Cardiac Surgery Quality Research Articles

Development of American Association for Thoracic Surgery Quality Gateway outcome models, analytics, and visualizations for quality assurance

ObjectiveThe study objective was to develop comprehensive quality assurance models for procedural outcomes after adult cardiac surgery. MethodsBased on 52,792 cardiac operations in adults performed in 19 hospitals of 3 high-performing hospital systems, models were developed for operative mortality (n = 1271), stroke (n = 895), deep sternal wound infection (n = 122), prolonged intubation (6182), renal failure (1265), prolonged postoperative stay (n = 5418), and reoperations (n = 1693). Random forest quantile classification, a method tailored for challenges of rare events, and model-free variable priority screening were used to identify predictors of events. ResultsA small set of preoperative variables was sufficient to model procedural outcomes for virtually all cardiac operations, including older age; advanced symptoms; left ventricular, pulmonary, renal, and hepatic dysfunction; lower albumin; higher acuity; and greater complexity of the planned operation. Geometric mean performance ranged from .63 to .76. Calibration covered large areas of probability. Continuous risk factors provided high information content, and their association with outcomes was visualized with partial plots. These risk factors differed in strength and configuration among hospitals, as did their risk-adjusted outcomes according to patient risk as determined by counterfactual causal inference within a framework of virtual (digital) twins. ConclusionsBy using a small set of variables and contemporary machine-learning methods, comprehensive models for procedural operative mortality and major morbidity after adult cardiac surgery were developed based on data from 3 exemplary hospital systems. They provide surgeons, their patients, and hospital systems with 21st century tools for assessing their risks compared with these advanced hospital systems and improving cardiac surgery quality.

Outcomes of nonemergency cardiac surgery after overnight operative workload: A statewide experience

ObjectiveCardiac surgeons experience unpredictable overnight operative responsibilities, with variable rest before same-day, first-start scheduled cases. This study evaluated the frequency and associated impact of a surgeon's overnight operative workload on the outcomes of their same-day, first-start operations. MethodsA statewide cardiac surgery quality database was queried for adult cardiac surgical operations between July 1, 2011, and March 1, 2021. Nonemergency, first-start, Society of Thoracic Surgeons predicted risk of mortality operations were stratified by whether or not the surgeon performed an overnight operation that ended after midnight. A generalized mixed effect model was used to evaluate the effect of overnight operations on a Society of Thoracic Surgeons composite outcome (5 major morbidities or operative mortality) of the first-start operation. ResultsOf all first-start operations, 0.4% (239/56,272) had a preceding operation ending after midnight. The Society of Thoracic Surgeons predicted risk of morbidity and mortality was similar for first-start operations whether preceded by an overnight operation or not (overnight operation: 11.3%; no overnight operation: 11.7%, P = .42). Unadjusted rates of the primary outcome were not significantly different after an overnight operation (overnight operation: 13.4%; no overnight operation: 12.3%, P = .59). After adjustment, overnight operations did not significantly impact the risk of major morbidity or mortality for first-start operations (adjusted odds ratio, 1.1, P = .70). ConclusionsFirst-start cardiac operations performed after an overnight operation represent a small subset of all first-start Society of Thoracic Surgeons predicted risk operations. Overnight operations do not significantly influence the risk of major morbidity or mortality of first-start operations, which suggests that surgeons exercise proper judgment in determining appropriate workloads.

A DEBRECENI SZÍVSEBÉSZET TÖRTÉNETE

The establishment of cardiac surgery in Debrecen is closely interlinked with thoracic surgery. This activity started and continued for many decades at the Auguszta Sanatorium, later the University of Debrecen's Department of Surgery II, which housed thoracic surgery at the time. In the Auguszta Sanatorium, which was nationalised after World War II, a thoracic surgery department was established in 1948, under the direction of Dr. József Schnitzler, whose professional interests in the 1960s turned towards cardiac surgery. He found a suitable partner for his groundbreaking goal in the pioneering work of Hungarian cardiac surgery, Dr. Árpád Eisert, a leading surgeon of the Jósa András County Hospital in Nyíregyháza. As a result of their exemplary professional cooperation, the first closed heart surgery was performed in Debrecen in 1963. The heart-lung machine required for cardiopulmonary bypass necessary to start open heart operations was provided by a donation from Béla Köteles, the son of Hungarian emigrants born in America, who founded his own instrument manufacturing company there. The first open heart surgery was performed by visiting professor Gábor Kovács from Szeged with Professor Schnitzler in 1968. In 1972, András Gömöry was entrusted with the management of cardiac surgery, and he succeeded in creating a team of highly qualified doctors and specialists even under the prevailing difficult circumstances. This, provided a solid basis for further development within the field. In 1983, after the retirement of Professor Schnitzler, Árpád Péterffy, Associate Professor of Cardiothoracic Surgery at Karolinska Hospital in Stockholm, was appointed as Head of the Department of Surgery II. Due to the knowledge, professional and work organisation experience he had gained abroad, cardiac surgery in Debrecen developed with great strides. The number of operations increased significantly, while the mortality rate was reduced by a third. He managed to acquire a new building for cardiac surgery in 1993, which created the opportunity for further development. The new building significantly improved the quantity and quality of cardiac surgery and made Debrecen an internationally recognised flagship of Hungarian cardiac surgery. Due to his work in international exchanges his students were able to improve their knowledge in Western European countries and elsewhere overseas. After his retirement in 2008, he continued to work as Professor Emeritus in our clinic, remaining fully committed to supporting our work, the development of cardiac surgery in Debrecen, and the preservation and enhancement of its reputation. As his professional successor, Associate Professor Tamás Szerafin was entrusted with the leadership of the cardiac surgery department. Together with his colleagues, their aim has been to preserve and further develop the patient-centred spirit and professional dedication of their predecessors, and to preserve the built heritage.

Abstract 18926: Skeletonization Mitigates Risk of Deep Sternal Wound Infection in Patients With Diabetes Undergoing CABG With Bilateral Internal Mammary Arterial Grafting

Background Bilateral internal mammary artery (BIMA) grafting may provide benefits compared to single artery coronary artery bypass grafting (CABG). However, many surgeons cite deep sternal wound infections (DSWI) as a deterrent for use of BIMA in patients with diabetes (DM). Aim To evaluate the effect of DM and skeletonization on the incidence of DSWI in patients with BIMA grafting. Hypothesis Skeletonization reduces risk of DSWI in DM patients with BIMA. Methods A retrospective analysis from 11 hospitals in the Maryland Cardiac Surgery Quality Initiative was performed. Of 27,930 adult non-emergent CABGs between 2017 and 2022, 2,010 patients (7%) received BIMA grafting among whom 764 (38%) had DM. Effect of DM and skeletonization of ≥ 1 IMA on DSWI in BIMA patients was evaluated by chi-square analyses and multivariable logistic regressions adjusting for DSWI-specific STS risk score. Results There was no significant difference in preoperative glycosylated hemoglobin (HgbA1c) level for DM patients with and without BIMA (7.2 [6.5-8.4] vs 7.2 [6.5-8.5], P=0.842. BMI was significantly higher in DM vs non-DM patients (30 [27 - 33] vs 28 [25 - 31], respectively, P<0.001]. Skeletonization of ≥ 1 IMA in DM patients reduced DSWI vs. no skeletonization (0.3% vs 4.1%, respectively, P=0.023) but did not alter DSWI in non-DM patients (0.4% vs 1.2%, P=0.280). In patients with skeletonization of ≥1 IMA, there was no difference in DSWI between patients with and without DM (0.3% vs 0.4%, respectively, P>0.999; Figure 1). After adjusting the DSWI-specific STS risk scores, skeletonization remained independently associated with reduced DSWI risk in DM patients with BIMA (OR=0.09, P =0.044). Conclusions Skeletonization of ≥1 IMA was associated with lower risk of DSWI in BIMA patients with DM. This supports the use of BIMA with skeletonization in patients with DM barring other prohibitive risk factors, and may encourage its increased usage in skeptical surgeons.

Institutional Variability in Red Blood Cell Transfusion With Coronary Bypass in a Statewide Database

BackgroundThe decision to perform transfusion is common but varies among centers and surgeons. This study looked at variables associated with red blood cell (RBC) transfusion in a statewide database. The study aimed to understand discrepancies in transfusion rates among hospitals and to establish whether the hospital itself was a significant variable in transfusion, independent of variables known to affect transfusion in patients undergoing cardiac surgical procedures. MethodsThe Maryland Cardiac Surgery Quality Initiative is a consortium of centers in the state. Patients undergoing isolated coronary artery bypass grafting from January 2018 to June 2020 from 10 centers in Maryland were included. Multivariable logistic regression was used to determine probability of RBC transfusion with covariates, including age, preoperative hemoglobin value, The Society of Thoracic Surgeons predicted risk of mortality, emergency status, preoperative adenosine diphosphate receptor blocker use, sex, body mass index, and off-pump status. ResultsA total of 5343 patients were included and had an overall RBC transfusion rate of 30.3% (range, 11.3%-55.8%). There was significant variability in the incidence of RBC transfusion among hospitals (χ2 = 604.7; P < .001). After covariate adjustment, a significant effect of hospital on transfusion remained (Wald = 547.3; P < .001). Hospital variation in RBC transfusion was not correlated with hospital variation in median age (P = .467), hemoglobin (P 0 855), The Society of Thoracic Surgeons predicted risk of mortality (P = .855), or sex (P = .726). ConclusionsIn a statewide analysis, wide variability in transfusion rates was observed, with hospital-specific management strongly associated with RBC transfusion. This study suggests that RBC transfusion may be affected by the culture and practices of an institution independent of clinical and demographic variables.

The Search for an Outcome Variable That Measures Both Quality and Processes in Cardiac Surgery: Comparing the Quality Process Index and Mortality.

The translation of a large quantity of data into valuable insights for daily clinical practice is underexplored. A considerable amount of information is overwhelming, making it difficult to distill and assess quality and processes at the hospital level. This study contributes to this necessary translation by developing a Quality Process Index that summarizes clinical data to measure quality and processes. The Quality Process Index was constructed to enable retrospective analyses of quality and process evolution from 2011 to 2021 for various surgery types in the Amsterdam Cardiosurgical Database (n = 5497). It is presented alongside mortality rates, which are the golden standard for quality measurement. The two outcome variables are compared as quality and process measurement options. Results showed that the mean Quality Process Index appeared rather stable, even though analysis of variance found that the mean Quality Process Index differed significantly over the years (p < 0.001). The 30-day and 120-day mortality rates appeared to fluctuate more, but interestingly, we failed to reject the null hypothesis of equal means. The Quality Process Index and mortality rates were statistically negatively correlated, and the extent of correlation was more pronounced with the 120-day mortality rate, as computed using the Pearson correlation coefficient r (30-day rQPI,30 = -0.07, p < 0.001 and 120-day mortality rates rQPI,120 = -0.12, p < 0.001). The Quality Process Index seeks to address the need to translate data for quality and process improvement in healthcare. While mortality remains the most impactful outcome measure, the Quality Process Index provides a more stable and comprehensive measurement of quality and process improvement or deterioration in healthcare. Therefore, the Quality Process Index as a quantification reinforces the understanding of the definition of quality and process improvement.

Injectable Polyzwitterionic Lubricant for Complete Prevention of Cardiac Adhesion.

After cardiac surgery, tissue damage to the heart may cause adhesion between heart and its surrounding tissues. Post-operative cardiac adhesion may lead to limited normal cardiac function, decreased quality of cardiac surgery, and increased risk of major bleeding during reoperation. Therefore, it is necessary to develop an effective anti-adhesion therapy to overcome cardiac adhesion. An injectable polyzwitterionic lubricant is developed to prevent adhesion between the heart and surrounding tissues and to maintain normal pumping function of the heart. This lubricant is evaluated in a rat heart adhesion model. Poly (2-methacryloyloxyethyl phosphorylcholine) (i.e., PMPC) polymers are successfully prepared via free radical polymerization of monomer MPC, and the optimal lubricating performance, biocompatibility both in vitro and in vivo is demonstrated. Besides, a rat heart adhesion model is conducted to evaluate the bio-functionality of lubricated PMPC. The results prove that PMPC is a promising lubricant for complete adhesion-prevention. The injectable polyzwitterionic lubricant shows excellent lubricating properties and biocompatibility and can effectively prevent cardiac adhesion.

Cardiac Surgery Quality Is in the Eyes of the Beholder, and It May Only Be Perception

Cardiac Surgery Quality Is in the Eyes of the Beholder, and It May Only Be Perception

Possibilities of using hyperbaric oxygen therapy at different stages of cardiac surgery

Nowadays, the evolution of cardiac surgery is impossible without a continuous improvement of all the treatment stages. One of the promising ways to achieve this goal is the active use of hyperbaric oxygen therapy in the preoperative preparation and postoperative rehabilitation. In this review, we present a short history of the hyperbaric oxygen therapy development in cardiac surgery, the pathophysiological and pathobiochemical mechanisms of its therapeutic effect and the scenarios for its use in the preoperative preparation and postoperative rehabilitation of cardiac surgery patients. The introduction of hyperbaric oxygen therapy into cardiac surgery can improve the results of the surgical treatment, as well as reduce the times of the preoperative preparation and postoperative rehabilitation of cardiac surgery patients, that will significantly increase the quality and efficiency of cardiac surgery.

Impact of Preoperative Hematocrit, Body Mass Index, and Red Cell Mass on Allogeneic Blood Product Usage in Adult Cardiac Surgical Patients: Report From a Statewide Quality Initiative

The study aims were to evaluate current blood transfusion practice in cardiac surgical patients and to explore associations between preoperative anemia, body mass index (BMI), red blood cell (RBC) mass, and allogeneic transfusion. Multicenter retrospective study. Academic and non-academic centers. After Institutional Review Board approval, 26,499 patients who underwent coronary artery bypass grafting ± valve replacement/repair between 2011 and 2019 were included from the Maryland Cardiac Surgery Quality Initiative database. Patients were stratified into BMI categories (<25, 25 to <30, and ≥30 kg/m2), and a multivariable logistic regression model was fit to determine if preoperative hematocrit, BMI, and RBC mass were associated independently with allogeneic transfusion. Preoperative anemia was found in 55.4%, and any transfusion was administered to 49.3% of the entire cohort. Females and older patients had lower BMI and RBC mass. Increased RBC and cryoprecipitate transfusions occurred more frequently after surgery in the lower BMI group. After adjustments, increased transfusion was associated with a BMI <25 relative to a BMI ≥30 at an odds ratio (OR) of 1.26 (95% confidence interval [CI]: 1.08-1.39). For each 1% increase in preoperative hematocrit, transfusion was decreased by 9% (OR: 0.91; 95% CI: 0.90-0.92). For every 500 mL increase in RBC mass, there was a 43% reduction of transfusion (OR: 0.57; 95% CI: 0.55-0.58). Transfusion probability modeling based on calculated RBC mass eliminated sex differences in transfusion risk based on preoperative hematocrit, and may better delineate which patients may benefit from more rigorous perioperative blood conservation strategy.

Optimal blood management as priority route in cardiac surgery

Introduction. Generating manifold publications over decades, research continues assessing the burden of perioperative bleeding, preoperative anaemia and red blood component (RBC) transfusion in cardiac surgical patients. The past decade is witnessing a trend towards limited RBC transfusion. Nevertheless, the risk and justifi cation of a restrictive or liberal transfusion strategy in cardiac surgery remain a matter of debate.Aim — a description of evidence estimating the impact of bleeding, preoperative anaemia, red-cell transfusion and restrictive vs. liberal strategies on the risk of mortality and other adverse events in adults with cardiac surgery.Methods. Relevant evidence was mined in PubMed for the period 2012–2019. The query phrases were: cardiac surgery [кардиохирургия], bleeding [кровотечение], preoperative anaemia [предоперационная анемия], red-cell transfusion [переливание эритроцитов], restrictive and liberal transfusion strategy [рестриктивная и либеральная трансфузионная стратегия]. The review includes 18 studies describing outcomes related to bleeding, preoperative anaemia of varying severity and variant-volume RBC transfusion in patients with cardiac surgery. Nine studies comparatively assessed the cardiac surgical clinical outcomes under restrictive and liberal transfusion strategies. A total of 24 full texts have been analysed, one randomised clinical trial (RCT) summary, one retrospective trial summary and one meta-analysis review. Additional studies of concern to discussion have also been considered.Results. One prospective and four retrospective studies evaluated the effect of perioperative bleeding on the risk of subsequent adverse events in patients with cardiac surgery. Three prospective, fi ve retrospective studies and one RCT revealed the association of red-cell transfusion with adverse outcomes. Five retrospective studies exposed a link between preoperative anaemia and reason for RBC transfusions. Six retrospective studies found an independent association between the risk of postoperative complications and mortality in patients having cardiac surgery and preoperative anaemia. Eight RCTs and one meta-analysis of seven RCTs presented comparative data on clinical outcomes of restrictive and liberal transfusion strategies in patients after heart surgery.Conclusion. Preoperative anaemia, haemorrhage and donated component transfusion independently contribute to the risk of serious postoperative complications and death unifying in the “deadly triad” of cardiac surgery. RBC transfusions are integrally indicative of the aid quality in cardiac surgery reflecting the success of blood management system in the hospital. Leveraging a good patient blood management practice at all treatment steps to involve a multispecialty blood-team approach can significantly improve patient outcomes at a higher cost efficiency.

Comparison of results of transcatheter femoral aortic valve replacement under local and general anesthesia: A protocol for systematic review and meta-analysis.

Background:Traditionally, TAVR (Transcatheter Aortic Valve Replacement) has been performed under general anesthesia (GA). Thus GA facilitates the use of TEE (Transesophageal echocardiography), and the use of TEE is an important means to improve the quality of cardiac surgery and reduce postoperative complications. However, GA was also associated with prolonged mechanical ventilation, longer hospitalization and intensive care unit hours, and the need for positive inotropic agents. With increasing clinical experience and advances in transcatheter techniques, transfemoral TAVR may also be feasible under local anesthesia (LA). Studies have shown that LA can avoid hemodynamic fluctuations caused by general anesthesia and lung damage caused by positive pressure ventilation, and can also reduce medical costs.Methods:Two researchers independently read the titles and abstracts of the literature obtained. After excluding the studies that did not meet the inclusion criteria, they read through the full text of the remaining literatures to determine whether they truly met the inclusion criteria. When two researchers disagree on the included literature, the third researcher decides whether to include it or not. For literature with incomplete data, contact the author via email for unpublished data. The included studies were assessed by two researchers for the risk of bias, and cross-checked. Stata16.0 was used for meta-analysis. Heterogeneity was assessed by χ2 test and I2 quantification. Pooled analysis was performed by random effects model. Sensitivity analysis was performed by excluding references one by one. We will perform subgroup analysis based on data conditions.Results:In this study, high quality evidence was provided by selecting local anesthesia and general anesthesia during transfemoral transcatheter aortic valve replacement for patients with primary arterial stenosis.Conclusion:Local anesthesia provides anaesthetic-guided sedation that does not require intubation and is safe and effective. Local anesthesia may be a better alternative to TAVR under general anesthesia.Ethics and dissemination:The study does not require ethical approval.INPLASY registration number:INPLASY202170078

Novel Assessments of Technical and Nontechnical Cardiac Surgery Quality: Protocol for a Mixed Methods Study.

BackgroundOf the 150,000 patients annually undergoing coronary artery bypass grafting, 35% develop complications that increase mortality 5 fold and expenditure by 50%. Differences in patient risk and operative approach explain only 2% of hospital variations in some complications. The intraoperative phase remains understudied as a source of variation, despite its complexity and amenability to improvement.ObjectiveThe objectives of this study are to (1) investigate the relationship between peer assessments of intraoperative technical skills and nontechnical practices with risk-adjusted complication rates and (2) evaluate the feasibility of using computer-based metrics to automate the assessment of important intraoperative technical skills and nontechnical practices.MethodsThis multicenter study will use video recording, established peer assessment tools, electronic health record data, registry data, and a high-dimensional computer vision approach to (1) investigate the relationship between peer assessments of surgeon technical skills and variability in risk-adjusted patient adverse events; (2) investigate the relationship between peer assessments of intraoperative team-based nontechnical practices and variability in risk-adjusted patient adverse events; and (3) use quantitative and qualitative methods to explore the feasibility of using objective, data-driven, computer-based assessments to automate the measurement of important intraoperative determinants of risk-adjusted patient adverse events.ResultsThe project has been funded by the National Heart, Lung and Blood Institute in 2019 (R01HL146619). Preliminary Institutional Review Board review has been completed at the University of Michigan by the Institutional Review Boards of the University of Michigan Medical School.ConclusionsWe anticipate that this project will substantially increase our ability to assess determinants of variation in complication rates by specifically studying a surgeon’s technical skills and operating room team member nontechnical practices. These findings may provide effective targets for future trials or quality improvement initiatives to enhance the quality and safety of cardiac surgical patient care.International Registered Report Identifier (IRRID)PRR1-10.2196/22536

Evaluating Quality in Adult Cardiac Surgery.

National and institutional quality initiatives provide benchmarks for evaluating the effectiveness of medical care. However, the dramatic growth in the number and type of medical and organizational quality-improvement standards creates a challenge to identify and understand those that most accurately determine quality in cardiac surgery. It is important that surgeons have knowledge and insight into valid, useful indicators for comparison and improvement. We therefore reviewed the medical literature and have identified improvement initiatives focused on cardiac surgery. We discuss the benefits and drawbacks of existing methodologies, such as comprehensive regional and national databases that aid self-evaluation and feedback, volume-based standards as structural indicators, process measurements arising from evidence-based research, and risk-adjusted outcomes. In addition, we discuss the potential of newer methods, such as patient-reported outcomes and composite measurements that combine data from multiple sources.

Surgical Ablation for Atrial Fibrillation During Mitral Valve Surgery: Can We Do More?

Evidence surrounding the benefits of surgical ablation (SA) for atrial fibrillation (AF) at the time of mitral surgery is well established and supported by multiple randomized controlled trials and large observational studies.1 Therefore, the highest level of recommendation supporting its performance was granted by societal guidelines.2,3 In this issue of The Annals of Thoracic Surgery, Mehaffey and colleagues4 from the Virginia Cardiac Surgery Quality Initiative demonstrated that the overall performance and inclusion of SA resembles the current national trends.

Clinical Practice Variation and Outcomes for Stanford Type A Aortic Dissection Repair Surgery in Maryland: Report from a Statewide Quality Initiative.

Background Stanford Type A aortic dissection repair surgery is associated with high mortality and clinical practice remains variable among hospitals. Few studies have examined statewide practice variation. Methods Patients who had Stanford Type A aortic dissection repair surgery in Maryland between July 1, 2014 and June 30, 2018 were identified using the Maryland Cardiac Surgery Quality Initiative (MCSQI) database. Patient demographics, comorbidities, surgery details, and outcomes were compared between hospitals. We also explored the impact of arterial cannulation site and brain protection technique on outcome. Results A total of 233 patients were included from eight hospitals during the study period. Seventy-six percent of surgeries were done in two high-volume hospitals (≥10 cases per year), while the remaining 24% were done in low-volume hospitals. Operative mortality was 12.0% and varied between 0 and 25.0% depending on the hospital. Variables that differed significantly between hospitals included patient age, the percentage of patients in shock, left ventricular ejection fraction, creatinine level, arterial cannulation site, brain protection technique, tobacco use, and intraoperative blood transfusion. The percentage of patients who underwent aortic valve repair or replacement procedures differed significantly between hospitals ( p < 0.001), although the prevalence of moderate-to-severe aortic insufficiency was not significantly different ( p = 0.14). There were no significant differences in clinical outcomes including mortality, renal failure, stroke, or gastrointestinal complications between hospitals or based on arterial cannulation site (all p > 0.05). Patients who had aortic cross-clamping or endovascualr repair had more embolic strokes when compared with patients who had hypothermic circulatory arrest ( p = 0.03). Conclusion There remains considerable practice variation in Stanford Type A aortic dissection repair surgery within Maryland including some modifiable factors such as intraoperative blood transfusion, arterial cannulation site, and brain protection technique. Continued efforts are needed within MCSQI and nationally to evaluate and employ the best practices for patients having acute aortic dissection repair surgery.

Abstract 31: Center-specific Variation in Use of Dual Antiplatelet Therapy Prior to Coronary Surgery: an Outcomes Analysis from the Maryland Cardiac Surgery Quality Initiative

Background: Understanding institutional practices and associated outcomes of patients managed with different dual antiplatelet therapy (DAPT) strategies prior to coronary artery bypass grafting (CABG) could inform practice improvement. We hypothesized that, while receipt of DAPT within 5 days prior to CABG would increase risk for postoperative bleeding, there is institutional variation in preoperative DAPT management. Methods: A retrospective cohort study was performed using data from the Maryland Cardiac Surgery Quality Initiative (MCSQI), a consortium aggregating data from the 10 hospitals that perform cardiac surgery in Maryland. Isolated CABG patients between 2011 and 2018 were included. The exposure variable of interest was DAPT use within 5 days prior to CABG. The temporal trend in preoperative use of DAPT, heterogeneity in DAPT usage between centers, and perioperative outcomes are reported. The primary outcomes were the STS major morbidity/mortality composite measure and postoperative bleeding events. Results: The sample included 13,965 patients, of which 23% ( n =3,219) received preoperative DAPT within 5 days of surgery. The percentage of CABG patients treated with DAPT within 5 days decreased over time from 26% in 2011 to 15% in 2018 (Figure, P &lt;0.001 for trend). There was significant heterogeneity in preoperative DAPT use among centers within the state (Figure, P &lt;0.001 for difference in proportions). CABG patients receiving preoperative DAPT were more likely to present with acute MI (49% v 27%, P &lt;0.001) and less likely to present electively (19% v 34%, P &lt;0.001). The ratio of observed-to-expected STS-defined morbidity/mortality was similar between DAPT (O/E 0.85, 95% CI 0.77-0.92) and non-DAPT groups (O/E 0.84, 95% CI 0.79-0.89). Median transfusion of blood products was higher for the DAPT group (1 [0-4] v 0 [0-3], P &lt;0.001). In adjusted models, preoperative DAPT was associated with greater odds of reoperation for bleeding (OR=1.38, P =0.017) and transfusion of ≥2 PRBC units (OR=1.27, P &lt;0.001). Conclusion: Many isolated CABG patients in the state of Maryland are treated with DAPT within 5 days prior to CABG with notable variation between centers. Given the associated risk of postoperative bleeding, standardized management of preoperative DAPT therapy could improve post-CABG outcomes.

Medical Evaluation of the Surgical Patient

Medical evaluation prior to surgery includes risk assessment and the institution of therapies to decrease perioperative morbidity and mortality to improve patient outcomes. The most effective medical consultation for surgical patients begins with an assessment of the individual patient and knowledge of the planned surgery and anesthesia followed by clear communication of a concise and specific recommended plan of perioperative care to the surgical team. This chapter describes anesthetic, cardiac, pulmonary, hepatic, nutritional, and endocrine risk assessment. Perioperative thrombotic management and postoperative care and complications, including fluid management; pulmonary, cardiac, renal complications; and delirium are discussed. Tables outline the American Society of Anesthesiologists class and perioperative mortality risk, a comparison of the Revised Cardiac Risk Index and National Surgery Quality Improvement Program, Duke Activity Status Index, high-risk stress test findings, markers for increased perioperative risk in pulmonary hypertension, aortic stenosis and nonemergent noncardiac surgery, risk factors for pulmonary complications in noncardiac surgery, the Model for End-Stage Liver Disease score to predict postoperative mortality, venous thromboembolism risk factors and options for pharmacologic prophylactic regimens, perioperative management of warfarin, and Brigham and Women’s Hospital guidelines for postoperative blood product replacement. Figures include a care algorithm for noncardiac surgery, an illustration of types of myocardial infarction, and an algorithm for the treatment of postoperative delirium. This review contains 3 highly rendered figures, 12 tables, and 68 references.

Bilateral Internal Mammary Artery Use in Diabetic Patients: Friend or Foe?

Bilateral internal mammary artery (BIMA) grafting in diabetic patients undergoing coronary artery bypass grafting remains controversial. Our study compared morbidity and mortality between (1) diabetic and nondiabetic BIMA patients and (2) diabetic BIMA versus diabetic patients who underwent left internal mammary artery (LIMA) grafting only. Patients who underwent isolated coronary artery bypass grafting from July 2011 to June 2016 at any of the 10 Maryland Cardiac Surgery Quality Initiative centers were propensity scored across 16 variables. Diabetic BIMA patients were matched 1:1 by nearest neighbor matching to nondiabetic BIMA patients and were separately matched 1:1 to diabetic LIMA patients. We calculated observed-to-expected (O/E) ratios for composite morbidity/mortality, operative mortality, unplanned reoperation, stroke, renal failure, prolonged ventilation, and deep sternal wound infection and compared ratios among matched populations. During the study period, 812 coronary artery bypass grafting patients received BIMA grafts, including 302 patients (37%) with diabetes. We matched 259 diabetic and nondiabetic BIMA patients. O/E ratios were higher in matched diabetic (versus nondiabetic) BIMA patients when comparing composite morbidity/mortality, reoperation, stroke, renal failure, and prolonged ventilation (all O/E ratios >1.0); however, the O/E ratio for operative mortality was higher in nondiabetic BIMA patients. We additionally matched 292 diabetic BIMA to diabetic LIMA patients. Diabetic BIMA patients had a higher O/E ratio for composite morbidity/mortality, operative mortality, stroke, renal failure, and prolonged ventilation. In this statewide analysis, diabetic patients who received BIMA grafts (compared with diabetic patients with LIMA grafts or nondiabetic patients with BIMA grafts) had higher O/E ratios for composite morbidity/mortality as a result of higher O/E ratios for major complications.

Public Reporting of Congenital Heart Surgery Outcomes: Counting Numbers, Caring for Patients

The purpose of public reporting is to provide transparency and accountability so that patients and their families can make informed choices. Our ability to assess and publicly report quality in congenital cardiac surgery is constrained by the available data and statistical techniques. Efforts should be directed toward collecting and evaluating information that provides a broad picture of what makes a high-quality program. For public reporting to succeed, the outcomes presented must be accessible, relevant, and understandable.