Coronary Surgery Research Articles

The impact of a preoperative nurse-led orientation program on postoperative delirium after cardiovascular surgery: a retrospective single-center observational study

BackgroundPostoperative delirium in intensive care is common and associated with mortality, cognitive impairment, prolonged hospital stays and high costs. We evaluate whether a nurse-led orientation program could reduce the incidence of delirium in the intensive care unit after cardiovascular surgery.MethodsIn this retrospective cohort study, we enrolled patients admitted to the intensive care unit for planned cardiovascular surgery between January 2020 and December 2021. A nurse-led orientation program based on a preoperative visit was routinely introduced from January 2021. We assessed the association between these visits and postoperative delirium in the intensive care unit. We also assessed predictors of postoperative delirium with baseline and intraoperative characteristics.ResultsAmong 253 patients with planned cardiovascular surgery, 128 (50.6%) received preoperative visits. Valve surgery comprised 44.7%, coronary surgery 31.6%, and aortic surgery 20.9%. Cardiopulmonary bypass use and transcatheter surgery were 60.5% and 12.3%, respectively. Incidence of delirium was lower in patients that received preoperative visits, and median hospital stay was shorter than in those without visits (18 patients [14.1%] vs 34 patients [27.2%], P < 0.01; 14 days vs 17 days, P < 0.01). After adjusting predefined confounders, preoperative visits were independently associated with decreased incidence of delirium (adjusted odds ratio [aOR] 0.45; 95% confidence interval [95% CI] 0.22–0.84). Other predictors of delirium were higher European System for Cardiac Operative Risk Evaluation II score and lower minimum intraoperative cerebral oxygen saturation.ConclusionsA preoperative nurse-led orientation program was associated with reduction of postoperative delirium and could be effective against postoperative delirium after cardiovascular surgery.Trial registration UMIN Clinical Trial Registry no. UMIN000048142. Registered 22, July, 2022, retrospectively registered, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000054862.

Cardiac Surgery 2022 Reviewed.

PubMed displayed almost 37,000 hits for the search term "cardiac surgery AND 2022." As before, we used the PRISMA approach and selected relevant publications for a results-oriented summary. We focused on coronary and conventional valve surgery, their overlap with interventional alternatives, and briefly assessed surgery for aorta or terminal heart failure. In the field of coronary artery disease (CAD), key manuscripts addressed prognostic implications of invasive treatment options, classically compared modern interventions (percutaneous coronary intervention [PCI]) with surgery (coronary artery bypass grafting [CABG]), and addressed technical aspects of CABG. The general direction in 2022 confirms the superiority of CABG over PCI in patients with anatomically complex chronic CAD and supports an infarct-preventative effect as underlying mechanism. In addition, the relevance of proper surgical technique to achieve durable graft patency and the need for optimal medical treatment in CABG patients was impressively illustrated. In structural heart disease, the comparisons of interventional and surgical techniques have been characterized by prognostic and mechanistic investigations underscoring the need for durable treatment effects and reductions of valve-related complications. Early surgery for most valve pathologies appears to provide significant survival advantages, and two publications on the Ross operation prototypically illustrate an inverse association between long-term survival and valve-related complications. For surgical treatment of heart failure, the first xenotransplantation was certainly dominant, and in the aortic surgery field, innovations in arch surgery prevailed. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation, but provides up-to-date information for decision-making and patient information.

Cirugía cardiovascular en España en el año 2021. Registro de intervenciones de la Sociedad Española de Cirugía Cardiovascular y Endovascular

This report provides the data corresponding to the cardiovascular surgery activity performed in Spain during 2021. The Spanish Registry is an anonymous and voluntary registry of aggregated data in which hospitals in the national territory have taken part, transferring their data to the Spanish Society of Cardiovascular and Endovascular Surgery (SECCE). For the thirty-third consecutive year, the national activity data is reported. The 2021 registry may be of some value for analyzing the possible recovery of the cardiac surgery activity after the SARS-CoV-2 pandemic in our country.In 2021, 58 hospitals reported their activity compared to the 60 that shared their data in 2020. In total, 29,319 interventions were performed, with 19,229 major cardiac surgical procedures. Of these, 16,863 procedures were performed with cardiopulmonary bypass, 17,616 were indicated because of acquired disease and 1,613 for congenital disease. In addition, 2,637 peripheral vascular surgical interventions were registered.As in previous years, both congenital heart surgery and heart transplantation activity and outcomes will be reported in separate registries. Within the different types of major cardiac surgical procedures, the following were performed: 7,673 isolated valve procedures, 1,523 combined valve and coronary surgeries, 4,287 coronary revascularization procedures, 2,159 aortic surgeries, and 654 transcatheter valve implantations. Compared to 2020, we observed a general increase in activity, which was 7.9% compared to the previous year, but with a reduction of more than 12% compared to the mean of the previous 9 years (2012-2020).

Purinergic 2X Receptors Contribute to the Exaggerated Mechanoreflex in Rats with Heart Failure

Skeletal muscle contraction stimulates mechanically activated channels on the sensory endings of thin fiber muscle afferents which evokes reflex increases in sympathetic nerve activity and blood pressure. This reflex is termed the mechanoreflex and its activation in healthy populations plays a key role in facilitating oxygen delivery to contracting muscles and exercise performance. However, mechanoreflex activation in patients with heart failure with reduced ejection fraction (HF-rEF) results in excessive peripheral vasoconstriction and impaired limb blood flow during exercise. Recent evidence in a rat model of HF-rEF demonstrated that hindlimb arterial injection of PPADS, an antagonist for ATP-sensitive purinergic 2X (P2X) receptors, reduced thin fiber muscle afferent responsiveness to static hindlimb muscle stretch (a model of mechanoreflex activation isolated from contraction-induced metabolite production) to a greater extent in HF-rEF rats than in healthy counterparts. Those data suggest that, in HF-rEF, P2X receptor stimulation results in the sensitization of co-localized mechanically activated channels on the sensory endings of muscle afferents. To date, however, those electrophysiological findings have not been extended to reflex experiments investigating the cardiovascular consequences of mechanoreflex activation. Accordingly, we sought to determine the role played by P2X receptors in evoking the exaggerated blood pressure response to isolated mechanoreflex activation in HF-rEF rats. We hypothesized that hindlimb arterial injection of the P2X receptor antagonist PPADS (5mg) would reduce the integrated area under the blood pressure signal (the blood pressure index: BPI) evoked during 30 seconds of static hindlimb skeletal muscle stretch in decerebrate, unanesthetized HF-rEF rats to a greater extent than in healthy rats. Experiments were performed six to eight weeks following either a coronary artery ligation surgery to induce myocardial infarction and HF-rEF ( n=8M/2F; ejection fraction 37±6%) or a sham procedure ( n=1M/4F; ejection fraction 84±4; P&lt;0.01versus HF-rEF). In sham rats, P2X receptor blockade had no effect on the BPI response to hindlimb muscle stretch (control: 197±67, PPADS: 211±159mmHg⋅s; p=0.46). Conversely, in HF-rEF rats P2X receptor blockade reduced the BPI response to hindlimb muscle stretch (control: 425±60, PPADS: 257±83mmHg⋅s; p=0.01). The integrated area of the muscle tension signal during the stretch maneuver (tension-time-index; TTI) was not different between control and P2X receptor blockade conditions in either sham (control: 20±2, PPADS: 21±2kg·s; P=0.31) or HF-rEF (control: 24±2, PPADS: 25±2kg·s; P=0.09) rats. The data suggest that P2X receptors on the sensory endings of thin fiber muscle afferents do not play a role in the cardiovascular responses to mechanoreflex activation in health, but contribute importantly to the cardiovascular responses to mechanoreflex activation in HF-rEF. This work was supported by the National Institutes of Health (NIH) R01HL142877 to S.W.C. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Learning Curve of Thoracoscopic Nonrobotic Harvest of the Left Internal Mammary Artery in Minimally Invasive Coronary Artery Bypass Grafting.

Harvest of the left internal mammary artery (LIMA) is a technically demanding element of minimally invasive coronary surgery. We aimed to evaluate the learning curve of thoracoscopic, nonrobotic LIMA harvest during endoscopic coronary artery bypass (Endo-CAB) surgery. Eighty patients undergoing Endo-CAB surgery were included. LIMA harvest was performed using commonly available video-assisted thoracoscopic instruments. Time from incision until heparin administration was defined as total LIMA harvest time (this includes opening of the pericardium and identification of coronary targets). LIMA harvest times (N = 80) and total procedure times for single-vessel grafting (n = 51) were analyzed. The mean LIMA harvest time was 58 ± 19 min, ranging from 15 to 113 min. The mean procedure time was 150 ± 39 min. Significant reductions in both LIMA harvest and total Endo-CAB procedure times were observed with increasing experience (logarithmic regression Y = 109 - 14.9*log(x), P < 0.001; Y = 227 - 24.4*log(x), P < 0.001, respectively). No damage to the LIMA occurred during thoracoscopic harvesting. Total thoracoscopic (nonrobotic) LIMA harvest is an efficient technique with a steep learning curve using routine instruments. More patients might benefit from minimally invasive coronary surgery using thoracoscopic LIMA harvest techniques.

Sistemik Otoimmün Hastalık Tanılı Hastalarda Koroner Arter Bypass Greftleme Cerrahisi

Introduction:&#x0D; Systemic autoimmune diseases are risk factors for cardiovascular diseases and have also been identified as a factor that worsens perioperative outcomes in various surgical specialities. This study investigated the effects of systemic autoimmune diseases on coronary surgery outcomes.&#x0D; &#x0D; Methods:&#x0D; &#x0D; One hundred fifty-one patients were included in this study. hundred-forty-four patients without autoimmune disease were in the second group and seven patients with systemic autoimmune disease who underwent isolated coronary surgery were in the second group. Hospital Electronic recording systems were used for data collection. The follow-up period is 12 months. A statistically significant P value was taken as 0.05.&#x0D; &#x0D; Results:&#x0D; &#x0D; The two groups were comparable preoperatively, only the prevalence of hypertension and diabetes was significantly higher in the second group. There was no significant difference between the two groups in terms of intraoperative variables. Perioperative complications (excluding stroke), 30-day mortality and post-operative cardiopulmonary resuscitation rate were significantly higher in the second group, however there was no difference between the two groups in terms of 12-month survival.&#x0D; &#x0D; Conclusion: &#x0D; Despite systemic autoimmune diseases being found a factor that increases complications in terms of coronary surgery, coronary surgery is promising with its success in 12-month survival and repeated revascularization rate in these patients.

Kompanse Böbrek Yetmezlikli Hastalarda Koroner Bypass Morbiditesini Azaltan bir Teknik; Peroperatif Ultrafiltrasyon

INTRODUCTION: Preoperative renal dysfunction is one of the most important risk factors affecting postoperative morbidity and mortality in patients undergoing cardiac surgery. While patients with end-stage renal disease and dialysis-dependent constitute 1-3% of the renal failure spectrum, it should not be forgotten that coronary revascularization surgery is performed at a rate of 2-5% in the remaining asymptomatic majority. However, an optimal perioperative strategy has not been developed for this group of patients who have not yet undergone hemodialysis. In our study, conventional ultrafiltration was applied with a modified peroperative heart-lung machine and it was aimed to decrease mortality and morbidity. METHOD: 6303 patients who underwent coronary bypass surgery with the cardiopulmonary bypass technique between 2004 and 2011 at Başkent University Adana Hospitals were examined, and 99 patients with a preoperative serum creatinine level higher than 1.5 mg/dl were included in this retrospective study. 99 patients were divided into two groups as UF performed (35) and not performed (64); They were evaluated in terms of drainage amounts, length of hospital stay, early/late mortality and morbidity, and newly developing dialysis needs. RESULTS: There was no significant difference between the groups in terms of post-operative hemodialysis need, length of hospital stay and major complications. However; Peroperative ultrafiltration in obese, diabetic, recent MI, COPD and congestive heart failure patients; postoperatively less inotrope (P=0.0001), less diuretic requirement (P=0.0001), less colloidal fluid replacement (p=0.009), and relatively fewer minor complications. DISCUSSION AND CONCLUSION: Ultrafiltration to be applied during cardiopulmonary bypass in order to create a more balanced intravascular volume in patients with compensated renal failure, to reduce the need for volume expander fluid used for this purpose, to remove inflammation mediators that occur during cardiopulmonary bypass, and therefore to protect renal functions without the need for additional medication, especially COPD. We recommend it in the diabetic and obese patient group.

Vasilii I Kolesov: The First Series of Best Option Coronary Bypass Pioneer

Heart surgery is one of the areas of greatest achievement in 20th century medical science. As the number one killer, Ischemic heart disease (IHD) was a big hurdle in achieving health for all. In this century, cardiovascular scientists put effort to combat the disease. Vasilii Ivanovich Kolesov is the early and successful contributor among them in the field of coronary surgery. On 25 February 1964, V.I. Kolesov successfully performed the first anastomosis between the left internal thoracic artery and the left circumflex artery. This was the beginning of a new era of coronary bypass surgeries, carried out on a regular basis to re-establish coronary flow in patients with IHD. This operation, in combination with Rene G. Favaloro’s method of using the saphenous vein in coronary surgery become the most commonly performed surgical procedure in the world. Cardiovasc j 2023; 15(2): 189-194

Association of body mass index with 30-day mortality and red blood cell transfusions in open heart surgery.

Obesity is associated with increased burden of cardiovascular risk factors, morbidity and mortality. However, several studies have counterintuitively shown better outcome after cardiac surgery in obese than in normal weight patients, a phenomenon known as obesity paradox. Furthermore, obesity has been linked with decreased need of red blood cell (RBC) transfusions. The purpose of this study was to evaluate the impact of body mass index (BMI) on 30-day mortality and RBC transfusions in patients undergoing cardiac surgery, a clinically important topic with conflicting previous data. We retrospectively investigated 1691 patients who underwent coronary and/or valve or aortic root surgery using cardiopulmonary bypass between 2013 and 2016. The patients were categorized by BMI based on the World Health Organization classification. For analysis, logistic regression was used with adjustment for potential confounding factors. Of the patients, 28.7% were normal weight, 43.3% overweight, 20.5% mildly obese and 7.5% severely obese. Thirty-day mortality was 1.9% without significant differences between the BMI groups. 41.0% of patients received RBC transfusion. Overweight [odds ratio (OR) 0.75, 95% confidence interval (CI) 0.56-0.99, P = 0.045], mildly (OR 0.65, 95% CI 0.46-0.92, P = 0.016) and severely obese (OR 0.41, 95% CI 0.24-0.70, P = 0.001) patients needed less frequently RBC transfusions than patients with normal weight. Obesity was not associated with 30-day mortality but was associated with lower use of RBC transfusions in cardiac surgery.

Management of Patients With Myocardial Infarction After Coronary Surgery: The Importance of Repeat Revascularization

Management of Patients With Myocardial Infarction After Coronary Surgery: The Importance of Repeat Revascularization

Cognitive functions and patterns of brain activity in patients after simultaneous coronary and carotid artery revascularization.

On-pump coronary artery bypass grafting (CABG) is associated with a high risk of neurological complications in patients with severe carotid stenosis. Moreover, early postoperative cognitive dysfunction (POCD) incidence remains high in patients undergoing simultaneous coronary and carotid surgery. Recent studies have shown that even moderate carotid stenosis (≥50%) is associated with postoperative cognitive decline after CABG. Data on brain health in the postoperative period of simultaneous coronary and carotid surgery are limited. This study aimed to analyze early postoperative changes in the cognitive function and patterns of brain electrical activity in patients after simultaneous coronary and carotid artery revascularization. Between January 2017 and December 2020, consecutive patients were assigned to on-pump CABG with or without carotid endarterectomy (CEA) according to clinical indications. An extended neuropsychological and electroencephalographic (EEG) assessment was performed before surgery and at 7-10 days after CABG or CABG + CEA. A total of 100 patients were included [median age 59 (55; 65), 95% men, MMSE 27 (26; 28)], and among these, 46 underwent CEA. POCD was diagnosed in 29 (63.0%) patients with CABG + CEA and in 32 (59.0%) patients with isolated CABG. All patients presented with a postoperative theta power increase. However, patients with CABG + right-sided CEA demonstrated the most pronounced theta power increase compared to patients with isolated CABG. The findings of our study show that patients with CABG + CEA and isolated CABG have comparable POCD incidence; however, patients with CABG + right-sided CEA presented with lower brain activity.

Early asymptomatic graft failure in coronary artery bypass grafting: a study based on computed tomography angiography analysis

BackgroundAsymptomatic graft failure after coronary bypass grafting surgery (CABG) may have negative impact on the patients’ short- and long-term outcomes. Cardiac computed tomography angiography (CTA) has been proved to be another choice to detect graft failure besides coronary artery angiography in several studies. We aimed to identify the rate and predictors of asymptomatic graft failure detected by CTA before discharge.Methods and resultsA total of 955 grafts of 346 consecutive asymptomatic patients who received CTA examination after CABGs were included in this retrospective study from July 2017 to Dec 2019. We divided 955 grafts into the patent group and occluded group by CTA results. Logistic regression model at graft-level were established to determine predictors of the early asymptomatic graft occlusion. The overall asymptomatic graft failure rate was 4.71% (45/955), and there was no difference between the arterial and venous conduits in different target territories (P > 0.05). The logistic regression at graft-level analysis showed that female (OR 3.181, CI 1.58–6.40, P = 0.001), composite grafting (OR 6.762, CI 2.26–20.28, P = 0.001), pulse index value (OR 1.180, CI 1.08–1.29, P < 0.001) and new postoperative atrial fibrillation (POAF) (OR2.348, CI 1.15–4.78, P = 0.018) were independent risk factors that affect graft failure, while early postoperative dual-antiplatelet treatment with aspirin and clopidogrel was a protective factor (OR 0.403, CI 0.19–0.84, P = 0.015).ConclusionsEarly asymptomatic graft failure is associated with both patient and surgical factors including female gender, high PI value, composite graft strategy and the new POAF. However, the early dual- antiplatelet therapy with aspirin and clopidogrel may be useful for preventing graft failure.

Coronary surgery provides better survival than drug-eluting stent: A pooled meta-analysis of Kaplan–Meier-derived individual patient data

ObjectivesWe explored the current evidence on coronary disease treatment comparing the survival of 2 therapeutic strategies: coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stent (DES). MethodsPubMed, Embase, and Google Scholar were searched for randomized clinical trials comparing CABG versus PCI with DES. The end point was overall mortality. Two statistical approaches were used: the generic inverse variance method, which was used to pool the incident rate ratios, and the pooled meta-analysis of Kaplan–Meier-derived individual patient data. ResultsEight randomized clinical trials comparing 4975 patients undergoing CABG and 4992 patients undergoing PCI were included in our meta-analysis. Generic inverse variance method showed a statistically significant survival benefit of the CABG group (incident rate ratio, 1.21; 95% confidence interval, 1.09-1.35; P < .01). The Kaplan–Meier estimates of survival at 1, 5, and 10 years of the CABG group were 97.1%, 90.3%, and 80.3%, respectively. The Kaplan–Meier estimates of survival at 1, 5, and 10 years of the PCI group were 97.0%, 87.7%, and 76.4%, respectively. The log-rank analysis confirmed a statistically significant benefit in term of overall mortality of the CABG group (hazard ratio, 1.24; 95% confidence interval, 1.11-1.38; P = .0001). ConclusionsThe present meta-analysis suggests that CABG provides a consistent survival benefit over PCI with DES.

Endothelial Function and Hypoxic–Hyperoxic Preconditioning in Coronary Surgery with a Cardiopulmonary Bypass: Randomized Clinical Trial

A hypoxic-hyperoxic preconditioning (HHP) may be associated with cardioprotection by reducing endothelial damage and a beneficial effect on postoperative outcome in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Patients (n = 120) were randomly assigned to an HHP and a control group. A safe, inhaled oxygen fraction for the hypoxic preconditioning phase (10-14% oxygen for 10 min) was determined by measuring the anaerobic threshold. At the hyperoxic phase, a 75-80% oxygen fraction was used for 30 min. The cumulative frequency of postoperative complications was 14 (23.3%) in the HHP vs. 23 (41.1%), p = 0.041. The nitrate decreased after surgery by up to 20% in the HHP group and up to 38% in the control group. Endothelin-1 and nitric oxide metabolites were stable in HHP but remained low for more than 24 h in the control group. The endothelial damage markers appeared to be predictors of postoperative complications. The HHP with individual parameters based on the anaerobic threshold is a safe procedure, and it can reduce the frequency of postoperative complications. The endothelial damage markers appeared to be predictors of postoperative complications.

Late Clinical Outcomes of Total Arterial Revascularization or Multiple Arterial Grafting Compared to Conventional Single Arterial with Saphenous Vein Grafting for Coronary Surgery.

Coronary surgery provides better long-term outcomes than percutaneous coronary intervention. Conventional practice is to use a single arterial conduit supplemented by saphenous vein grafts. The use of multiple arterial revascularization (MAG), or exclusive arterial revascularization (TAR), however, is reported as having improved late survival. Survival is a surrogate for graft failure that may lead to premature death, and improved survival reflects fewer graft failures in the non-conventional strategy groups. The reasons for not using MAG or TAR may be due to perceived technical difficulties, a lack of definitive large-scale randomized evidence, a lack of confidence in arterial conduits, or resources or time constraints. Most people consider radial artery (RA) grafting to be new, with use representing approximately 2-5% worldwide, despite select centers reporting routine use in most patients for decades with improved results. In conclusion, the current body of evidence supports more extensive use of total and multiple arterial revascularization procedures in the absence of contraindications.

Elevated troponin I is associated with a worse long-term prognosis in patients undergoing beating-heart coronary surgery.

The impacts of elevated troponin I levels after coronary artery bypass grafting (CABG) on long-term outcomes were investigated. A total of 996 patients who underwent elective isolated CABG for stable or unstable angina were enrolled. Patients were divided into higher and lower groups based on 80th percentile postoperative peak troponin I (ppTnI) levels. The relationship between ppTnI and long-term clinical outcomes was analysed. The median ppTnI was 1.55 (2.74) ng/ml and was significantly higher in the conventional CABG subgroup than in the beating-heart CABG subgroup: 4.04 (4.71) vs 1.24 (1.99) ng/ml, P < 0.001. The 80th percentile of ppTnI was 3.3 ng/ml in the beating-heart CABG subgroup and 8.9 ng/ml in the conventional CABG subgroup. In the conventional CABG subgroup (n = 150), 10-year overall survival showed no significant difference between the higher (≥8.9 ng/ml) and lower (<8.9 ng/ml) ppTnI groups: 71% (10%) vs 76% (5%), P = 0.316. However, the beating-heart CABG subgroup (n = 846) showed significantly worse 10-year overall survival in the higher ppTnI group (≥3.3 ng/ml) than in the lower ppTnI group (<3.3 ng/ml): 64% (6%) vs 73% (3%), P = 0.010. In the beating-heart CABG subgroup, multivariable analysis showed that ppTnI exceeding the 80th percentile was a risk factor for overall death (hazard ratio: 1.505, 95% confidence interval: 1.019-2.225, P = 0.040). Higher ppTnI over the 80th percentile was associated with worse long-term survival in beating-heart CABG, but not in conventional CABG.

Cardiac Surgery in Nonagenarians Following the TAVI/TMVI Era: A Multicenter 23-Year Comparative Analysis.

Studies reporting on the outcome of 90-year-old patients undergoing cardiac surgery are scant in literature; and currently, those regarding the implementation of trans-catheter techniques number even fewer. We compared patients aged >89 years operated on between 1998 and 2008 at 8 Italian cardiac surgery centers, with patients of the same age operated on between 2009 and 2021. All of the patients were operated on with "open" surgery, with the exclusion of percutaneous valve repair/implantation procedures. The patients of the two groups (group 98-08-127 patients, and group 09-21-101 patients) had comparable preoperative risk factors in terms of the LogEuroSCORE (98-08: 21.3 ± 6.1 vs. 09-21: 20.9 ± 11.1, p = 0.12). There was a considerable difference in the type of surgery (isolated valve, isolated coronary, and combined surgery, 46.5, 38.5, and 15% vs. 52, 13, and 35% in 98-08 and 09-21, respectively, p = 0.01). Analogous operating durations were recorded (cross-clamp time: 98-08: 46 ± 28 min vs. 09-21: 51 ± 28 min, p = 0.06). The number of packed bypasses was lower in 09-21 (1.3 ± 0.6 vs. 2.4 ± 1.2, p = 0.001). In the postoperative period, there was a statistically significant difference in the 30-day survival in favor of the "more recent" patients (98-08: 17 deaths (13.4%) versus 09-21: 6(5.9%); p = 0.001), also confirmed in the subgroups (12.2% vs. 0% in isolated coronary surgery, p < 0.001; and 12.3% vs. 0% in isolated valve surgery, p < 0.001). Accurate pre-, intra-, and post-operative evaluation/management to reduce biological impacts facilitate significant improvements in the outcomes in nonagenarian patients when compared to the results recorded in previous years.

Derivation and validation of predictive indices for cardiac readmission after coronary and valvular surgery – A multicenter study

ObjectiveTo derive and validate models to predict the risk of a cardiac readmission within one year after specific cardiac surgeries using information that is commonly available from hospital electronic medical records. MethodsIn this retrospective cohort study, we derived and externally validated clinical models to predict the likelihood of cardiac readmissions within one-year of isolated CABG, AVR, and combined CABG+AVR in Ontario, Canada, using multiple clinical registries and routinely collected administrative databases. For all adult patients who underwent these procedures, multiple Fine and Gray subdistribution hazard models were derived within a competing-risk framework using the cohort from April 2015 to March 2018 and validated in an independent cohort (April 2018 to March 2020). ResultsFor the model that predicted post-CABG cardiac readmission, the c-statistic was 0.73 in the derivation cohort and 0.70 in the validation cohort at one-year. For the model that predicted post-AVR cardiac readmission, the c-statistic was 0.74 in the derivation and 0.73 in the validation cohort at one-year. For the model that predicted cardiac readmission following CABG+AVR, the c-statistic was 0.70 in the derivation and 0.66 in the validation cohort at one-year. ConclusionsPrediction of one-year cardiac readmission for isolated CABG, AVR, and combined CABG+AVR can be achieved parsimoniously using multidimensional data sources. Model discrimination was better than existing models derived from single and multicenter registries.

First-in-Human µCAB™ Coronary Revascularization Surgery.

Less invasive coronary artery bypass grafting surgery is underused despite more than 25 years of interest from surgeons and growing patient demands for less pain and rapid full recovery. New approaches may offer surgeons additional options to provide enhanced clinical results through reliable subxiphoid bilateral internal thoracic artery harvesting and the creation of durable anastomoses through very small thoracotomy incisions. This first-in-human case report describes 2 patients who received surgical coronary revascularization using the µCAB™ technology and techniques. The encouraging early results indicate that the µCAB™ approach may offer a new ergonomic, affordable method for coronary revascularization with less surgical trauma.

Comment on "Association of Intraoperative Red Blood Cell Transfusions With Venous Thromboembolism and Adverse Outcomes After Cardiac Surgery".

We read with great interest a recently published work by Raphael et al.1 Their primary hypothesis was to establish independent causality of intraoperative transfusion of red blood cells (RBCs) on venous thromboembolism (VTE) after coronary bypass grafting surgery (n = 751,893) using the database of the Society of Thoracic Surgeons. In their secondary analyses, they further explored the types of VTE, mortality, readmission rate, and length of hospital stay. Their analyses of these data were extensive; however, there are issues that warrant further discussion. First, the overall exposure to RBCs was reported as 17.8% in the current study, but it is important to note the authors handled missing data on intraoperative/postoperative blood products as “no transfusion.” Previous studies in similar patients have shown that intraoperative transfusion rates varied between 12.8% and 60.3% due to variations in institutional practice.2 Missing data labeled as “no transfusion” and omission of any postoperative transfusion before any VTE might have skewed the relationship between intraoperative RBCs and VTE. Second, 37% of women versus 12% of men received blood transfusion. The women were 3 times more likely to receive more than 3–4 units of transfusion than men; however, the adjusted odds ratio for VTE was 0.90 for women. Others also demonstrated that women were more likely to receive >4 U RBC transfusion.3 Women tend to have a lower body mass index (BMI) compared with men, and thus they are more prone to dilutional anemia, and subsequently RBC transfusion. A causality relationship between RBCs and VTE was not supported by the lower odds of VTE in women. As a related issue, we would like to discuss their use of conditional imputation for handling missing data. The extent or presumed pattern of missing data was not specified, but BMI was mentioned as an example of conditional imputation. BMI is known to have a wide variation, particularly by geographic location. Conditional imputation without consideration of regional clustering might have distorted the relationship of BMI (and other predictors) and transfusion in development of the propensity score.4,5 Third, the authors attempted to isolate the effect of intraoperative RBCs by addressing or adjusting all the other risk factors for VTE. From Table 3, the exposures to non-RBC components, recombinant activated factor VII, and factor VIII inhibitor bypassing agent were increased in those with increased RBC transfusion. Hemostatic components were treated as a confounder in the model, but there may be causal associations with both acute and subacute VTE and arterial thromboses.6,7 Patients with severe postoperative bleeding tend to have prolonged hospital stay. The authors showed that cohorts with ≥3 units of RBC had longer hospital stay (mean, 9.8–11.2 days) compared with nontransfused patients (mean, 6.6 days). Although not captured in the database, delayed thromboprophylaxis during a prolonged hospital stay may also exacerbate VTE risk. Lastly, the authors utilized inverse probability treatment weighting method using inverse probability of treatment weighting based on the matching as shown in their Table 2; however, the authors did not mention the handling of extreme weights, which may lead to undue influence of otherwise less common groups (ie, patients with 3 or 4+ units of RBCs) (Tables S1–S10, https://links.lww.com/SLA/E307). While inverse probability treatment weighting adequately accounted for measured confounders pertinent to transfusion (eg, cardiopulmonary bypass [CPB] time), it is speculated that there are residual confounders that impact VTE rates.8 For example, extensive tissue injury and CPB are well known to trigger activations of endothelial cells and leukocytes. Cross-talks between coagulation and immune systems are referred to as “thrombo-inflammation,” and it plays a pivotal role in the pathogenesis of VTE.9 Patient-level inflammation parameters are neither routinely measured nor captured in the database. The statistical adjustment for CPB time does not account for inter-individual variability in inflammation and VTE risk. Given the modest area under the curve statistics they reported for these models, it seems clear there remains an unmet need to improve precision of VTE prediction by including patient-level biomarkers with sufficient sensitivity and specificity. ACKNOWLEDGMENTS A.L.B. conceptualized the letter, and writing up of the first draft of the letter. E.C.W., K.A.T., and K.S. have helped write the letter, and approved the final article. All authors have written and reviewed the article, and approved the final article.