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The aim of this study was to compare the long-term survival rates of patients undergoing isolated first-time coronary artery bypass grafting (CABG) by off-pump CABG with the long-term survival rates in patients undergoing CABG using cardioplegic cardiopulmonary bypass techniques.All patients undergoing isolated CABG at a single center (Manchester Heart Centre, Manchester, United Kingdom) between 2000 and 2014 were included. Propensity score matching was performed on the basis of on demographic variables. The in-hospital morbidity and long-term all-cause mortality rates for matched patients were compared.A total of 8,055 patients were identified, with a median follow-up of 7.0 years. With patients matched for preoperative patient characteristics, there was no significant difference in long-term survival between cardiopulmonary bypass and off-pump CABG (n = 2,082 each; 11.5 years vs 11.3 years; p = 0.178). In the off-pump CABG group, there were significantly fewer in-hospital cerebrovascular complications (0.5% vs 1.1%; p = 0.017), and mean length of stay was shorter (7.6 days vs 8.1 days; p0.0001). Arterial conduit use was significantly higher in the off-pump group, with more right mammary artery grafts (16.3% vs 4.3%; p0.0001) and sequential grafts (27.1% vs 13.5%; p0.0001). The mean number of grafts was higher in the on-pump group (3.28 ± 0.94 vs 3.10 ± 1.10; p0.0001).Long-term survival after off-pump CABG is not inferior to long-term survival after on-pump CABG despite a lower mean number of grafts. A statistically significant difference in cerebrovascular complications may be related to conduit choice and reduced aortic manipulation.

Cardiac reoperation carries additional risks compared with surgery in patients who are sternotomy-naïve. To identify if preoperative computerized tomography (CT) can reduce this risk, we performed a systematic review of the literature and meta-analysis. Literature search identified 178 studies of which 4 retrospective cohort studies incorporating 900 patients met inclusion criteria. There were no statistically significant differences in the risk of death, re-entry injury, renal failure or perfusion/ischaemic times. CT scan reduced the risk of stroke by 0.42 [95% confidence interval (CI): 0.19-0.93, P = 0.03] and a composite of major complications by 0.65 (95% CI: 0.47-0.88, P = 0.006). The use of preoperative cross-sectional imaging to reduce the risk of complications following cardiac reoperation is advocated.

As little is known about the impact of non-dialysis-dependent renal dysfunction on short- and mid-term outcomes following coronary surgery we have conducted a large multi-centre study comparing patients with no history of renal dysfunction to those with preoperative renal dysfunction.Data was prospectively collected on 19,625 consecutive patients undergoing isolated coronary surgery between 1997 and 2003 from four institutions. Sixty-seven patients had a history of dialysis support prior to coronary surgery, and were excluded from the main analysis of the study. The remaining 19,558 patients were divided into two groups based on preoperative serum creatinine level, patients with preoperative renal dysfunction with serum creatinine levels200 micromol/L without dialysis support and control patients with preoperative serum creatinine levels200 micromol/L. Case-mix was accounted for by developing a propensity score, which was the probability of belonging to the non-dialysis-dependent renal dysfunction group, and included in the multivariable analyses.There were 19,172 patients with preoperative serum creatinine levels200 micromol/L and 386 patients with serum creatinine levels200 micromol/L without dialysis support. The propensity score included sex, body mass index, co-morbidity factors (respiratory disease, diabetes, cerebrovascular disease, hypertension, and hypercholesterolemia), ejection fraction, left main stem stenosis, emergency status, prior cardiac surgery, off-pump surgery, and the logistic EuroSCORE. After adjusting for the propensity score, patients with preoperative non-dialysis-dependent renal dysfunction had significantly higher in-hospital mortality (adjusted odds ratio 3.0, p0.001), stroke (adjusted odds ratio 2.0, p = 0.033), atrial arrhythmia (adjusted odds ratio 1.5, p = 0.003), prolonged ventilation (adjusted odds ratio 2.1, p0.001), and post-op stay6 days (adjusted odds ratio 2.6, p0.001). One thousand one hundred and eighty-three (6.1%) deaths occurred during 58,062 patient-years follow-up. After adjusting for the propensity score, the adjusted hazard ratio of mid-term mortality for non-dialysis-dependent renal dysfunction was 2.7 (p0.001).Patients undergoing coronary surgery with non-dialysis-dependent renal dysfunction have significantly increased perioperative morbidity and mortality. Mid-term survival is also significantly reduced at 5-years.

Objective As a result of recent failures in clinical governance the government has made a commitment to bring individual surgeons9 mortality data into the public domain. We have analysed a database to compare crude mortality after coronary artery bypass surgery with outcomes that were stratified by risk. Design Retrospective analysis of prospectively collected data. Setting All NHS centres in the geographical north west of England that undertake cardiac surgery in adults. Participants All patients undergoing isolated bypass graft surgery for the first time between April 1999 and March 2002. Main outcome measures Surgeon specific postoperative mortality and predicted mortality by EuroSCORE. Results 8572 patients were operated on by 23 surgeons. Overall mortality was 1.7%. Observed mortality between surgeons ranged from 0% to 3.7%; predicted mortality ranged from 2% to 3.7%. Eighty five per cent (7286) of the patients had a EuroSCORE of 5 or less; 49% of the deaths were in this lower risk group. A large proportion of the variability in predicted mortality between surgeons was due to a small but differing number of high risk patients. Conclusions It is possible to collect risk stratified data on all patients undergoing coronary bypass surgery. For most the predicted mortality is low. The small proportion of high risk patients is responsible for most of the differences in predicted mortality between surgeons. Crude comparisons of death rates can be misleading and may encourage surgeons to practise risk averse behaviour. We recommend a comparison of death rates that is stratified by risk and based on low risk cases as the national benchmark for assessing consultant specific performance.

Objective: Non-elective coronary artery surgery (emergent/salvage or urgent) carries an increased risk in most risk-stratification models. Off-pump coronary surgery is increasingly used in non-elective cases. We aimed to investigate the effect of avoiding cardiopulmonary bypass on outcomes following non-elective coronary surgery. Methods: Of the 3771 consecutive coronary artery bypass procedures performed by five surgeons between April 1997 and March 2002, 828 (22%) were non-elective and 417 (50.4%) of these patients had off-pump surgery. Multivariate logistic regression was used to assess the effect of off-pump on in-hospital outcomes, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score from core patient characteristics, which was the probability of avoiding cardiopulmonary bypass. The C statistic for this model was 0.8. Results: Off-pump patients were more likely to be hypertensive, stable, had less extensive disease and better left ventricular function. The left internal mammary artery was used in 91.8% (n ¼ 383) of off-pump patients compared to 79.3% (n ¼ 326) of on-pump cases (P , 0:001). After adjusting for the propensity score, no difference in in-hospital mortality was observed between off-pump and on-pump (adjusted odds ratio (OR) 0.83 (95% confidence intervals (CI) 0.36‐ 1.93); P ¼ 0:667). Off-pump patients were less likely to require intra-aortic balloon pump support (adjusted OR 0.44 (95% CI 0.21 ‐ 0.96); P ¼ 0:039), less likely to have renal failure (adjusted OR 0.44 (95% CI 0.22‐ 0.90); P ¼ 0:025), and have shorter lengths of stay (adjusted OR 0.51 (95% CI 0.37‐ 0.70); P , 0:001). Other morbidity outcomes were similar in both groups. Conclusions: In this experience, off-pump coronary surgery in non-elective patients is safe with acceptable results. Non-elective off-pump patients have a significantly reduced incidence of renal failure, and shorter post-operative stays compared to on-pump coronary artery bypass surgery. q 2003 Elsevier Science B.V. All rights reserved.

Background: Various risk stratification systems have been developed in coronary artery bypass graft surgery (CABG), based mainly on patients undergoing procedures with cardiopulmonary bypass. Objective: To assess the validity and applicability of the Parsonnet score, the EuroSCORE, the American College of Cardiology/American Heart Association (ACC/AHA) system, and the UK CABG Bayes model in patients undergoing off-pump coronary artery bypass surgery (OPCAB) in the UK. Methods: Data on 2223 patients who underwent OPCAB in eight cardiac surgical centres were collected. Predicted mortality risk scores were calculated using the four systems and compared with observed mortality. Calibration was assessed by the Hosmer–Lemeshow (HL) test. Discrimination was assessed using the receiver operating characteristic (ROC) curve area. Results: 30 of 2223 patients (1.3%) died in hospital. For the Parsonnet score the HL test was significant (p < 0.001) and the receiver operating characteristic curve (ROC) area was 0.74. For the EuroSCORE the HL test was also significant (p = 0.008) and the ROC area was 0.75. For the ACC/AHA system the HL test was non-significant (p = 0.7) and the ROC area was 0.75. For the UK CABG Bayes model the HL test was also non-significant (p = 0.3) and the ROC area was 0.81. Conclusions: The UK CABG Bayes model is reasonably well calibrated and provides good discrimination when applied to OPCAB patients in the UK. Among the other three systems, the ACC/AHA system is well calibrated but its discrimination power was less than for the UK CABG Bayes model. These data suggest that the UK CABG Bayes model could be an appropriate risk stratification system to use for patients undergoing OPCAB in the UK.

Objectives: Gastrointestinal (GI) complications following on-pump coronary artery bypass grafting (CABG) are rare, but carry a high mortality rate. Prolonged cardiopulmonary bypass (CPB) has been associated with a higher incidence of such complications. Little is known about the effect of avoiding CPB on GI complications. Our hypothesis was that off-pump CABG might reduce such complications. Methods: A total of 2327 consecutive cases undergoing isolated CABG between April 1997 and May 2001 were identified from four consultants' practice at the two cardiothoracic centres involved in this study. We performed a multivariable logistic regression analysis to identify the risk factors for development of post-operative GI complications. Potential risk factors considered in the logistic model were age, sex, angina, ejection fraction, peripheral vascular disease, renal dysfunction, redo operations, previous GI complications, priority of surgery and the use of CPB. Results: A total of 1210 cases were performed on CPB, compared to 1117 off-pump. The incidence of GI complications was 1.2% (n = 14) in the on-pump group and 1.6% (n = 18) in the off-pump group (P = 0.347). The incidence of in-hospital mortality, in the patients who had a GI complication, was 28.6% (n = 4) and 22.2% (n = 4), respectively (P = 0.681). The results of the logistic regression analysis showed that renal dysfunction, advancing age and previous history of GI surgery are significant risk factors for GI complications after coronary bypass surgery whether CPB is used or not. Conclusions: Our study suggests that off-pump and on-pump techniques are similar in the rates of GI complications. We suggest that a properly designed randomized control trial is needed to verify our findings.

Hamid et al. [1] present the well-known fact that reoperative cardiac surgery has a higher mortality, by virtue of the fact that the operation is a repeat one. The study had an operative mortality rate of 9.5%. Re-entry complications occurred in 2.7% although the mortality rate of this group was less than 1%. The reasons that a repeat cardiac operation has an increased mortality compared with a primary operation have been described by the current study. Reoperative cardiac surgery, as demonstrated by multiple series, carries a higher risk of re-entry injuries which reflects in poor early and late outcomes [2]. The authors have outlined the anatomical structures that might be inadvertently encountered during re-entry and discussed the role of computed tomography (CT) in helping ameliorate this risk, which we totally agree with. They have highlighted a significant change in the trend towards preoperative preparation in reoperative cardiac surgery. However, there are additional reasons for increased mortality. These patients may have ischaemic heart disease that is more mature, with declining left and right ventricular function and they may be older with more comorbidity. Careful preoperative planning and meticulous operative skills are two key steps to successful outcomes for complex reoperative procedures. The crux of both preoperative planning and surgical technique is precise and accurate demonstration and understanding of mediastinal anatomy. The authors have demonstrated that multislice CT scan imaging is readily available and it allows understanding of possible re-entry injuries by demonstrating precise anatomy and proximity to key structures. Preoperative CT imaging not only reduces the risk of re-entry and prevents adverse outcomes but also has shown to reduce hospital stay with significant reductions in hospital charges [3]. Risks to a patent internal thoracic artery are not only during re-entry but also during its mobilization which is necessary for repeat grafting. Clearly defining the position, lie and proximity to key anatomical structures helps reduce the risks of such later inadvertent injury. Over the past decades, CT imaging prior to reoperative procedures has gained popularity with cardiac surgeons. All patients at our centre have routine preoperative CT scans with 3D reconstructions. 3D reconstruction with CT angiography provides accurate delineation of previous patent coronary artery grafts which are at risk during re-entry [4–6]. As the authors demonstrate, some patients with suspected renal injuries could be excluded from CT imaging due to significant risk of contrast nephropathy. All patients excluded from CT imaging should be considered for tagged cine magnetic resonance imaging with a finite element model. This modality not only provides precise anatomical proximity of key structures but underlines an accurate quantitative assessment of retrosternal adhesions before reoperative cardiac surgery. It also provides quantitative assessment of right ventricular strain and the relationship to the posterior sternal border [7]. Sodian et al. have demonstrated virtual 3D printing models to demonstrate and enhance understanding of mediastinal anatomy for preoperative evaluation for reoperative procedures [8]. We have travelled on a journey of modalities stretching from plain lateral chest X-rays to virtual 3D printed models of the heart, with each modality providing a better understanding allowing us to deliver safer entry to the chest, minimizing the risk of re-entry injuries and should be utilized as a routine for reoperative cardiac procedures. These imaging modalities should be used to provide a tailored plan in each patient having their chest opened, which can vary from a routine straightforward sternotomy to opening the chest having established bypass, with cooling and decompression of the left ventricle. In addition, there will be the small group who may have a vital, and possibly a unitary, coronary graft sitting behind and on the sternum, where approaching the heart through a thoracotomy might be appropriate. There remain other strategies in repeat operations, in addition to understanding the anatomy and relationships of structures, such as the management of diseased bypass grafts, the dissection of adhesions to avoid damaging the heart itself and optimal protection of the heart during cross-clamping. One could argue that now that we have ascertained that reoperative surgery has such high risks, these procedures should be the domain of surgeons with established experience in reoperative surgery and the era of a surgeon performing an occasional repeat procedure has passed.

Cervical aortic arch is rare with a prevalence of less than 1/10000 live births (Pediatr Cardiol 10 (1989) 205); but may occur with other cardiovascular congenital abnormalities. We report pseudocoarctation of a left-sided cervical aortic arch with an aberrant right subclavian artery and aortic and mitral regurgitation, corrected by an anterior mediastinal shunt from ascending to descending aorta and aortic and mitral valve replacements, as a one-stage procedure.

OBJECTIVE: To study the use of the additive and logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) to predict mortality following adult combined coronary artery bypass grafting (CABG) and valve surgery. METHODS: Data were collected prospectively, from all four centres providing adult cardiac surgery in the north west of England, on 1769 consecutive patients undergoing combined CABG and valve surgery between April 1997 and March 2002. Observed in-hospital mortality was compared to predicted mortality as determined by both additive and logistic EuroSCORE. RESULTS: Observed mortality for simultaneous CABG and valve surgery was 8.7%, compared to 6.7% (additive) and 9.4% (logistic). Sixty-five percent of patients were classified as high-risk (additive EuroSCORE >5); the observed mortality was 11.5%, compared to 8.1% (additive) and 12.8% (logistic). Discrimination was similar in both systems as measured by the C statistic (additive 0.73, logistic 0.73). CONCLUSIONS: The logistic EuroSCORE is more accurate at predicting mortality in simultaneous CABG and valve surgery, as the additive EuroSCORE significantly under-predicts in this high-risk group.

Background An increasing number of patients with peripheral vascular disease are undergoing coronary artery bypass grafting. Such patients have an increased risk of adverse outcomes. Our aim was to quantify the effect of avoiding cardiopulmonary bypass in this group of patients. Methods Between April 1997 and March 2002, 3,771 consecutive patients underwent coronary artery bypass grafting performed by five surgeons. Four hundred and twenty-two (11.2%) had peripheral vascular disease and of these, 211 (50%) received off-pump surgery. We used multivariate logistic regression analysis to assess the effect of off-pump surgery on in-hospital mortality and morbidity, while adjusting for treatment selection bias. Treatment selection bias was controlled for by constructing a propensity score, which was the probability of receiving off-pump surgery and included core patient characteristics. The C statistic for this model was 0.8. Results Off-pump patients were more likely to have preoperative renal dysfunction, previous gastrointestinal surgery, and less extensive disease. The left internal mammary artery was used more in off-pump compared to on-pump cases (90.1% vs 82.9%; p = 0.033). In the univariate analyses, off-pump patients were less likely to have a postoperative stroke ( p = 0.007), and had shorter postoperative hospital stays ( p p = 0.028). After adjustment for differences in case-mix (propensity score), avoidance of cardiopulmonary bypass was still associated with a significant reduction in postoperative stroke (adjusted odds ratio 0.09 [95% confidence interval 0.02 to 0.50]; p = 0.005), and shorter postoperative hospital stay ( p = 0.001). Conclusions Off-pump coronary surgery is safe in patients with peripheral vascular disease, with acceptable results. The incidence of postoperative stroke is substantially reduced when avoiding cardiopulmonary bypass in patients with peripheral vascular disease.

Objective— Off-Pump Coronary Artery Bypass (OPCAB) surgery is gaining more popularity worldwide. The aim of this United Kingdom (UK) multi-center study was to assess the early clinical outcome of the OPCAB technique and perform a risk-stratified comparison with the conventional Coronary Artery Bypass Grafting (CABG) using the Cardio-Pulmonary Bypass (CPB) technique. Methods— Data were collected on 5,163 CPB patients from the database of the National Heart and Lung institute, Imperial College, University of London, and on 2,223 OPCAB patients from eight UK cardiac surgical centers, which run established OPCAB surgery programs. All patients had undergone primary isolated CABG for multi-vessel disease through a midline sternotomy approach, between January 1997 and April 2001. Postoperative morbidity and mortality were compared between the CPB and OPCAB patients after adjusting for case-mix. The mortality of the OPCAB patients was also compared, using risk stratification, to the mortality figures reported by the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS) based on 28,018 patients in the national database who were operated on between January 1996 and December 1999. Results— Morbidity and mortality were significantly lower in the OPCAB patients compared with the CPB patients and the UK national database of CABG patients, over the same period of time, after adjusting for case-mix. Conclusion— This study demonstrates that risk stratified morbidity and mortality are significantly lower in OPCAB patients than CPB patients and patients in the UK national database.

Background . Recent studies examining neuroprotective effects of off-pump coronary artery bypass grafting (CABG) have shown inconsistent results. We examined our database to quantify the independent effects of avoidance of cardiopulmonary bypass (CPB) and aortic manipulation on neurologic outcomes after CABG. Methods . A total of 2,327 consecutive cases undergoing isolated CABG between April 1997 and May 2001 were identified at our two institutions. Patients were divided into three groups: on CPB, off-pump with aortic manipulation, and off-pump without aortic manipulation. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, redo operations, diabetes, chronic obstructive pulmonary disease, neurologic disease, peripheral vascular disease, ejection fraction, and priority of operation. Results . A total of 1,210 cases were performed on CPB, compared with 520 off-pump with aortic manipulation, and 597 off-pump without aortic manipulation. The incidence of focal neurologic deficit was 1.6% (n = 19) in the on-pump group, 0.4% (n = 2) in the off-pump with aortic manipulation group, and 0.5% (n = 3) for the off-pump without aortic manipulation group ( p for trend=0.027). The results of the multivariate logistic regression analysis demonstrated that use of CPB was a risk factor for focal neurologic deficit, with an odds ratio of 3.82 (95% confidence interval, 1.41 to 10.34; p = 0.005). Aortic manipulation did not significantly influence neurologic outcome in off-pump patients. Conclusions . Off-pump operation, with or without aortic manipulation, reduces adverse neurologic outcomes compared with on-pump procedures.

Chemical pleurodesis using tetracycline is an accepted and commonly employed treatment of pneumothorax and pleural effusions. We describe a case of chemical burn of the pleura in a ventilated 41-year-old who came to thoracotomy after 3 days of continuous intrapleural infusion of tetracycline at another hospital. To our knowledge this has not been previously reported although other adverse effects of this procedure are documented. We suggest that damage to the pleura and underlying lung may occur if excessive amounts of tetracycline are used in attempted pleurodesis.

We report the interesting case of an elderly woman who presented with hypoglycaemic episodes and weight loss. She was found to have a solitary fibrous tumour weighing more than 1.7 kg arising from the diaphragmatic pleura, which had been producing insulin-like growth factor II. After surgical removal of this well-encapsulated, pedunculated tumour her hypoglycaemia resolved and she returned to normal both clinically and biochemically.