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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.)

Purpose: To determine the characteristics of clinically active academic physicians most affected by administrative burden; the correlation between administrative burden, burnout, and career satisfaction among academic physicians; and the relative value and burden of specific administrative tasks., Method: The authors analyzed data from the 2014 Massachusetts General Physicians Organization Survey. Respondents reported the percentage of time they spent on patient-related administrative duties and rated the value and burden associated with specific administrative tasks. A five-point Likert scale and multivariate regression identified predictors of administrative burden and assessed the impact of administrative burden on perceived quality of care, career satisfaction, and burnout., Results: Of the eligible workforce, 1,774 physicians (96%) responded to the survey. On average, 24% of working hours were spent on administrative duties. Primary care physicians and women reported spending more time on administrative duties compared with other physicians. Two-thirds of respondents reported that administrative duties negatively affect their ability to deliver high-quality care. Physicians who reported higher percentages of time spent on administrative duties had lower levels of career satisfaction, higher levels of burnout, and were more likely to be considering seeing fewer patients in the future. Prior authorizations, clinical documentation, and medication reconciliation were rated the most burdensome tasks., Conclusions: Administrative duties required substantial physician time and affected physicians' perceptions of being able to deliver high-quality care, career satisfaction, burnout, and likelihood to continue clinical practice. There is variation in administrative burden across specialties, and multiple areas of work contribute to overall administrative workload.

Background: Under the Affordable Care Act, health care reimbursement will increasingly be linked to quality and costs. In this environment, teaching hospitals will be closely scrutinized, as their care is often more expensive. Furthermore, although they serve vital roles in education, research, management of complex diseases, and care of vulnerable populations, debate continues as to whether teaching hospitals deliver better outcomes for common conditions., Objective: To determine the association between risk-standardized mortality and teaching intensity for 3 common conditions., Research Design: Using CMS models, 30-day risk-standardized mortality rates were compared among US hospitals classified as Council of Teaching Hospital (COTH) members, non-COTH teaching hospitals, or nonteaching hospitals. These analyses were repeated using ratios of interns and residents to beds to classify teaching intensity., Subjects: The study cohort included Medicare fee-for-service beneficiaries aged 66 years or older hospitalized in acute care hospitals during 2009-2010 for acute myocardial infarction (N = 342,145), heart failure (N = 647,081), or pneumonia (N = 598,366)., Outcome Measure: The 30-day risk-standardized mortality rates for each condition, stratified by teaching intensity., Results: For each diagnosis, compared with nonteaching hospitals there was a 10% relative reduction in the adjusted odds of mortality for patients admitted to COTH hospitals and a 6%-7% relative reduction for patients admitted to non-COTH teaching hospitals. These findings were insensitive to the method of classifying teaching intensity and only partially explained by higher teaching hospital volumes., Conclusions: Health care reimbursement strategies designed to increase value should consider not only the costs but also the superior clinical outcomes at teaching hospitals for certain common conditions.

Physicians are increasingly becoming salaried employees of hospitals or large physician groups. Yet few published reports have evaluated provider-driven quality incentive programs for salaried physicians. In 2006 the Massachusetts General Physicians Organization began a quality incentive program for its salaried physicians. Eligible physicians were given performance targets for three quality measures every six months. The incentive payments could be as much as 2 percent of a physician's annual income. Over thirteen six-month terms, the program used 130 different quality measures. Although quality-of-care improvements and cost reductions were difficult to calculate, anecdotal evidence points to multiple successes. For example, the program helped physicians meet many federal health information technology meaningful-use criteria and produced $15.5 million in incentive payments. The program also facilitated the adoption of an electronic health record, improved hand hygiene compliance, increased efficiency in radiology and the cancer center, and decreased emergency department use. The program demonstrated that even small incentives tied to carefully structured metrics, priority setting, and clear communication can help change salaried physicians' behavior in ways that improve the quality and safety of health care and ease the physicians' sense of administrative burden.

The management literature reveals that many successful organisations have strategic plans that include a bold 'stretch-goal' to stimulate progress over a ten-to-thirty-year period. A stretch goal is clear, compelling and easily understood. It serves as a unifying focal point for organisational efforts. The ambitiousness of such goals has been emphasised with the phrase Big Hairy Audacious Goal ('BHAG'). President Kennedy's proclamation in 1961 that 'this Nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to earth' provides a famous example. This goal energised the US National Aeronautics and Space Administration, and it captured the attention of the American public and resulted in one of the largest accomplishments of any organisation. The goal set by Sony, a small, cash-strapped electronics company in the 1950s, to change the poor image of Japanese products around the world represents a classic BHAG. Few examples of quality goals that conform to the BHAG definition exist in the healthcare literature. However, the concept may provide a useful framework for organisations seeking to transform the quality of care they deliver. This review examines the merits and cautions of setting overarching quality goals to catalyse quality improvement efforts, and assists healthcare organisations with determining whether to adopt these goals.

Purpose: To compare the performance of U.S. teaching and nonteaching hospitals using a portfolio of contemporary, publicly reported metrics., Method: The authors classified acute care general hospitals filing a Medicare Institutional Cost Report according to teaching intensity: nonteaching, teaching, or Council of Teaching Hospitals member. They compared aggregate results across categories for Hospital Compare process compliance, mortality, and readmission rates (acute myocardial infarction [AMI], heart failure, pneumonia); Surgical Care Improvement Project (SCIP) performance; compliance with Leapfrog standards; patient experience; patient services and key technologies; safety (computerized physician order entry, intensive care unit staffing, National Quality Forum safe practices, hospital-acquired conditions); and cost/resource utilization (Medicare-adjusted expense per case; Leapfrog efficiency and resource use standards)., Results: Availability of patient services and advanced technologies were associated with teaching intensity (P < .0001), as were most hospital safety metrics. Teaching intensity was favorably associated with SCIP performance, AMI and heart failure process scores, and mortality (P < .0001). It was unfavorably associated with higher AMI and pneumonia readmission rates (P < .0001) and lower scores for individual patient satisfaction measures. Costs per case were similar (P = .4194) across hospital categories after correction for federally allowed adjustments (case mix, wages, and low-income patient care)., Conclusions: Teaching hospitals offer advanced clinical capabilities, educate the next generation of providers, care for disadvantaged urban populations, and are leaders in health care research and innovation. However, many stakeholders may be unaware of an additional value-relatively higher quality and safety in many areas, with similar adjusted costs.

Background: In 2003, a satellite cardiac surgery program (SAT) was implemented at an affiliated community hospital located in an area historically served by an academic medical center (AMC). This study assessed the financial consequences and the changes in case-mix that occurred at the AMC after SAT implementation., Methods: From June 2002 through December 2005, 4593 adult patients underwent cardiac operations at the AMC. Excluded were 400 patients operated on during the 4-month transition period after SAT implementation and 1210 patients living more than 35 miles from the AMC. Multivariable regression was used to compare changes in case-mix and propensity-score adjusted costs for AMC patients referred from SAT area (N(before/after =) 328/291) vs other patients (N(before/after =) 897/1467)., Results: The SAT area referral rate decreased by 55%. Compared with other patients, AMC patients referred from the SAT area showed a greater increase in age in the second period (p = 0.013). The nursing workload and adjusted mean costs increased more for patients from the SAT area (p = 0.015 and 0.014, respectively). The hospital margin decreased in the second period for both referral areas (p < 0.001). For the patient subgroup undergoing coronary artery bypass grafting, this hospital margin decrease was greater for SAT area patients (p = 0.017)., Conclusions: After implementation of SAT program, fewer patients of lower complexity came to the AMC from the SAT area, and there was a significant increase in nursing workload and costs. During this interval, hospital margin for cardiac operations decreased from both referral areas but decreased significantly more for coronary artery bypass graft patients from the SAT area., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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

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

Objective: Increasing attention has been afforded to the ubiquity of medical error and associated adverse events in medicine. There remains little data on the frequency and nature of precursor events in cardiac surgery, and we sought to characterize this., Methods: Detailed, anonymous information regarding intraoperative precursor events (which may result in adverse events) was collected prospectively from six key members of the operating team during 464 major adult cardiac surgical cases at three hospitals and were analyzed with univariable statistical methods., Results: During 464 cardiac surgical procedures, 1627 reports of problematic precursor events were collected for an average of 3.5 and maximum of 26 per procedure. 73.3% of cases had at least one recorded event. One-third (33.3%) of events occurred prior to the first incision, and 31.2% of events occurred while on bypass. While 68.0% of events were regarded as minor in severity (e.g., delays and missing equipment), a substantial proportion (32.0%) was considered major and included anastomotic problems, pump failure, and drug errors. Most problems (90.4%) were reported as being compensated for, although many (30.9%) were never discussed among the team. Major events were more likely to be discussed (p<0.0001) and less likely to have been previously encountered (p=0.0005). Perceptions of the severity and compensation of events varied across the team, as did temporal patterns of reporting (p<0.0001)., Conclusions: A wide range of problematic precursor events occurs during the majority of cardiac surgery procedures. Attention to causes and ways of preventing these precursor events could have an impact on the rate of significant errors and improve the safety of cardiac surgery.

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

Demand is increasing for public accountability in health care. In 2000, the Massachusetts legislature mandated a state report card for cardiac surgery and percutaneous coronary interventions. During the planning and implementation of this report card, a number of observations were made that may prove useful to other states faced with similar mandates. These include the necessity for constructive, nonadversarial collaboration between regulators, clinicians, and statisticians; the advantages of preemptive adoption of The Society of Thoracic Surgeons [STS] National Cardiac Database, preferably before a report card is mandated; the support and resources available to cardiac surgeons through the STS, the National Cardiac Database Committee, and the Duke Clinical Research Institute; the value of a state STS organization; and the importance of media education to facilitate fair and dispassionate press coverage. Some important features of report cards may vary from state to state depending on the legislative mandate, local preferences, and statistical expertise. These include the choice of a statistical model and analytical technique, national versus regional reference population, and whether individual surgeon profiling is required.

Purpose: The purpose of this study was to investigate the function of a trileaflet pulmonary valve constructed from a sheet of porcine small intestinal submucosa., Description: In four sheep, the native pulmonary valve and a segment of the pulmonary trunk was excised and replaced with a trileaflet valve constructed from decellularized porcine small intestinal submucosa. The valve construct was created from a sheet of the xenograft material by a method of involuting flaps of tissue inside a cylinder of itself. The function of the valve was assessed by echocardiography, catheter pullback across the valve, and observation of an excised valve in a flow simulator., Evaluation: The valve constructs exhibited low gradients and symmetrical leaflet movement with good mobility when tested under physiologic conditions in an acute sheep model., Conclusions: This method offers a means to create a functional trileaflet valve replacement from a sheet of tissue.

Background: We sought to characterize patient survival and degree of late mitral regurgitation (MR) in patients undergoing surgical revascularization with moderate ischemic MR., Methods: We retrospectively reviewed 251 patients undergoing coronary artery bypass graft (CABG) surgery between 1991 and 2001 with 3+ ischemic MR, including 31 patients who had concomitant mitral annuloplasty. Univariate and multivariable testing was employed., Results: Actuarial 1-, 5-, and 10-year survival was 84.0%, 67.5%, and 37.1% in the overall group of 251 patients. Independent predictors of long-term mortality were age 70 years or more (hazard ratio 2.50 [95% confidence interval 1.82 to 3.44]), prior myocardial infarction (3.99 [2.15 to 7.39]), unstable angina (2.27 [1.69 to 3.04]), chronic renal failure (4.87 [3.13 to 7.58]), atrial fibrillation (2.21 [1.65 to 2.96]), left internal mammary artery to left anterior descending artery graft (0.28 [0.18 to 0.43]), preoperative beta-blocker (0.43 [0.28 to 0.67]), ejection fraction (0.71/10% [0.64 to 0.80]), left atrium size (0.88/mm [0.84 to 0.92]), diffuse wall motion abnormalities (2.83 [1.77 to 4.55]), and mitral leaflet restriction (3.85 [2.46 to 5.99]). The model controlled for the performance of annuloplasty, which did not emerge as an independent predictor. Patients undergoing annuloplasty did have less mean late MR than those having CABG alone (p = 0.005). Overall, 57.8% of patients (63 of 109) with follow-up echocardiograms had improvement in grade of MR compared with baseline. In 54 of 95 patients (56.8%), intraoperative transesophageal echocardiography downgraded the degree of MR compared with the preoperative study., Conclusions: Patients with moderate ischemic MR undergoing CABG had relatively poor long-term survival, with significant differences when stratified according to preoperative characteristics. Performance of mitral annuloplasty reduced the degree of regurgitation but was not a predictor of long-term survival. Intraoperative transesophageal echocardiography frequently downgraded the degree of MR.

Introduction: Gastrointestinal (GI) complications following heart operation may be life-threatening. Systematic analysis of risk factors to allow early identification of patients at risk for GI complication may lead to the development of strategies to mitigate this complication as well as to optimize management after its occurrence., Methods: Of 8709 consecutive patients undergoing heart operation during 7 years (1997-2003), 46 (0.53%) developed GI complications requiring surgical consultation. Preoperative, intraoperative, and postoperative predictors of complication and death were identified and compared with a control group., Results: Significant (P < 0.05) preoperative predictors of complication were prior cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), type II heparin-induced thrombocytopenia, atrial fibrillation, prior myocardial infarction, renal insufficiency, hypertension, and need for intra-aortic balloon counter-pulsation. The most frequent serious GI complication was mesenteric ischemia, which developed in 31 (67%) patients. Twenty-two (71%) of these patients were explored, and 14 (64%) died within 2 days of heart operation. Of the 9 patients with mesenteric ischemia who were not explored, 7 (78%) died within 3 days of heart operation. Other complications included diverticulitis (5), pancreatitis (4), peptic ulcer disease (4), and cholecystitis (2). The mortality rate in this group of other diagnoses was lower (40%), and death occurred later (32 days) after heart operation (P = 0.03 compared with mesenteric ischemia). Predictors of death from GI complication included New York Heart Association (NYHA) class III and IV heart failure, smoking, chronic obstructive pulmonary disease, history of syncope, aspartate aminotransferase (AST) >600 U/L, direct bilirubin >2.4 mg/dL, pH < 7.30, and the need for >2 pressors., Conclusions: The most common catastrophic GI complication after cardiac surgery is mesenteric ischemia, which is frequently fatal. This complication may be a result of atheroembolization, heparin-induced thrombocytopenia, or hypoperfusion. Techniques to reduce the occurrence of and/or preemptively diagnosis postcardiotomy mesenteric ischemia are necessary to decrease its associated mortality.

The availability of telemanipulation robots has not yet resulted in the emergence of a reliable endoscopic coronary bypass procedure. A major challenge in performing a closed-chest coronary operation is creating a high-quality anastomosis in a reasonable period of time. In this experimental study, the impact of distal vessel orientation on the speed and accuracy of anastomosis was quantifed. We found that vessel orientation and the relative angle of the surgical plane influence anastomosis speed, the trauma to the vessel, the accuracy of stitch placement, and the eventual achievement of hemostasis. Our results suggest that the speed and accuracy of a robotically performed anastomosis of a vessel graft to a coronary artery can be improved by making small changes in vessel orientation. Vessels should be positioned between the horizontal and diagonal orientation and inclined between the horizontal and +45 degrees . Because the 6-o'clock stitch is particularly challenging, surgeons may benefit from an orientation that moves the heel or the toe of the anastomosis away from this critical position.

BioGlue is a commercially available sealant manufactured by Cryolife (Atlanta, GA) as a hemostatic adjunct for cardiac and vascular surgery. This type of sealant has evolved conceptually from the gelatin resorcinol formalin glue (GRF or "French Glue") in the sense that it is devised not only to act a sealant but also as an agent to strengthen friable tissues, particularly in acute aortic dissection. In fact, the initial availability of BioGlue in the United States was under an FDA humanitarian device exemption for use in acute aortic dissection. This novel regulatory strategy expedited clinical use of BioGlue in acute aortic dissection and was permissible because of the small number of patients (less than 4000 per annum) in the potential treatment population. In this article, we will discuss the mechanism of action and composition of this agent, preclinical experience, the results of a prospective randomized trial as well as the results of our initial experience with BioGlue at MGH.

Focalseal is a polyethylene glycol based synthetic hydrogel. It is FDA approved as a sealant to limit airleak following pulmonary resection. In preclinical use, this type of sealant has also been shown to be effective as a hemostatic adjunct to prevent anastomotic bleeding and to seal other types of closure such as the dura, pancreatic stump, or open wounds. The sealant has two components, a primer and a sealant, and is applied in two steps and then polymerized by the application of a blue-green light (Fig. 1) (Genzyme Biosurgery, Inc. Cambridge, MA). The sealant does not bond covalently to tissue and is degraded by hydrolysis. This kind of sealant is flexible and nontoxic and has many intriguing possible applications as well as some mechanical properties that are essential to understand for safe use.

Background: The development of conveniently sprayed, tissue-adherent, inert hydrogel films has made possible the creation of novel products that can serve a dual function, as a surgical sealant to achieve immediate hemostasis, and as a barrier to prevent adhesion formation over time., Methods: A sprayable, in situ formed absorbable hydrogel film was evaluated as a tissue sealant in a heparinized canine carotid artery graft model. PTFE grafts with leaking end-to-side anastomoses were treated with the synthetic sealant, and hemostasis was evaluated upon restoration of blood flow. Also, the hydrogel films were evaluated as an adhesion barrier in a rabbit pericardial abrasion model., Results: The sprayable, in situ forming hydrogel film was shown to immediately seal carotid-PTFE anastomoses in six of six applications. Hydrogel application in a rabbit pericardial abrasion model resulted in a statistically significant reduction in the number and tenacity of adhesions., Conclusions: This novel in situ formed sprayable hydrogel film has demonstrated a dual function as an effective tissue sealant and as an adhesion barrier in cardiovascular preclinical models. These next generation synthetic biomaterials are currently undergoing clinical investigations.

Properly selected port sites for robot-assisted coronary artery bypass graft (CABG) improve the efficiency and quality of these procedures. In clinical practice, surgeons select port locations using external anatomic landmarks to estimate a patient's internal anatomy. This paper proposes an automated approach to port selection based on a preoperative image of the patient, thus avoiding the need to estimate internal anatomy. Using this image as input, port sites are chosen from a grid of surgeon-approved options by defining a performance measure for each possible port triad. This measure seeks to minimize the weighted squared deviation of the instrument and endoscope angles from their optimal orientations at each internal surgical site. This performance measure proves insensitive to perturbations in both its weighting factors and moderate intraoperative displacements of the patient's internal anatomy. A validation study of this port site selection was performed. cardiac algorithm also Six surgeons dissected model vessels using the port triad selected by this algorithm with performance compared to dissection using a surgeon-selected port triad and a port triad template described by Tabaie et al., 1999. With the algorithm-selected ports, dissection speed increased by up to 43% (p = 0.046) with less overall vessel trauma. Thus, this algorithmic approach to port site selection has important clinical implications for robot-assisted CABG which warrant further investigation.

Background: The use of computer-enhanced telemanipulation robots in cardiothoracic surgery can reduce the need for open surgical access and enable closed-chest, endoscopic procedures, but these procedures hav e been limited to anterior target vessels. The feasibility of fully endoscopic multivessel, coronary artery bypass grafting (CABG) was examined., Methods: Fully endoscopic, multivessel CABG solely through surgical ports was performed on 23 dogs weighing 75 to 85 pounds. A proximal anastomosis was made with the Symmetry bypass system aortic connector. The aorta was cross clamped, and cardioplegia solution was administered through the vein graft into the ascending aorta., Results: Eighteen of 23 procedures yielded successful proximal anastomoses and 1 to 3 distal anastomoses., Conclusion: Endoscopic anastomosis to the ascending aorta is feasible with the Symmetry bypass connector. Antegrade cardioplegia and aortic root venting can then be easily accomplished. This approach simplifies closed chest cardioplegic arrest for mulitivessel CABG.

Background: Micropump additive systems allow for continuous modification of cardioplegia composition during heart surgery. Although the use of such systems in warm heart surgery is theoretically desirable, the role of the systems has been clinically limited by coronary vasoreactivity with higher potassium concentration and unreliable mechanical arrest at lower potassium concentration. Adenosine, a potent coronary vasodilator and arresting agent, has the potential to reduce the potassium concentration required for arrest and to improve distribution of cardioplegia. However, clinical use of adenosine has been limited by a short half-life in blood and difficulty in titrating the dose. This study tested the hypothesis that continuous addition of adenosine with an in-line linear micropump system would facilitate whole blood hyperkalemic perfusion for cardiac surgery., Methods: Canine hearts (n = 9) were randomized to 20 minutes of arrest with whole blood cardioplegia or cardioplegia with adenosine at either low (0.5 M) or high (8 M) concentration. Potassium was supplemented at an arresting dose (24 mEq/L) for 5 minutes and then at a maintenance dose (6 mEq/L) for an additional 15 minutes. Coronary flow was held constant (4 mL/kg per minute), and aortic root pressure was measured. Myocardial performance was assessed by measurement of the end-diastolic pressure to stroke volume relationship at constant afterload. Myocardial tissue perfusion was evaluated with colored microspheres., Results: During the initial period of high-concentration potassium arrest, coronary resistance rose progressively regardless of adenosine addition. Coronary resistance remained elevated during the period of low potassium perfusion, except when high-concentration adenosine was added. With addition of 8 M adenosine, coronary resistance returned to baseline, and left ventricular endocardial perfusion was augmented. Electromechanical quiescence improved with adenosine perfusion and was complete with high-dose adenosine addition. Function was preserved in all hearts., Conclusion: Use of a modern micropump system allowed for continuous addition of adenosine and potassium to whole blood cardioplegia. Adenosine minimized potassium-induced coronary vasoconstriction and improved endocardial perfusion and mechanical quiescence. These findings supported addition of adenosine to the perfusate during warm whole blood cardioplegia.

Background: Patients who survive out-of-hospital cardiac arrest are at high risk for recurrent arrest. Coronary artery bypass grafting (CABG) confers a survival advantage, but it is unclear whether antiarrhythmic drugs or an implanted defibrillator confer added benefit. This study was designed to determine predictors for further treatment, survival, and therapeutic internal cardiac defibrillator (ICD) discharge in this patient population., Methods: One hundred and eight patients undergoing CABG after out-of-hospital cardiac arrest were identified over a 12-year period. Case records were retrospectively reviewed. Follow-up was obtained and predictors of outcome events were analyzed., Results: Fifty-four (50%) patients underwent CABG only. Fifty-four received additional treatment that included ICD placement in 23 (21%), antiarrhythmic medications in 19 (18%), or both in 12 (11%). Predictors of ICD placement included left ventricular ejection fraction (LVEF) less than 40% and perioperative intraaortic balloon counterpulsation. ICD or medical management increased survival in patients with LVEF <40%. Predictors of increased mortality included age >65 years, Cleveland Severity Score >8, and female gender. Predictors of therapeutic ICD discharge included age >65 years, reoperative CABG, LVEF <40%, and positive postoperative electrophysiological (EP) study. No patient with a negative postoperative EP study received an ICD, and none suffered sudden cardiac death during follow-up., Conclusions: Patients with coronary artery disease anatomically suitable for CABG who survive an acute out-of-hospital cardiac arrest should undergo EP testing after CABG. Approximately half of these patients are adequately treated by CABG alone. The remainder may benefit from ICD placement or medical antiarrhythmic management.

Background: Concomitant coronary artery disease with aortic valve disease is an established risk factor for diminished late survival. This study evaluated the results of bioprosthetic (BAVR) or mechanical aortic valve replacement (MAVR) performed with coronary artery bypass grafting (CABG)., Methods: From January 1984 through July 1997, combined AVR + CABG was performed in 750 consecutive patients; 469 received BAVR and 281 received MAVR. BAVR recipients were significantly older (mean age, 75 vs 65 years), and had more nonelective operations, congestive heart failure, peripheral vascular disease, preoperative intraaortic balloons, lower cardiac indices, more severe aortic stenosis, less aortic regurgitation, and more extensive coronary artery disease., Results: Early complications included operative mortality, 32 patients (4.3% total: 3.8% BAVR and 5.0% MAVR); perioperative infarction, 10 (1.3%); and perioperative stroke, 22 (2.9%). Significant multivariable predictors of early mortality were age, perioperative infarction or stroke, nonelective operation, operative year, ventricular hypertrophy, and need for intraaortic balloon. Ten-year actuarial survival was 41.7% for all patients. Predicted survival for age- and gender-matched cohorts from the general population versus observed survival were BAVR, 45% versus 36%; MAVR, 71% versus 48% (survival differences BAVR 9% vs MAVR 23%, p < 0.007). Significant multivariable predictors of late mortality included age, congestive failure, perioperative stroke, extent of coronary disease, peripheral vascular disease, and diabetes. Valve type was not significant. Ten-year actuarial freedom from valve-related complications were (BAVR vs MAVR) structural deterioration, 95% versus 100%, p = NS; thromboembolism, 86% versus 84%, p = NS; anticoagulant bleeding, 93% versus 88%, p < 0.005; reoperation, 98% versus 98%, p = NS., Conclusions: AVR + CABG has diminished late survival despite the type of prosthesis inserted. Although valve type did not predict late mortality, mechanical AVR was associated with worse survival compared with predicted and more valve-related complications due to anticoagulation requirements.

Background: Over the decade of the 1990s, hospital stay after operation declined in response to prospective payment and managed care. As a result, complications previously detected and treated in the hospital may have begun to occur after discharge. In addition, discharge to nursing homes and rehabilitation hospitals may have increased. To address these questions, we used a statewide database to look at the use of postacute care and the 30-day readmission and mortality after coronary bypass operation., Methods: A modification of the Commonwealth of Massachusetts Division of Health Care Finance and Policy discharge data to include a unique patient identifier allowed us to retrospectively track patient destination at discharge and study 30-day readmission to all hospitals in the state., Results: Over the 3-year period after the institution of the unique patient identifier (1993 to 1996), postoperative length of stay after coronary bypass operation decreased from 7.4 to 6 days (19%, P <.0005), but the 30-day readmission rate (17.7%) did not increase. Discharge to rehabilitation hospitals and skilled nursing facilities rose significantly (11.7% to 23.8%), especially in the Medicare population (17.2% to 38.5%). Mortality in the 30 days after discharge remained constant at 0.3%., Conclusions: A shorter postoperative length of stay did not appear to disadvantage coronary artery bypass patients by increasing their likelihood of readmission or death. Cost savings from reduced length of stay were offset by increased use of postacute services.

Background: Late tamponade is a rare cause of morbidity and mortality after cardiac valve operation. We describe our recent experience with this entity., Methods: This is a single institution, procedure-matched, retrospective review of patients undergoing pericardiocentesis more than 7 days after cardiac operation, during a 7-year period., Results: Pericardiocentesis for delayed tamponade was performed in 43 of 9,612 patients. Although isolated valve operation accounted for 17% of all patients overall, 76% of patients undergoing pericardiocentesis (33 of 43) had undergone isolated valve operation. The average age in this group was 58 years, compared to an average of 68 years in all patients. Patients presented with tamponade an average of 18 days after operation. Positive predictors included elevated prothrombin time on presentation. Of the patient cohort 75% presented with dyspnea, 61% with inability to diurese, and 61% with hypotension. Echocardiography detected effusions in all patients, but specific echocardiographic signs of tamponade were present in only 30%. Of the patients, 97% were successfully treated by pericardiocentesis. All were safely restarted on warfarin. One patient required pericardial window., Conclusions: Delayed cardiac tamponade is more common after isolated valve operation, as opposed to coronary artery bypass grafting and valve/coronary artery bypass grafting. It tends to occur in the third postoperative week in younger patients who are aggressively anticoagulated. Pericardiocentesis with catheter placement is highly effective, and patients can be reanticoagulated safely. This series underestimates the incidence of late tamponade, as some patients may present to outside facilities. The diagnosis is aided by a high degree of suspicion.

Background: Wound complications associated with long incisions used to harvest the greater saphenous vein are well documented. Recent reports suggest that techniques of endoscopic vein harvest may result in decreased wound complications. A prospective, nonrandomized study was developed to compare outcomes of open versus endoscopic vein harvest procedures., Methods: There were 106 patients in the open vein harvest group, and 154 patients in the endoscopic vein harvest group. Patient characteristics and demographics were similar in both groups. Wound complications identified were dehiscence, drainage for greater than 2 weeks postoperatively, cellulitis, hematoma, and seroma/lymphocele., Results: Wound complications were significantly less in the endoscopic vein harvest group (9 of 133, 6.8%) versus the open vein harvest group (26 of 92, 28.3%), p less than 0.001. By multivariable analysis with logistic regression, the open vein harvest technique was the only risk factor for postoperative leg wound complication (relative risk 4.0)., Conclusions: Endoscopic vein harvest offered improved patient outcomes in terms of wound healing compared with the open vein harvest technique.

Public report cards and confidential, collaborative peer education represent distinctly different approaches to cardiac surgery quality assessment and improvement. This review discusses the controversies regarding their methodology and relative effectiveness. Report cards have been the more commonly used approach, typically as a result of state legislation. They are based on the presumption that publication of outcomes effectively motivates providers, and that market forces will reward higher quality. Numerous studies have challenged the validity of these hypotheses. Furthermore, although states with report cards have reported significant decreases in risk-adjusted mortality, it is unclear whether this improvement resulted from public disclosure or, rather, from the development of internal quality programs by hospitals. An additional confounding factor is the nationwide decline in heart surgery mortality, including states without quality monitoring. Finally, report cards may engender negative behaviors such as high-risk case avoidance and "gaming" of the reporting system, especially if individual surgeon results are published. The alternative approach, continuous quality improvement, may provide an opportunity to enhance performance and reduce interprovider variability while avoiding the unintended negative consequences of report cards. This collaborative method, which uses exchange visits between programs and determination of best practice, has been highly effective in northern New England and in the Veterans Affairs Administration. However, despite their potential advantages, quality programs based solely on confidential continuous quality improvement do not address the issue of public accountability. For this reason, some states may continue to mandate report cards. In such instances, it is imperative that appropriate statistical techniques and report formats are used, and that professional organizations simultaneously implement continuous quality improvement programs. The statistical methodology underlying current report cards is flawed, and does not justify the degree of accuracy presented to the public. All existing risk-adjustment methods have substantial inherent imprecision, and this is compounded when the results of such patient-level models are aggregated and used inappropriately to assess provider performance. Specific problems include sample size differences, clustering of observations, multiple comparisons, and failure to account for the random component of interprovider variability. We advocate the use of hierarchical or multilevel statistical models to address these concerns, as well as report formats that emphasize the statistical uncertainty of the results.

Background and Aim of the Study: The study aim was to describe the long-term results and determinants of mortality after operative treatment of native and prosthetic valve endocarditis at a single institution., Methods: Between March 1985 and October 1999, 171 patients underwent surgery for native (NVE) or prosthetic valve endocarditis (PVE). NVE was present in 98 patients (57%), and PVE in 73 patients (43%). Mean follow up was 5.6+/-3.9 years (range: 0 to 15 years)., Results: Overall hospital mortality was 9.9% (n = 17). Hospital mortality was higher among patients with PVE (15.1%) than those with NVE (6.1%; p = 0.05). Overall survival at 10 years was 46+/-5%. Patients with NVE had a higher 10-year survival rate (53+/-7%) than those with PVE (37+/-7%; p = 0.02). At 10 years, overall freedom from any late complication was 47+/-6% and from residual or recurrent endocarditis was 78+/-5%. Predictors of hospital death were emergency surgery (p <0.003) and preoperative renal insufficiency (p <0.008). Predictors of late death were age >70 years (p <0.002), renal failure (p <0.03) and fungal endocarditis (p <0.04)., Conclusion: These findings demonstrate the increased perioperative, as well as postoperative, risks associated with PVE versus NVE. Cardiac and extracardiac manifestations of the disease, as well as fungal organisms, but not the activity of the endocarditis, were significant adverse determinants of late outcome.

Infection is an uncommon (0% to 6.7%) but serious complication after implantable cardioverter-defibrillator (ICD) implantation. All ICD primary implants, replacements, or revisions performed at the Massachusetts General Hospital between April 1983 and May 1999 were reviewed. A total of 21 ICD-related infections (1.2%) were identified among 1,700 procedures affecting 1.8% of the 1,170 patients who underwent a primary implant, a generator change, or a revision of their systems. The mean follow-up time was 35 +/- 33 months. Of the 959 patients with long-term follow-up, 19 of the 584 patients (3.2%) with abdominal and 2 of the 375 patients (0.5%) with pectoral systems developed ICD-related infections (p = 0.03). There was no significant difference between the infection rate among the 959 primary ICD implants and the 447 replacements or system revisions. Only 5 of the patients (24%) had systemic signs of infection, including fever (T>100.5) and elevated white blood count >12,000. Cultures from the wound revealed staphylococcal species in 16 patients (76%). Nineteen patients were treated with removal of the entire ICD system in addition to intravenous antibiotics for 2 to 4 weeks. A decrease in the incidence of ICD-related infection has occurred since the advent of transvenous pectoral systems. The main organism responsible for ICD infection is Staphylococcus. The mainstay of ICD infection management consists of complete removal of the entire implanted system.

Cardiac hamartomas are a rare type of benign tumor affecting the heart. We describe a 33-year-old patient who presented with a wide complex tachycardia. Diagnostic imaging revealed a mass in the patient's left ventricular wall, near the apex of the heart. The mass was surgically resected and appeared benign. Its pathology was that of a hamartoma of mature cardiac myocytes. Postoperative electrophysiology evaluation showed no inducible focus and the patient remains alive and asymptomatic after 2 years of follow-up.

Background: Cold cardioplegic arrest can produce cooling contracture and suboptimal myocardial protection. This study examines whether cooling contracture is associated with maldistribution of cardioplegic solution, particularly subendocardial hypoperfusion, which may impair recovery., Methods: Canine hearts were arrested by antegrade cold and warm blood cardioplegia in random order. Cardioplegic distribution was measured using radiolabeled microspheres before and just after induction of each period of arrest., Results: With cold cardioplegia, perfusion of left ventricular subepicardial and midwall regions decreased. Subendocardial to subepicardial perfusion ratios increased significantly in the left ventricle as a whole, the anterior and posterior regions of the left ventricular free wall, and the interventricular septum. With warm arrest, transmural flow distribution was not significantly altered from preceding prearrest values. At constant coronary flow, coronary perfusion pressure was initially similar after induction of arrest at both temperatures, but it rose subsequently during warm cardioplegia., Conclusions: The data suggest that during normothermic arrest, vasomotor tone regulates cardioplegic distribution, and hyperkalemic vasoconstriction is of slow onset. In the absence of beating and with vasomotion inhibited by hypothermia, cardioplegic distribution during cold arrest appears to be primarily dependent on vascular anatomy. There was no evidence of subendocardial underperfusion during cooling contracture.

Background: Warm continuous blood cardioplegia provides excellent protection, but must be interrupted by ischemic intervals to aid visualization. We hypothesized that (1) as ischemia is prolonged, the reduced metabolic rate offered by cooling gives the advantage to hypothermic cardioplegia; and (2) prior cardioplegia mitigates the deleterious effects of normothermic ischemia., Methods: Isolated cross-perfused canine hearts underwent cardioplegic arrest followed by 45 minutes of global ischemia at 10 degrees C or 37 degrees C, or 45 minutes of normothermic ischemia without prior cardioplegia. Left ventricular function was measured at baseline and during 2 hours of recovery. Metabolism was continuously evaluated by phosphorus-31 magnetic resonance spectroscopy., Results: Adenosine triphosphate was 71% +/- 4%, 71% +/- 7%, and 38% +/- 5% of baseline at 30 minutes, and 71% +/- 4%, 48% +/- 5%, and 39% +/- 6% at 42 minutes of ischemia in the cold ischemia, warm ischemia, and normothermic ischemia without prior cardioplegia groups, respectively. Left ventricular systolic function, left ventricular relaxation, and high-energy phosphate levels recovered fully after cold cardioplegia and ischemia. Prior cardioplegia delayed the decline in intracellular pH during normothermic ischemia initially by 9 minutes, and better preserved left ventricular relaxation during recovery, but did not ameliorate the severe postischemic impairment of left ventricular systolic function, marked adenosine triphosphate depletion, and creatine phosphate increase. Left ventricular distensibility decreased in all groups., Conclusions: When cardioplegia is followed by prolonged ischemia, better protection is provided by hypothermia than by normothermia. Prior cardioplegia confers little advantage on recovery after prolonged normothermic ischemia but delays initial ischemic metabolic deterioration, which would contribute to the safety of brief interruptions of warm cardioplegia.

Background and Purpose: The pathophysiology of cardiac injury after subarachnoid hemorrhage (SAH) remains controversial. Data from animal models suggest that catecholamine-mediated injury is the most likely cause of cardiac injury after SAH. However, researchers also have proposed myocardial ischemia to be the underlying cause, as a result of coronary artery disease, coronary artery spasm, or hypertension and tachycardia. To test the hypothesis that SAH-induced cardiac injury occurs in the absence of myocardial hypoperfusion, we developed an experimental canine model that reproduces the clinical and pathological cardiac lesions of SAH and defines the epicardial and microvascular coronary circulation., Methods: Serial ECG, hemodynamic measurements, coronary angiography, regional myocardial blood flow measurements by radiolabeled microspheres, 2D echocardiography, and myocardial contrast echocardiography were performed in 9 dogs with experimental SAH and 5 controls., Results: Regional wall motion abnormalities were identified in 8 of 9 SAH dogs and 1 of 5 controls (Fisher's Exact Test, P=0.02) but no evidence was seen of coronary artery disease or spasm by coronary angiography and of significant myocardial hypoperfusion by either regional myocardial blood flow or myocardial contrast echocardiography., Conclusions: In this experimental model of SAH, a unique form of regional left ventricular dysfunction occurs in the absence of myocardial hypoperfusion. Future studies are justified to determine the cause of cardiac injury after SAH.

Context: Explicit information about the quality of coronary artery bypass graft (CABG) surgery has been available for nearly a decade in New York State; however, the extent to which managed care insurance plans direct enrollees to the lowest-mortality CABG surgery hospitals remains unknown., Objective: To compare the proportion of patients with managed care insurance and fee-for-service (FFS) insurance who undergo CABG surgery at lower-mortality hospitals., Design: A retrospective cohort study of CABG surgery discharges from 1993 to 1996, using New York Department of Health databases and multivariate analysis to estimate the use of lower-mortality hospitals by patients with different types of health insurance., Setting: Cardiac surgical centers in New York, of which 14 were classified as lower-mortality hospitals (mean rate, 2.1%) and 17 were classified as higher-mortality hospitals (mean rate, 3.2%)., Patients: A total of 58,902 adults older than 17 years who were hospitalized for CABG surgery. Patients were excluded if their CABG surgery was combined with any valve procedure or left ventricular aneurysm resection or if they were younger than 65 years and enrolled in Medicare FFS or Medicare managed care., Main Outcome Measure: Probability of a patient receiving CABG surgery at a lower-mortality hospital., Results: Compared with patients with private FFS insurance (n = 18,905), patients with private managed care insurance (n=7169) and Medicare managed care insurance (n=880) were less likely to receive CABG surgery at a lower-mortality hospital (relative risk [RR] of surgery at a lower-mortality hospital compared with patients with private FFS insurance, 0.77; 95% confidence interval [CI], 0.74-0.81; P<.001; and RR, 0.61; 95% CI, 0.54-0.70; P<.001, respectively, after controlling for multiple potential confounding factors). Patients with Medicare FFS insurance used lower-mortality hospitals at rates more similar to those with private FFS insurance (n = 31,948; RR, 0.95; 95% CI, 0.91-0.98; P=.004)., Conclusions: Patients in New York State with private managed care and Medicare managed care insurance were significantly less likely to use lower-mortality hospitals for CABG surgery compared with patients with private FFS insurance.

Background: Enhanced recovery after cardioplegic arrest has been observed in rat hearts with hypertrophy induced by hemodynamic overload. We hypothesize that this is related to altered characteristics of hypertrophied myocardium-reflected by increased V(3) isomyosin and glycolytic potential-other than increased left ventricular mass., Materials and Methods: Isolated hearts from age-matched nonoperated and sham-operated control rats and from aortic-banded, hyperthyroid, and hypothyroid rats-groups in which hypertrophy and V(3) as a percentage of left ventricular myosin vary independently-underwent 2 h of multidose cardioplegic arrest at 8 degrees C followed by reperfusion at 37 degrees C. Left ventricular V(3) isomyosin was evaluated after separation by gel electrophoresis., Results: Moderate left ventricular hypertrophy was produced by aortic banding or hyperthyroidism and atrophy by hypothyroidism. V(3) isomyosin was increased in banded (28%) and hypothyroid (75%) rats compared to control (12%) and hyperthyroid rats (7%). Myocardial glycogen content closely paralleled %V(3). At 30 min of working reperfusion, functional recovery (assessed as percentage prearrest cardiac output) was 66 +/- 4 and 68 +/- 5% in control and hyperthyroid hearts and 81 +/- 2 and 80 +/- 5% in hearts from banded and hypothyroid rats (each P < 0.05 vs controls), respectively. At 30 min, hearts from banded and hypothyroid rats were also more efficient (as indexed by cardiac output at constant mean aortic pressure/myocardial oxygen consumption) than control and hyperthyroid hearts., Conclusions: The data suggest that recovery is related not to increased mass but to other changes in overload hypertrophy. Increased percentage V(3) isomyosin and glycogen reflect these changes and may themselves contribute to improved functional recovery after cardioplegic arrest, as may increased postischemic efficiency., (Copyright 2000 Academic Press.)

Background: In spite of advances in the management of bleeding associated with cardiac surgery, hemorrhage remains a troublesome problem, particularly in complex cases and high risk patients. In minimally invasive cardiac surgery, limited exposure and tight quarters may make accurate suturing difficult, and increase the risk of surgical bleeding. A surgical sealant that effectively prevents suture line bleeding would be a valuable resource for cardiac surgeons and might help to facilitate minimal access cases., Methods: We undertook acute canine studies with a new polyethylene glycol-based tissue sealant (FocalSeal, Focal, Inc., Lexington, MA) to determine its effectiveness in controlling bleeding from graduated needle punctures sites in the arteries of heparinized animals. For chronic canine studies, the sealant was applied to the suture line of a left internal mammary artery (LIMA) to left anterior descending (LAD) anastomoses. The anastomoses were then evaluated for patency and tissue reaction after a three-month recovery period., Results: The sealant prevented bleeding from arterial puncture wounds up to 2.5 mm in diameter. Three months following the application of sealant to coronary anastomoses, no adverse tissue reaction was found on histologic examination. All anastomoses treated with the sealant remained patent., Conclusion: When applied as a hemostatic adjunct to sutures at a coronary anastomosis, the sealant appears to be an effective means of preventing bleeding without adverse tissue reaction or scarring.

Background: Atheroembolization is a recognized complication of cardiac surgical procedures, and has been implicated in postoperative stroke, renal failure, multiorgan failure, and death. Preoperative identification of patients at risk for developing atheroemboli is essential. The aim of this study was to determine preoperative risk factors for atheroemboli and to assess the postoperative course of the patients who developed atheroembolic syndrome., Methods: A retrospective record review was conducted. From 1/1990 to 12/1994 5486 patients underwent coronary artery bypass grafting (CABG), valve operations, or other cardiac surgical procedures at Massachusetts General Hospital. Of this population, 107 patients (1.9%) developed atheroembolic syndrome., Results: Patients who develop atheroemboli were older, with an increased incidence (p < 0.01) of hypertension, cerebrovascular disease, and aortoiliac disease. Many had a complicated course after catheterization, with renal insufficiency (35%) and evidence of peripheral emboli (12%). Average Intensive Care Unit stay, hospital stay, and hospital cost of these patients were respectively 16.8 days, 48.4 days, and $88,000, compared to 1.5 days, 9.6 days and $23,000 for a concurrent population undergoing CABG surgery. Of these 107 patients only 2 were discharged home, the others either died (48 patients, or 25% of all cardiac surgical deaths during this period), or went to rehabilitation or chronic hospital facilities. Twenty-seven autopsies were performed and invariably showed a diffusely diseased aorta, with calcification, mural thrombus, and ulceration., Conclusions: Atheroembolization during cardiac surgical procedures has profound medical and economic consequences. Because of the diffuse nature of aortic disease, measures approaching the disease as a local process are likely to be unsuccessful. Appropriate evaluation would ideally identify patients with extensive aortic atheromatous disease, prior to rather than during surgery.