery patency is sensitive to both target location and proximal target stenosis. Selective use of the radial artery to targets of the left anterior descending and circumflex distributions remains encouraging. Radial artery grafts to targets of the right coronary artery or those with moderate stenosis appear to be at particularly high risk of failure.

ABSTRACT Background Markers of operation room (OR) efficiency in cardiac surgery are focused on 'knife to skin' and 'start time tardiness.' These do not evaluate the middle and later parts of the cardiac surgical pathway. The purpose of this analysis was to evaluate knife to skin time as an efficiency marker in cardiac surgery. Methods We looked at knife to skin time, procedure time, and transfer times in the cardiac operational pathway for their correlation with predefined indices of operational efficiency (Index of Operation Efficiency - InOE, Surgical Index of Operational Efficiency - sInOE). A regression analysis was performed to test the goodness of fit of the regression curves estimated for InOE relative to the times on the operational pathway. Results The mean knife to skin time was 90.6 ± 13 minutes (23% of total OR time). The mean procedure time was 282 ± 123 minutes (71% of total OR time). Utilization efficiencies were highest for aortic valve replacement and coronary artery bypass grafting and least for complex aortic procedures. There were no significant procedure-specific or team-specific differences for standard procedures. Procedure times correlated the strongest with InOE (r = −0.98, p < 0.01). Compared to procedure times, knife to skin is not as strong an indicator of efficiency. A statistically significant linear dependence on InOE was observed with 'procedure times' only. Conclusions Procedure times are a better marker of OR efficiency than knife to skin in cardiac cases. Strategies to increase OR utilization and efficiency should address procedure times in addition to knife to skin times. doi: 10.1111/jocs.12528 (J Card Surg 2015;30:477-487) [ABSTRACT FROM AUTHOR]

The Cox Maze III procedure has been simplified with the availability of tissue ablation devices; however, complications related to their use are recognized. We report a case of 45-year-old woman who underwent mitral valve repair and concomitant Cryo-Maze procedure. She had reversible right coronary artery spasm develop after the procedure demonstrated by ST-segment elevation changes and coronary angiography, which was reversed with intracoronary nitroglycerin. The region of spasm suggested it as a consequence of proximity of the right coronary artery to the right atrial ablation lines. [ABSTRACT FROM AUTHOR]

Background: We sought to evaluate freedom from reinfection after surgery for infected aortic root replacement (ARR) and the impact of use of synthetic material at reoperation. Methods: Adult patients (aged more than 18 years) undergoing surgery for infected composite aortic root prosthesis at our institution were identified and their perioperative outcomes and late survival evaluated. Results: Between January 1, 1993, and December 31, 2009, 15 patients (male, 87%; mean [SD] age, 57 [16] years) underwent surgery. All but 1 patient (6.7%) underwent reconstruction with a homograft. Eight patients (53.3%) required synthetic material to complete the repair, including 4 patients who underwent hemiarch reconstruction. Ten patients (66.7%) had circulatory arrest (mean [SD] time, 23.3 [11.0] minutes) and 3 (20.0%) underwent concomitant coronary artery bypass grafting. The 30-day mortality rate was 13.3% (n = 2). Three patients (20.0%)—2 of whom had positive blood cultures in hospital after redo ARR—had reinfection, for which 2 underwent re-replacement of the aortic root. Survival was 86.7%, 65.0%, and 50.6%, and freedom from reinfection was 90.9%, 79.5%, and 79.5% at 3, 6, and 12 months, respectively. Freedom from reinfection was less for the patients who had positive blood cultures within 2 weeks of redo ARR (p < 0.03) and for patients who had multiple previous sternotomies (p = 0.006). Use of synthetic graft material had no adverse impact. Conclusions: Infected ARR prostheses can be replaced with a homograft with favorable outcomes. Use of synthetic material to complete the repair does not adversely impact outcome. [ABSTRACT FROM AUTHOR]

Background: Coronary artery bypass graft and cardiac valve surgeries are frequently performed in medical facilities in the United States, and postoperative nausea (PON) is a prevalent problem in this patient population. The purpose of this study was to evaluate the efficacy of a single preoperative acupuncture treatment in the prevention of PON in patients undergoing coronary artery bypass graft or cardiac valve surgery, or both. Methods: Ninety participants presenting for coronary artery bypass graft or cardiac valve surgery, or both, were recruited for this study. Patients were randomly assigned to receive either one preoperative acupuncture and standard postoperative care (acupuncture group) or solely standard postoperative care (control group). Acupuncture was performed 0.5 to 3 hours before surgery. The PON incidence and severity on postoperative day (POD) 2 and POD 3 were measured with validated nausea tools. Results: The acupuncture group had a significantly lower incidence of nausea compared with the control group (POD 2, odds ratio [OR], 0.38; p = 0.05; and POD 3, OR, 0.26; p = 0.01). The acupuncture group also had a significantly lower score of nausea severity than the control group (POD 2, OR, 0.29; p = 0.01; and POD 3, OR, 0.25; p = 0.01). No adverse effects due to acupuncture treatment were reported. Antiemetics, pain medications, and anesthetics administered intraoperatively did not differ between the two groups and did not influence study results. Conclusions: A single preoperative acupuncture treatment decreased incidence and severity of PON in patients undergoing coronary artery bypass graft or cardiac valve surgery, or both, and caused no adverse effects. [Copyright &y& Elsevier]

Background: The Cox-maze procedure is the standard to which other surgical treatments of atrial fibrillation (AF) are compared. However, evaluation of new devices and lesion sets is difficult because of variable methods of reporting success in eliminating AF. We analyzed 10-year outcome with the “cut and sew” Cox-maze procedure and present rhythm at last follow-up, interval contact, and actuarial AF freedom. Methods: Between March 1993 and December 2002, 335 patients (211 men) underwent the Cox-maze procedure (age, 22 to 83 years; median, 62 years). Atrial fibrillation was chronic (CAF) in 175 patients and paroxysmal (PAF) in 160. Results: Concomitant mitral valve procedures were performed in 59%, coronary artery bypass grafting in 19%, and tricuspid valve repairs in 7%. Early mortality was 0.9%. During hospitalization, transient AF occurred in 29% of patients and 10% required implantation of a new permanent pacemaker (PPM). Dismissal electrocardiogram was normal sinus rhythm in 64%, junctional rhythm in 18%, AF in 11%, and PPM in 7%. At last follow-up (mean 42 ± 6 months), 88% of patients were free of AF. However, when analyzed by the Kaplan-Meier method, freedom from AF was lower for patients with preoperative lone PAF (5 years, 90%; 10 years, 64%), preoperative lone CAF (5 years, 80%; 10 years, 62%), and patients undergoing combined maze-mitral valve surgery (5 years, 68%; 10 years, 41%). Conclusions: Ten-year results with the standard Cox-maze procedure confirm high effectiveness, but reporting methods should be standardized to account for patients who have transient atrial arrhythmias during long-term follow-up. [Copyright &y& Elsevier]

Background and Aim: Aneurysmal dilatation of the aortic arch is uncommon, and the complex anatomy involved imposes unique technical challenges. The results of surgical intervention reported from large centers are improving; however, the degree to which these results are reproducible by other surgeons is less clear. We therefore reviewed our recent experience with total aortic arch replacement. Methods: Between July 1, 1997 and July 1, 2001 19 patients underwent complete aortic arch replacement, with or without concomitant procedures. We retrospectively reviewed perioperative results retrieved from the computerized database and clinical records. Results: The mean age of the study population was 68 ± 8.3 years (range 52 to 82), with women predominating (11 women, 8 men). All patients had hypertension. Patient history indicated active or past tobacco abuse in 16 patients (80%); cerebrovascular disease in 3, and peripheral vascular disease in 7 patients. Associated procedures included an elephant trunk in 12 (63%), replacement of the upper descending thoracic aorta in 5 (26%), concomitant coronary artery bypass in 5 (26%), and aortic root replacement in 3 (16%). One patient underwent replacement of the entire aorta from sinotubular ridge to iliac bifurcation in a single procedure. Brachiocephalic reconstruction with a "Y-graft" permitting early antegrade cerebral perfursion was performed in 12 patients. Retrograde cerebral perfusion was performed in ten patients (53%). Perioperatively, death occurred in two patients (11%) and stroke in two (11%). Conclusions: With cautious application, techniques developed in high-volume centers can also achieve satisfactory results when used at centers with a more modest case volume. [ABSTRACT FROM AUTHOR]

Objectives: We examined the role of prosthesis–patient mismatch on left ventricular mass regression after aortic valve replacement for chronic aortic valve regurgitation. Methods: We selected patients who had complete preoperative and follow-up echocardiograms with measurement of left ventricular mass. Patients were excluded who had moderate or greater aortic valve stenosis, concomitant coronary artery bypass grafting, or mitral valve procedures. Results: Patients’ mean age was 55 ± 17 years; 21% were female. The mean preoperative indexed left ventricular mass was 150 ± 45 g/m2. Patients with mildly (n = 44; mean indexed mass, 126 ± 15 g/m2), moderately (n = 31; mean indexed mass, 168 ± 11 g/m2), or severely (n = 15; mean indexed mass, 241 ± 34 g/m2) increased preoperative indexed left ventricular mass, were similar, except for lower ejection fractions, larger end-diastolic dimensions, and larger ventricular wall thicknesses in the severely enlarged group (P < .001). Thirteen patients had prosthesis–patient mismatch and were similar to patients without prosthesis–patient mismatch, except for a greater body surface area, fewer mechanical valves, and smaller valve sizes in those with prosthesis–patient mismatch (P < .05). At a mean follow-up of 3.2 ± 2.4 years, the average reduction in indexed left ventricular mass was 50 ± 38 g/m2; late mass regression was unrelated to labeled valve size, prosthesis–patient mismatch, or measured indexed effective aortic valve area. A greater preoperative indexed left ventricular mass (P < .001) was an independent predictor of greater left ventricular mass regression. Despite having greater left ventricular mass regression, patients with severe preoperative indexed left ventricular mass did not return to normal values (mean, 142 ± 25 g/m2). Conclusions: Left ventricular mass regression after aortic valve replacement for chronic aortic regurgitation is unrelated to indexed prosthetic valve area. Although incomplete, regression is greatest in patients with the largest preoperative indexed left ventricular mass. [Copyright &y& Elsevier]

Objectives: We sought to examine temporal trends in the utilization of coronary revascularization in a geographically defined population. Background: Earlier reports on revascularization utilization focused on inpatient settings and did not distinguish incident from recurrent procedures. Furthermore, little is known on age- and gender-specific trends. Finally, longitudinal data on the utilization and results of coronary angiography as explanatory factors for the changing revascularization practice are lacking. Methods: Data integrating diagnostic and therapeutic coronary procedures performed in Olmsted County (Minnesota) between 1990 and 2004 were analyzed. Standardized rates were calculated applying the direct method and temporal trends compared using Poisson regression models. Results: Revascularization utilization increased by 24% during the study (95% confidence interval [CI] 5% to 46%), but the trends diverged by procedure type, with a sustained increase (69%, 95% CI 43% to 101%) for percutaneous coronary interventions (PCI) contrasting with a stabilization, then decline (−33%, 95% CI −16% to −47%) for coronary artery bypass grafting (CABG). For PCI, although the use increased in all categories, greater increases were noted in the elderly, in women, and for recurrent procedures. No such patterns were detected for CABG. Angiography use remained stable, and the rate of 3-vessel and/or left main disease declined (−22%, 95% CI −8% to −33%). Conclusions: Over the 15-year period, revascularization increased in the community with a large increase in PCI partially offset by a decrease in CABG. More PCIs are performed in women and the elderly and for recurrent disease. These changes occurred within the context of a decline in multivessel disease and thus likely reflect the natural history of coronary artery disease. [Copyright &y& Elsevier]

Duration of Secondary Prophylaxis for Rheumatic Fever Type Duration After Last Attack* Rheumatic fever with carditis and residual heart disease (persistent VHD†) 10 y or until patient is 40 y of age (whichever is longer) Rheumatic fever with carditis but no residual heart disease (no valvular disease†) 10 y or until patient is 21 y of age (whichever is longer) Rheumatic fever without carditis 5 y or until patient is 21 y of age (whichever is longer) *Lifelong prophylaxis may be recommended if the patient is at high risk of group A streptococcus exposure. Systemic Fibrinolysis Versus Surgery for Prosthetic Valve Thrombosis Favor Surgery Favor Fibrinolysis Readily available surgical expertise No surgical expertise available Low surgical risk High surgical risk Contraindication to fibrinolysis No contraindication to fibrinolysis Recurrent valve thrombosis First-time episode of valve thrombosis NYHA class IV NYHA class I, II, or III Large clot (>0.8 cm 2) Small clot (<=0.8 cm 2) LA thrombus No LA thrombus Concomitant CAD in need of revascularization No or mild CAD Other valve disease No other valve disease Possible pannus Thrombus visualized Patient choice Patient choice CAD indicates coronary artery disease; The threshold for valve operation for valve regurgitation is higher in the asymptomatic patient who might ever become pregnant than in patients who will not become pregnant because there always is the possibility that valve repair will not be successful and a prosthetic valve will be needed. Consultation with or referral to a Primary or Comprehensive Heart Valve Center is reasonable when treatment options are being discussed for 1) asymptomatic patients with severe VHD, 2) patients who may benefit from valve repair versus valve replacement, or 3) patients with multiple comorbidities for whom valve intervention is considered. [Extracted from the article]

Abstract: Objective: The optimal myocardial preservation strategy at re-operation for aortic valve replacement (AVR) after prior coronary artery bypass grafting (CABG) in the presence of a patent internal thoracic artery (ITA) remains undefined. Methods: Patients undergoing AVR after prior CABG at our institution between 1 January 1996 and 31 December 2007 were identified; operative notes and outcomes were reviewed. Results: Of 628 patients with prior CABG undergoing AVR with or without concomitant procedures, 427 patients had a patent ITA. In 390, management of the ITA was detailed in the operative note, including 251 in whom it was clamped and 139 in whom it was left uncontrolled. Groups were demographically similar, although re-operative CABG was more frequent in the clamped group (42% vs 23%, p <0.001). The operative mortality rate among those undergoing only AVR±CABG was 7.7% (19/246), while that for all cases was 10.8% (42/390), and was lower when the ITA was left uncontrolled both for AVR±CABG (4.1% vs 10.1%, p =0.08) and overall (7.2% vs 12.7%, p =0.09). By multivariate analysis, leaving the ITA uncontrolled appeared protective (odds ratio (OR) 0.46, p =0.08). There was no clear trend supporting an optimal perfusion temperature when the ITA was left uncontrolled. Conclusions: Efforts to control the patent ITA at re-operation for AVR after prior CABG increase risk of injury and may actually increase operative mortality rate compared with leaving this critical graft open and perfusing the heart. [Copyright &y& Elsevier]