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Left atrial-esophageal fistula (AEF) following radiofrequency ablation for atrial fibrillation is a rare and potentially lethal complication. Although surgical management is associated with improved outcomes, the optimal approach remains to be elucidated. We describe a case of AEF which was treated with a simultaneous repair of the atrium and esophagus via a right thoracotomy with an extra-pericardial off-pump approach.

Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).

Objective Preoperative anemia management reduces red blood cell (RBC) transfusion and adverse outcomes, but how best to optimize the patient's hemoglobin (Hgb) before cardiac surgery remains unclear. The authors sought to determine the optimal treatment of anemia using iron and epoetin alfa before cardiac surgery. Design Retrospective cohort study. Setting Sunnybrook Health Sciences Centre, University of Toronto. Participants The study comprised 532 consecutive patients referred to the outpatient Blood Conservation Clinic and who underwent cardiac surgery between 2008 and 2018. Interventions Of the 532 patients, 207 received oral iron, 84 received intravenous (IV) iron, 71 received epoetin alfa, 92 received combination therapy, and 78 received no treatment. Measurements and Main Results Multivariate linear, logistic, and Poisson regressions modelled preoperative Hgb, the change from referral to preoperative Hgb (∆Hgb), the odds of transfusion, and the number of RBC units transfused, while accounting for baseline covariates. Higher ∆Hgb was associated with IV iron >600 mg (9.80 g/L [6.17-13.42]), epoetin alfa >80,000 U (5.80 g/L [2.20-9.40]), and higher referral Hgb (1.91 g/L [1.09-2.74] per 10 g/L). Higher preoperative Hgb (odds ratio 0.76 [0.64-0.90]; count ratio 0.84 [0.77-0.93] per 10 g/L) corresponded to a lower likelihood of being transfused and transfusion of fewer RBC units. Conclusions Preoperative IV iron >600 mg and epoetin alfa >80,000 U each was associated with significant increases in Hgb. Higher preoperative Hgb was associated with a lower likelihood of transfusion and transfusion of fewer RBC units. The authors recommend that cumulative preoperative doses of IV iron >600 mg and epoetin alfa >80,000 U be used for treatment of anemia before cardiac surgery.

Background: Pneumothorax is a common complication of cardiac implantable electronic device (CIED) procedures. There is a paucity of data on the natural history and management of a CIED-associated pneumothorax. Methods: This is a single-centre retrospective study of all consecutive patients with a CIED-associated pneumothorax between March 2010 and March 2020. Pneumothorax size was determined on all chest x-rays after device implantation and before chest tube insertion (if placed). Changes in pneumothorax size on serial chest x-rays were reported. Clinical outcomes in patients with a severe-sized pneumothorax treated with a chest tube were compared with those treated conservatively. Results: A total of 86 CIED-associated pneumothoraxes were identified, with 55 (63.9%) patients having a pneumothorax severe in size. Thirty-seven patients with a severe pneumothorax received a chest tube, whereas 18 were managed conservatively. Chest tube use was associated with a higher rate of admission to hospital (100% vs 63%, P = 0.02) for patients undergoing outpatient procedure, longer length of stay (6.3 ± 3.9 vs 2.7 ± 2.9 days, P = 0.04), but fewer chest x-rays (1.9 ± 0.7 vs 4.1 ± 2.5, P = 0.002). Conclusion: An initial strategy of conservative management of a CIED-associated pneumothorax in select patients may be feasible and safe. Résumé: Contexte: Le pneumothorax est une complication courante des interventions visant à mettre en place un dispositif cardiaque électronique implantable (DCEI). Il n’existe que très peu de données sur l’évolution naturelle et la prise en charge du pneumothorax lié à la pose d’un DCEI. Méthodologie: Nous avons étudié rétrospectivement les cas de patients ayant présenté un pneumothorax lié à un DCEI et traités consécutivement dans un même centre entre mars 2010 et mars 2020. La taille du pneumothorax a été déterminée dans toutes les cradiographies pulmonaires obtenues après la pose du DCEI et avant l’insertion d’un drain thoracique (le cas échéant). Les variations de la taille du pneumothorax mesurée sur les radiographies pulmonaires successives ont été rapportées. Les résultats cliniques observés chez les patients présentant un pneumothorax important traités par drainage thoracique ont été comparés à ceux de patients traités selon l’approche classique. Résultats: Au total, 86 cas de pneumothorax liés à un DCEI ont été relevés; 55 patients (63,9 %) présentaient un pneumothorax important. De ce nombre, 37 patients ont subi un drainage thoracique, tandis que les 18 autres ont été pris en charge selon l’approche classique. Le recours à un drain thoracique a été associé à un taux d’admission à l’hôpital plus élevé (100 % vs 63 %; p = 0,02) dans le cas des interventions ambulatoires et à une hospitalisation plus longue (6,3 ± 3,9 vs 2,7 ± 2,9 jours; p = 0,04), mais à un moins grand nombre de radiographies pulmonaires (1,9 ± 0,7 vs 4,1 ± 2,5; p = 0,002). Conclusion: Dans certains cas, il est possible et sûr d’avoir recours à une prise en charge initiale classique du pneumothorax lié à un DCEI.

Background: Studies have demonstrated that female sex is an adverse risk factor in CABG. The primary aim of this study was to determine whether the radial artery (RA) was associated with reduced angiographic occlusion compared to the saphenous vein graft (SVG) stratified by sex in the multi-centered Radial Artery Patency Study (NCT00187356). Methods: Between 1996–2001, 529 patients less than 80 years, with graftable triple-vessel disease underwent isolated CABG across 11 centers with late angiographic and clinical follow-up. The primary objective was to compare complete occlusion of RA and SVG with respect to sex. The secondary objective was to determine cumulative patency of both grafts along with predictors of late graft occlusion stratified by sex. The additional objective was to compare major adverse cardiac events (MACE, defined as cardiac mortality, myocardial infarction or re-intervention) between women and men. Results: Of the 529 enrolled patients (13.4% women), 269 (women: n=41, 15.2%) underwent late angiography at a mean of 7.7±1.5 years after CABG. Women were older (64.1±6.7 versus 59.1±8.0 years, P

To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR).Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.

Objective The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. Methods We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. Results In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

Often, designers and developers of serious games (and virtual simulations in general) strive for high fidelity (realism). However, real-time high-fidelity rendering of complex environments across sensory modalities such as vision, audition, and haptic (sense of touch) is still beyond our computational reach. Previous work has demonstrated that multimodal effects can be considerable, to the extent that a large amount of detail of one sense may be ignored or enhanced by the presence of other sensory inputs. Taking advantage of such multimodal effects, perceptual-based rendering—whereby the rendering parameters are adjusted based on the perceptual system—can be employed to limit computational processing. Motivated by the general lack of emphasis given to the understanding of audio rendering in virtual environments and games, we have started investigating multimodal (audiovisual) interactions within such virtual environments. Our work has shown that sound can directly affect visual fidelity perception and task performance within a virtual environment. These effects can be very individualized, whereby the influence of sound is dependent on various individual factors including musical listening preferences, suggesting the importance of individualizing the virtual environment to each user. This chapter begins with an overview of virtual environments and serious gaming’s open problems, with an emphasis on fidelity, and multimodal interactions, and the implications that these may have on performance and computational requirements. A detailed summary of our own prior work will be provided along with insight and suggestions that may guide designers and developers of serious games and virtual learning environments in general. Although the chapter is contextualized in the use of serious games in health professions education, the information provided is generalizable across a variety of domains.

Background: Graft Imaging to Improve Patency (GRIIP), a single-center, randomized blinded clinical trial, reported that intraoperative graft assessment with graft revision according to a priori criteria of transit time flowmetry (TTF) and intraoperative fluorescent angiography did not improve graft patency at one year after coronary artery bypass grafting (CABG) when compared with standard intraoperative management. The objective of this study is to investigate whether other TTF values are more predictive of the saphenous vein graft (SVG) failure and/or clinical outcomes. Methods: This is a case control retrospective study of 65 SVGs from 44 patients from GRIIP. Study outcomes were graft patency at 12 months and major adverse cardiac events (MACE; death, myocardial infarction, repeat revascularization). Results: Twenty-two SVGs were occluded. In receiver operating characteristic curve analysis, TTF mean flow was significantly predictive of one-year SVG failure (area under the curve = 0.698, p

Increased cardiac troponin is observed after virtually every cardiac operation, indicating perioperative myocardial injury. The clinical significance of this elevation is controversial. This study aimed to correlate postoperative troponin levels with major adverse cardiac events (MACE).The study included 1918 consecutive patients undergoing adult cardiac operations, including 1515 isolated coronary procedures, 229 valvular operations, and 174 combined coronary/valve procedures. Peak troponin T (normal value0.1 microg/L) was measured at less than 24 hours postoperatively. Excluded were 506 patients with a recent myocardial infarction (30-days of operation). The primary outcome was a composite of death, electrocardiogram-defined infarction, and low output syndrome (MACE).Mortality rates were 1.4%, 6.1%, and 7% in the coronary bypass, valve, and combined groups, respectively (p0.001). The rates of MACE were 17%, 35%, and 44% (p0.0001), and mean troponin T levels were 0.9 +/- 1.5, 1.2 +/- 2.9, and 1.3 +/- 1.2 microg/L (p0.001), in the coronary bypass, valve, and combined groups, respectively. All patients were divided into quintiles based on their peak postoperative troponin level (Q1, 0.0 to 0.39; Q2, 0.4 to 0.59; Q3, 0.6 to 0.79; Q4, 0.8 to 1.29; and Q5,1.3 microg/L). Adverse outcomes were similar and stable in the lower quintiles. A stepwise increase in adverse outcomes was observed in the higher quintiles. Receiver operating characteristic curve analysis revealed a troponin cutoff of 0.8 microg/L was the most discriminatory for MACE (area under the curve, 0.7). Multivariable analyses showed a troponin value of more than 0.8 microg/L was independently associated with MACE.Moderate elevations in troponin are common after cardiac operations; troponin is a well-described predictor of outcomes. Troponin levels exceeding 0.8 microg/L are associated with increased MACE in patients without a history of preoperative myocardial infarction within 30 days of operation.

Background: The traditional recommendation has been to stop Aspirin seven to 10 days prior to coronary artery bypass surgery to reduce the potential risk of bleeding. A few reports have shown that Aspirin did not increase the risk of bleeding and may be beneficial to be continued until the time of surgery. The objective of this review was to evaluate the effect of preoperative Aspirin on bleeding in patients undergoing elective bypass surgery. Methods: A meta-analysis of 10 randomized and nonrandomized studies reporting comparisons between Aspirin and control was undertaken. The primary outcome was the total amount of postoperative chest tube drainage. Secondary outcomes were the number of units of packed red blood cell transfusion, platelet transfusion, fresh frozen plasma transfusion, and number of patients reexplored for bleeding. Results: Ten studies, involving 1748 patients, met the inclusion criteria for this review of whom 913 were in the Aspirin group and 835 were in the control group. Pooling the results of all studies showed a significant increase in blood loss and transfusion of red blood cells and fresh frozen plasma in the Aspirin group (p 0.05). Included studies were heterogeneous and of low methodological quality. Conclusion: Aspirin is associated with increased chest tube drainage and may be associated with a greater requirement for blood products. High-quality prospective studies are warranted to reassess the effect of Aspirin on important postoperative outcomes.

Background Graft stenosis may be associated with future graft failure. The purpose of this investigation was to compare graft stenosis between radial artery (RA) grafts and saphenous vein grafts (SVGs) at least 5 years postoperatively using the multicenter Radial Artery Patency Study (RAPS) data. Methods Two hundred thirty-four patients underwent late invasive angiography after coronary artery bypass operations. The study population consists of 163 patients with thrombolysis in myocardial infarction (TIMI) 3 flow of both the RA graft and study SVGs. Angiograms were reviewed centrally and in a blinded fashion. Graft stenosis was recorded for the proximal anastomosis, graft body, and distal anastomosis; significant stenosis was defined as greater than or equal to 50%. Major adverse cardiac events (MACE) were reported in patients with and those without significant graft stenosis. Results There was no difference in significant graft stenosis of the patent RA grafts and SVGs (14 of 163 [8.6%] versus 19 of 163 [11.7%]) or in the proximal anastomosis (5 of 163 [3.1%] versus 5 of 163 [3.1%]), graft body (6 of 163 [3.7%] versus 13 of 163 [8.0%]), or distal anastomosis (4 of 163 [2.5%] versus 5 of 163 [3.1%]) considered separately. However, the overall burden of graft body disease was higher in SVGs ( p = 0.03). MACE was higher in patients with significant graft stenosis than in patients without stenosis (10 of 28 [35.7%] versus 7 of 135 [5.2%]; p Conclusions There was no significant difference in the rates of significant stenosis of patent RA grafts and SVGs more than 5 years postoperatively. However, the burden of graft body stenosis was less in RA grafts compared with SVGs, suggesting that the RA grafts will continue to outperform the SVGs late after operation.

Objectives The study objective was to determine the impact of diabetes on radial artery and saphenous vein graft occlusion and clinical outcomes more than 5 years after coronary artery bypass surgery in the multicenter Radial Artery Patency Study (NCT00187356). Methods A total of 529 patients aged less than 80 years with triple-vessel disease undergoing coronary bypass surgery participated in this study. Angiographic follow-up occurred more than 5 years after surgery with annual clinical follow-up. The primary objective was to compare the proportion of complete graft occlusion between radial artery and saphenous vein grafts among diabetic and nondiabetic persons. Additional objectives included determining predictors of complete graft occlusion and comparison of major adverse cardiac events defined by cardiac death, late myocardial infarction, and reintervention. Results There were 148 of 529 patients (27.8%) with diabetes; 269 patients (83/269 [30.9%] diabetic) underwent late angiography at mean of 7.7 ± 1.5 years after surgery. In diabetic patients, the proportion of complete graft occlusion was significantly lower in the radial grafts (4/83 [4.8%]) than in the saphenous grafts (21/83 [25.3%]) ( P = .0004), and this was similar in nondiabetic patients ( P = .19). Multivariate modeling showed that the use of the radial artery and high-grade target vessel stenosis were protective against late graft occlusion, whereas female gender, smoking history, and elevated creatinine were associated with an increased risk; interaction between diabetic status and conduit type also was significant ( P = .02). Major adverse cardiac events were higher in diabetic patients (23/148 [15.5%] vs 35/381 [9.2%], P = .04). Conclusions The use of the radial artery should be strongly considered in diabetic patients undergoing coronary bypass surgery, especially with high-grade target vessel stenosis.

A 46-year-old man with polyarteritis nodosa and multiple myocardial infarctions treated with multiple percutaneous coronary interventions presented again with atypical angina. Coronary angiography revealed triple-vessel coronary artery disease. This patient underwent four-vessel coronary artery bypass graft and recovered uneventfully. A review of the literature and discussion of the surgical management of this patient is presented.

Giant left atrium (GLA) is seen in a variety of cardiac conditions. The GLA is diagnosed by combining the patient's history, physical examination, and imaging techniques, along with a computed tomographic chest scan, echocardiogram, and barium swallow test. We recently operated on a severely symptomatic 71-year-old woman with GLA (135 mm x 192 mm). We were forced to anesthetize her with negative pressure ventilation before connecting to the cardiopulmonary bypass circuit. Her postoperative course and long-term follow-up were uneventful. The procedure for GLA reduction is safe, even in very high-risk patients. Negative pressure ventilation may be used successfully as a bridge to cardiopulmonary bypass in certain cases.

OBJECTIVE: Neointimal hyperplasia secondary to vascular smooth muscle cell (VSMC) activation limits the long-term patency of saphenous vein grafts (SVGs). We compared markers of vascular injury and VSMC activation in SVGs harvested using the pedicled ‘no-touch’ (NT) vs the conventional (CON) technique. METHODS: Patients undergoing coronary artery bypass surgery were enrolled in the PATENT SVG trial (clinicaltrials.gov NCT01488084). Patients were randomly allocated to have SVGs harvested with the NT technique from one leg and the CON method from the other. SVG segments underwent morphometry, histological and electron microscopy assessments and transcript measurements of VSMC activation and differentiation markers. Leg wound functional recovery and harvest site complications were assessed using a quality-of-life questionnaire. RESULTS: A total of 17 patients (65.3±7.3 years) were enrolled. SVGs harvested using the NT vs CON technique exhibited preserved intimal, medial and adventitial architecture. CON harvest was associated with greater medial Kruppel-like factor 4 transcript levels (0.26±0.05 vs 0.11±0.02, P

Background: Pericardiectomy for constrictive or calcific pericarditis is a technical challenge because of dense adhesions to the epicardial surface of the heart. The procedure is fraught with the possibility of urgent cardiopulmonary bypass from excessive bleeding or cardiac laceration. We propose the use of a harmonic scalpel to perform adhesiolysis with less bleeding and cardiac trauma. Methods and Materials: A retrospective review of 7 pericardiectomies performed with a handheld harmonic scalpel over the past 2 years was performed. Requirements for blood products, the need for cardiopulmonary bypass, and mortality were examined. Results: Four of the patients underwent pericardiectomy alone, and 3 patients underwent pericardiectomy with additional cardiac procedures. The 30-day mortality was zero. No patient needed blood transfusions or urgent cardiopulmonary bypass for bleeding. No patient developed malignant arrhythmias. Conclusions: Use of a harmonic scalpel is a safe and efficient technique for pericardiectomy. Adhesiolysis is less treacherous because of the bloodless operative field; moreover, the harmonic scalpel is not arrhythmogenic.

The popularity of surgical specialties is declining amongst Canadian medical students. Limited early exposure of students to surgery and minor involvement of surgeons in preclerkship education are barriers to creating interest in the field. Although many informal observerships and interest groups exist, there are no structured programs in Canada that offer preclerkship medical students a comprehensive exposure to surgery.Twenty first-year medical students participated in the Surgical Exploration and Discovery (SEAD) Program. SEAD is a pilot project at the University of Toronto providing a unique combination of (1) observerships, (2) informal discussions on surgical careers, and (3) hands-on simulation workshops across all 7 direct-entry specialties within the Department of Surgery. All participants underwent pretraining and posttraining evaluation of learning through a paper-based knowledge test and all completed a structured survey on the benefit of the course.Comparison of test scores revealed an overall significant improvement in learning (p0.0001). The improvement in test scores was seen in the knowledge of all 3 components of the course (p0.0001). Qualitative evaluation revealed a positive student experience, with 100% of students indicating that SEAD helped them identify new interests in surgical subspecialties. Finally, 100% of students stated that they would recommend the program to incoming medical students.The SEAD Program successfully improves preclerkship students' knowledge of surgical principles, understanding of a career in surgery, and basic surgical skills. Participation in the program also positively influenced their interest in pursuing a career in surgery. Programs such as SEAD may be offered to preclerkship medical students to improve their exposure to surgery at this level of training and to enhance perspectives toward surgical careers.

Surgical proficiency requires command of both technical and cognitive skills. Although at times overlooked, cognitive skills training allows residents to practise detecting errors ultimately leading to a reduction of errors. Virtual simulations and serious games offer a viable alternative to practice in an actual operating room where traditionally both technical and cognitive skills acquisition takes places. They provide residents the opportunity to train until they reach a specific competency level in a safe, cost effective, fun, and engaging manner allowing them to make more effective use of their limited training time in the operating room. Here we introduce a serious game surgical cognitive education and training framework (SCETF) that is currently being developed specifically for cognitive surgical skills training. Domain-specific surgical “modules” can then be built on top of the existing framework, utilizing common simulation elements/assets. The SCETF is being developed as a research tool where various simulation parameters such as levels of audio and visual fidelity, can be easily adjusted allowing for the controlled testing of such factors on knowledge transfer and retention.

Background Simulation-based programs allow trainees to be progressively challenged in a systematic, learner-centered and patient-focused fashion. The design of these programs requires an understanding of the individual steps that comprise the entire surgical procedure and our ability to assess the progress of the learner. We present the results of the design and validation of performance assessment checklists for a progressive simulation-based program in cardiac surgery. Methodology Using a case study design, we videotaped 10 off-pump coronary artery bypass procedures and applied a new methodological framework to deconstruct the procedure into teachable components for which 6 simulation scenarios were developed. Individual checklists were designed and validated using the Delphi technique. An expert panel of 11 cardiac surgeons rated each checklist item by using a 5-point Likert-type scale and provided comments on the rating choice. The consistency of the experts' ratings were interpreted as consensus achieved when 70% of experts rated 3.5 or greater on the 5-point Likert-type scale for each assessment item. Results An in vivo workflow diagram was developed, and 6 simulation modules with progressive difficulty were selected to design an off-pump coronary artery bypass simulation-based program. The corresponding 6 assessment checklists were designed and validated. After 2 Delphi rounds, the overall average score across all checklists was 4.0, and all items were greater 3.5. The final checklists comprise between 12 and 23 items. Conclusion We have demonstrated the feasibility of designing simulation-based program for complex operative procedures in a progressive fashion. The complexity at each level was given by the predefined training objectives and assessment checklists were designed and validated as content-specific assessment tools for each simulation scenario.

We have begun development of an interactive, multi-player serious game for the purpose of training cardiac surgeons, fellows, and residents the series of steps comprising the Off-Pump Coronary Artery Bypass grafting (OPCAB) surgical procedure. It is hypothesized that by learning the OPCAB procedure in a "first-person-shooter gaming environment", trainees will have a much better understanding of the procedure than by traditional learning modalities. The serious game will allow for simulation parameters related to levels of fidelity to be easily adjusted so that the effect of fidelity on knowledge transfer can be examined.

Off Pump Coronary Artery Bypass (OPCAB) surgery is a strategy for revascularizing diseased coronary arteries without cardiopulmonary bypass. The complete operation can be deconstructed into individual tasks and subtasks that are ideal for creating simulation modules. Recently, we have developed a modular mechanical beating-heart OPCAB simulator for use in learner-centered training. In the present study, we describe the design of a progressive, simulation-augmented training program for OPCAB surgery. In particular, we a) define need-driven education and training goals, b) create simulation scenarios with progressive difficulty to specifically address these goals, and c) design corresponding assessment tools for both formative and summative purposes.

The off-pump coronary artery bypass grafting (OP-CAB) cardiac surgical procedure allows for a blocked coronary artery to be bypassed with a healthy artery or vein from another part of the body while the heart is beating in contrast to traditional coronary artery bypass grafting (CABG) which requires the use of a cardiopulmonary pump. Eliminating the cardiopulmonary pump, leads to a reduction in the number of postoperative complications. Despite the benefits associated with OPCAB and more specifically, its non-reliance on the cardiopulmonary pump, the OPCAB procedure itself is complex and technically challenging and therefore, it has been suggested that "appropriate training" be provided before operating on patients. Here we describe the preliminary development of an interactive, multi-player serious game for the purpose of training cardiac surgeons/residents the series of steps comprising the OPCAB procedure. By learning the OPCAB procedure in a "first-person-shooter gaming environment", trainees will have a much better understanding of the procedure than by traditional learning modalities.

The goal of simulation-based medical education and training is to help trainees acquire and refine the technical and cognitive skills necessary to perform clinical procedures. When designers incorporate simulation into programs, their efforts should be in line with training needs, rather than technology. Designers of simulation-augmented surgical training programs, however, face particular problems related to identifying a framework that guides the curricular design activity to fulfill the particular requirements of such training programs. These problems include the lack of (1) an objective identification of training needs, (2) a systematic design methodology to match training objectives with simulation resources, (3) structured assessments of performance, and (4) a research-centered view to evaluate and validate systematically the educational effectiveness of the program. In this report, we present a process called "Aim - FineTune - FollowThrough" to enable the connection of the identified problems to solutions, using frameworks from psychology, motor learning, education and experimental design.

Objective The benefit of stentless valves remains in question. In 1999, a randomized trial comparing stentless and stented valves was unable to demonstrate any hemodynamic or clinical benefits at 1 year after implantation. This study reviews long-term outcomes of patients randomized in the aforementioned trial. Methods Between 1996 and 1999, 99 patients undergoing aortic valve replacement were randomized to receive either a stented Carpentier–Edwards pericardial valve (CE) (Edwards Lifesciences, Irvine, Calif) or a Toronto Stentless Porcine Valve (SPV) (St Jude Medical, Minneapolis, Minn). Among these, 38 patients were available for late echocardiographic follow-up (CE, n = 17; SPV, n = 21). Echocardiographic analysis was undertaken both at rest and with dobutamine stress, and functional status (Duke Activity Status Index) was compared at a mean of 9.3 years postoperatively (range, 7.5–11.1 years). Clinical follow-up was 82% complete at a mean of 10.3 years postoperatively (range, 7.5–12.2 years). Results Preoperative characteristics were similar between groups. Effective orifice areas increased in both groups over time. Although there were no differences in effective orifice areas at 1 year, at 9 years, effective orifice areas were significantly greater in the SPV group (CE, 1.49 ± 0.59 cm 2 ; SPV, 2.00 ± 0.53 cm 2 ; P = .011). Similarly, mean and peak gradients decreased in both groups over time; however, at 9 years, gradients were lower in the SPV group (mean: CE, 10.8 ± 3.8 mm Hg; SPV, 7.8 ± 4.8 mm Hg; P = .011; peak: CE, 20.4 ± 6.5 mm Hg; SPV, 14.6 ± 7.1 mm Hg; P = .022). Such differences were magnified with dobutamine stress (mean: CE, 22.7 ± 6.1 mm Hg; SPV, 15.3 ± 8.4 mm Hg; P = .008; peak: CE, 48.1 ± 11.8 mm Hg; SPV, 30.8 ± 17.7 mm Hg; P = .001). Ventricular mass regression occurred in both groups; however, no differences were demonstrated between groups either on echocardiographic, magnetic resonance imaging, or biochemical (plasma B-type [brain] natriuretic peptide) assessment ( P = .74). Similarly, Duke Activity Status Index scores of functional status improved in both groups over time; however, no differences were noted between groups (CE, 27.5 ± 19.1; SPV, 19.9 ± 12.0; P = .69). Freedom from reoperation at 12 years was 92% ± 5% in patients with CEs and 75% ± 5% in patients with SPVs ( P = .65). Freedom from valve-related morbidity at 12 years was 82% ± 7% in patients with CEs and 55% ± 7% in patients with SPVs ( P = .05). Finally, 12-year actuarial survival was 35% ± 7% in patients with CEs and 52% ± 7% in patients with SPVs ( P = .37). Conclusion Although offering improved hemodynamic outcomes, the SPV did not afford superior mass regression or improved clinical outcomes up to 12 years after implantation.

PURPOSE : Clopidogrel is indicated in acute and chronic coronary syndromes and often administered prior to angiography. These patients are often sent subsequently for coronary artery bypass grafting (CABG) surgery, where potential increase in bleeding risk must be balanced with risk of ongoing ischemia if CABG delayed. This study aimed to test the hypothesis that patients undergoing urgent CABG who received clopidogrel, versus those who did not, have worse bleeding outcomes and early mortality. METHODS : We reviewed 451 consecutive patients (04/2005–12/2006) who underwent urgent CABG at our institution: 262 never received clopidogrel pre-CABG, 189 received clopidogrel 10U PRBC) or massive blood loss (>2L chest-tube loss/24 hrs). RESULTS : Patient characteristics were comparable between groups. Prior MI (71% vs 46%), NYHA class 3– 4 (94% vs 81%) and prior PCI (22% vs 13%) were higher in the clopidogrel group (p CONCLUSION : Clopidogrel, or the time it was stopped prior to CABG, was not a risk factor for in-hospital death, massive bleeding, or other poor early outcomes in patients undergoing urgent CABG. Practice measures such as the use of antifibrinolytic agents may ameliorate the adverse effects of clopidogrel.

Background and aim To review the various concepts, surgical experiments, and actual procedures performed for the treatment of ischemic heart disease, which eventually led to the evolution of direct coronary artery bypass surgery. Methods References were collected from original articles and through pubmed search. Results Various concepts and procedures were introduced, all with the aim of increasing myocardial blood flow and relief of angina. These included creation of vascular adhesions, denervation, thyroidectomies, using other organs for providing blood supply, and intramyocardial implantation of bleeding systemic arteries. Conclusion Historically various innovative concepts existed and a variety of procedures were performed for treating ischemic myocardium, with variable results. These procedures continued till the evolution of direct coronary artery bypass grafting.

Objectives The complexity of surgical treatment for acute type A dissection contributes to the variability in patient management. This study was designed to elucidate the contemporary practice preferences of cardiac surgeons regarding different phases of management of acute type A aortic dissection. Methods A 34-item questionnaire was distributed to all Canadian adult cardiac surgeons addressing the preoperative, intraoperative, and postoperative management of acute type A dissection. A total of 100 responses were obtained (82% of active surgeons in Canada). Outcomes were compared between high- and low-volume aortic surgeons. Results Seventy-six percent of respondents favored axillary artery cannulation. High-volume surgeons (>150 cases) were more likely to indicate a target lowest nasopharyngeal temperature more than 20°C (53% vs 25%, P = .02). The majority of surgeons (65%) recommended using selective antegrade cerebral perfusion, with a significantly greater proportion for higher-volume aortic surgeons ( P = .03). In addition, high-volume aortic surgeons were more likely to recommend aortic root replacement at smaller diameters (73% vs 55%, P = .02), to recommend more extensive distal aortic resection with routine open hemiarch anastomosis (85% vs 65%, P = .04), and to more commonly perform total arch reconstruction when needed (93% vs 77%, P = .04). In the follow-up period, frequency of serial imaging of the residual aorta was significantly higher for high-volume aortic surgeons ( P = .04). Conclusions This study identified some commonalities in practice preferences among Canadian cardiac surgeons for the management of acute type A aortic dissection. However, it also highlighted significant differences in temperature management, cerebral protection strategies, and extent of resection between high-volume and low-volume aortic surgeons.

The internal thoracic artery (ITA) has been universally accepted as a superior conduit for patients undergoing coronary artery bypass operations. The harvesting of the ITA is a routine procedure. Rarely, one encounters an ITA densely adherent to the overlying periosteum. We describe a technique of safely harvesting such an ITA using an orthopedic chisel. It is harvested along with a thin bone-flap and periosteum, giving a patent and uninjured ITA.

A 61-year-old male vasculopath presented for coronary revascularization and was found to have high-grade bilateral subclavian artery stenosis. The adequacy of the left internal mammary artery for bypass to the left anterior descending artery was in question. Rather than assessing the left internal mammary artery intraoperatively, we performed a preoperative cardiac computed tomography (CT) angiogram. This showed that the free left internal mammary artery was a suitable conduit and the procedure was performed expeditiously. Therefore, cardiac CT angiography is a noninvasive tool for preoperative planning in coronary revascularization.

In order to elucidate some of the factors which influence the low birth weight rate, 22,815 deliveries were studied. It is already known that low birth weight (LBW) underlies the majority of infant deaths. It is also associated with an increased risk of permanent disability such as cerebral palsy, learning difficulties, and mental retardation of various degrees in survivors. In modern society these problems require major resources from the health budget. The Israeli population is composed of Jews and non-Jews, who differ not only in their religion but also in their customs. Most of the Jews are immigrants from many parts of the world who still retain many of the habits, customs and lifestyles of the societies they had lived in for many generations. We evaluated the LBW rate in these different groups. Jews and non-Jews have similar rates of LBW and similar mean birth weights. Other factors such as maternal age, parity, and hypertensive disorders of pregnancy showed some statistically significant differences. LBW rates increase from 6.9% in the babies of women aged 24-40 years to 8.5% in those less than 24 years, and 9.5% in those over 40. The risk of LBW was increased in primiparae to 10%. The highest rates were found in babies of mothers with hypertension. Pregnancy induced hypertension is associated with a LBW rate of 15.6% and chronic hypertension with a rate of 23%. Moderate and severe preeclampsia are important risk factors since they increase the rate to 15% and 47.1%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)