Use Of Internal Mammary Artery Research Articles

Operativni tretman aneurizme intratorakalnog segmenta leve potključne arterije u dva akta nakon prethodne koronarne hirurgije

Introduction: We present a case of a 70-year-old patient who underwent successful two-stage repair of an intrathoracic left subclavian artery aneurysm (SAA) and who had previously undergone CABG. Case presentation: The patient had previously undergone three-vessel coronary artery bypass graft (CABG) repair with the use of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD). Percutaneous coronary intervention (PCI) was performed as a backup option in case of potential intra-operative LIMA-LAD bypass occlusion. Owing to the impossibility of hybrid repair due to a short proximal landing zone and aortic arch anomaly (bovine type), the vascular surgery review board decided to perform two-stage open surgery. Firstly, the patient underwent a left carotid-subclavian (C-S) bypass with the Dacron graft, with the application of the standard supraclavicular approach. After a few days, the second procedure, through the left posterolateral thoracotomy was performed. The left subclavian artery (SA) was ligated distally to the SAA but proximally to the origin of the LIMA. The distal aortic arch at the site of the left SAA was clamped partially and the aneurysm was excised. The defect of the aortic arch was sutured and reinforced with a felt patch. Postoperatively, the patient had a good recovery, without any signs of myocardial injury or any surgery-related issues. Conclusion: Careful planning and two-stage open surgical treatment of the left SAA, first with a left carotid-subclavian bypass, followed by aneurysm exclusion and suture of the outer aortic arch curvature may be a treatment option for patients not amenable to hybrid treatment.

R23 Twenty-Year Survival After RAY is the Same as BIMAY Operations for Coronary Bypass Surgery

Composite grafting with two arterial conduits efficiently achieves total arterial revascularisation of triple vessel disease. The left internal mammary artery may be used with the second conduit being a free right mammary (BIMAY) or a radial artery (RAY). There have been no direct comparisons of survival between BIMAY and RAY beyond 7 years. Use of both internal mammary arteries may increase the risk of deep sternal wound infection, whereas use of the radial artery may potentially reduce this risk.

Trends in per-operative parameters and postoperative complications associated with coronary artery bypass graft surgery (CABG); A four-year retrospective study

Objective:To determine the patterns of per-operative parameters and early outcomes of patients that underwent CABG surgery during a four-year period.Methods:This is a cross-sectional descriptive study conducted in a tertiary care of hospital from November 2020 to January 2021. All the patients that underwent the isolated coronary artery bypass grafting (CABG) procedure were included in the study from June 2017 till June 2020. Data was collected on a data extraction form and stored in SPSS format which was analyzed for qualitative statistics keeping p<0.05 as significant. All the results were represented in the form of tables.Results:A total of 1,613 patients were operated upon for Coronary Artery Bypass Grafting (CABG) procedure during the study period with 1,222 (75.8%) males and 391 (24.2%) females. Dyslipidemia (71.8%) was the most common risk factor. The average perfusion time decreased only slightly (~1 minute) from 96.01 minutes to 95.07 minutes (2017 to 2020). This change however was not significant (p=0.301). The rate of Left Internal Mammary Artery (LIMA) use stayed relatively stable over the 4-year period fluctuating between 88.7% and 92.9% (p=0.360). The average initial ICU stay (in hours), drain at 12 hours and 24 hours stays almost the same. The rate of mortality peaked in 2018 (4.76%) and subsequently fell to 3.57% by 2020.Conclusion:More males underwent CABG surgery at this tertiary care hospital and the overall complication rate and per-operative parameters improved over the years. The non-risk stratified mortality in this study was found to be higher than developed nations.

Long-term prognosis in patients with end-stage renal disease after coronary artery bypass grafting.

BackgroundCardiovascular disease is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Coronary artery bypass grafting (CABG) is beneficial in selected patients with ESRD. This study investigates the survival outcomes and prognostic factors in ESRD patients who underwent CABG.MethodsA retrospective analysis was performed for 149 patients with ESRD who underwent isolated CABG between 2006 and 2015.ResultsMean age was 59.4±8.7 years and 106 patients (71.1%) were male. Operative mortality occurred in 20 patients (13.4%). Overall survival was 81.1%±3.2% at 1 year, 41.5%±4.3% at 5 years and 19.2%±4.2% at 10 years. Median survival was 4.3 years. Multivariable analysis identified age [P=0.001, odds ratio (OR): 1.15 per 1-year increase, 95% confidence interval (CI): 1.06–1.25], preoperative left ventricular ejection fraction (LVEF) (P=0.020, OR: 0.94, 95% CI: 0.89–0.99) and non-elective status of operation (P=0.049, OR: 3.34, 95% CI: 1.00–11.1) as predictors of operative mortality. Cox regression analysis identified age [P<0.001, hazard ratio (HR): 1.05 per 1-year increase, 95% CI: 1.03–1.08], New York Heart Association (NYHA) class III or IV status (P=0.010, HR: 1.75, 95% CI: 1.15–2.67) and the use of a left internal mammary artery (LIMA) to left anterior descending artery (LIMA-LAD) graft (P=0.029, HR: 0.42, 95% CI: 0.19–0.92) as factors influencing long-term survival.ConclusionsCABG is associated with high operative mortality and poor long-term survival in ESRD patients. Age and NYHA class influenced late survival. LIMA-LAD grafting conferred a long-term survival advantage.

Short-Term Risk of Bilateral Internal Mammary Artery Grafting in Diabetic Patients

This study compares the morbidity and mortality at 30 days following the use of bilateral internal mammary arteries (BIMA) vs a single internal mammary artery (SIMA) at the time of coronary artery bypass grafting (CABG) in patients with a preoperative HbA1c. Patients undergoing CABG from January 2008 to December 2016 reported to the Society of Thoracic Surgeons database were retrospectively reviewed. The patients were divided into 2 groups: use of BIMA or use of SIMA and propensity matched. To assess the effect of preoperative HbA1c, both groups were further divided into 5 subgroups: patients without diabetes mellitus (DM), or patients with DM and a preoperative HbA1c level in one of four groups (< 7%, 7-9%, 9-11%, or >11%). The postoperative outcomes in both the BIMA and SIMA groups were compared. There were 700,504 and 28,115 patients with measured preoperative HbA1c levels in the SIMA and BIMA groups, respectively. Propensity score matching identified 23,635 comparable patients in each group for analysis. There was no difference in postoperative mortality between the BIMA and SIMA groups (1.3% vs 1.2%). The incidences of sternal wound infection (SWI) in patients undergoing placement of BIMA vs SIMA were: 0.8% vs 0.4% with no DM (P < 0.0001), 1.9% vs 1.0% with HbA1c < 7% (P < 0.001), 2.4% vs 1.2% with HbA1c 7-9% (P < 0.001), 2.8% vs 1.4% with HbA1c 9-11% (P = 0.02), 4.1% vs 1.5% with HbA1c > 11% (P = 0.01). Based on the incidence of SWI, BIMA is a reasonable approach with an HbA1c<7%.

Coronary artery bypass grafting: Factors affecting outcomes.

Coronary artery bypass grafting forms the bulk of a cardiac surgeon's workload. An extensive amount of research has been undertaken to improve the outcomes of this procedure. This literature review aimed to summarize key areas that influence coronary artery bypass grafting in modern day practice. A comprehensive electronic search was done using PubMed, Ovid, SCOPUS, Embase and google scholar from inception to July 2020. Articles were included if they discussed factors affecting outcomes in coronary bypass grafting (CABG). Case reports, expert opinion, and editorials were excluded. There are many factors that influence and predict outcomes following coronary artery bypass surgery. Age, diabetes, and isolated systolic hypertension were preoperative factors with strong correlation to mortality and morbidity rates post CABG. In addition to these, the degree of renal failure and heart failure correlated with poorer operative results. The use of the left internal mammary artery has transformed outcomes and has proven advantage over venous conduit use. Newer minimal invasive techniques have the potential to further optimize outcomes. The numerous and complex factors which impair outcomes following CABG need to be further researched and addressed using larger trials and possible optimization of multi-disciplinary team approach to further improve long term outcomes.

Bilateral vs Single Internal Mammary Artery Grafts for Coronary Artery Bypass in the United States

The use of the bilateral internal mammary artery (BIMA) in coronary artery bypass grafting remains controversial. The objective of this study was to investigate the long-term outcomes using the BIMA vs the single internal mammary artery (SIMA) in the United States. Medicare beneficiaries who underwent primary isolated coronary artery bypass surgery using the SIMA or BIMA from 1999 to 2010 were included in this retrospective study, with follow-up through 2014. Greedy matching algorithms were used for 1:4 matching on propensity score based on age, gender, year of surgery, and comorbidities. Kaplan-Meier survival analyses were performed. The primary outcome was death from any cause. A total of 1,156,339 and 25,005 patients who were 72 ± 7.6 years of age and 70.3 ± 7.9 years of age underwent primary isolated coronary artery bypass surgery using SIMA and BIMA, respectively. Matching created comparable groups with 95,780 SIMA and 24,160 BIMA patients. Matched median survival using SIMA vs BIMA was 11.8 vs 12.4 years (P < .001) and 9.6 vs 10 years in diabetic patients (P = .006), respectively. At 10 years of follow-up, the respective survival rates of using SIMA vs BIMA were 58.3% vs 61.1%, respectively. The stratified matched median survival using SIMA vs BIMA with 1, 2, 3, and 4 or more aortocoronary bypasses were 11.8 vs 12.3 years (P= .005), 11.7 vs 12.5 years (P < .001), 11.9 vs 12.3 years (P= .01), and 11.4 vs 12 years (P= .02), respectively. Primary isolated coronary artery bypass surgery using the BIMA rather than the SIMA was associated with improved long-term survival. This survival advantage was independent of aortocoronary bypass grafts or patient diabetes status.

Sternal healing after bilateral internal mammary arteries use for Coronary artery bypass grafting in diabetic Patients; short-term results

Background: Bilateral internal mammary artery (BIMA) use may improve long-term outcomes after coronary artery bypass grafting (CABG); however, the risk of infection is high. Skeletonization of the internal mammary may decrease the risk of infection, especially in patients with diabetes. Our study aimed at evaluation of sternal healing in diabetic patients with different techniques of bilateral internal mammary artery harvesting.&#x0D; Methods: This prospective randomized study included 200 diabetic patients who underwent CABG using BIMA between 2017 and 2019. We divided patients into two groups; Group A had skeletonization of both internal mammary arteries, and Group B had pedicled left mammary and skeletonized right mammary. Patients were observed for three months, post-operatively for any sternal wound problems.&#x0D; Results: There was no significant difference regarding the baseline variables. Type I diabetes mellitus was present in 25% in group A (n= 24) and 13.64% in group B (n= 12) (p= 0.324). There was no difference in harvest time between groups (83 ±4 vs. 81 ±3 minutes in group A vs. B, respectively. P= 0.1). The mean number of grafts was 3± 0.5 in Group A and 3± 0.6 in Group B (p= 0.8). Postoperative drainage was 402.9 ± 174.1 ml in Group A vs. 387.2 ± 153.6 ml in Group B (p= 0.474). The duration of ICU stay did not differ significantly between groups (2± 0.7 in Group A vs. 2± 0.5 in Group B; p= 0.8). Deep sternal wound infection occurred in 4.17% in group A (n= 4) and 4.55% in group B (n= 4) (p= 0.705). Superficial wound infection occurred in eight patients in group A (8.33%) and eight patients in group B (9.1%) (p= 0.59). No patient had sternal dehiscence in group A vs. four patients in group B (4.55%) (p= 0.39).&#x0D; Conclusion: We did not find differences between bilateral mammary artery harvest with skeletonization of both arteries versus skeletonization of the right mammary only on sternal healing nor wound infection in diabetic patients undergoing CABG. A larger study is recommended.

Use of the right internal mammary artery and the great saphenous vein for left anterior descending artery revascularization in patients whose left internal mammal artery cannot be used: a study based on transit-time flow measurement

BackgroundOwing to the high patency, the use of the left internal mammary artery (LIMA) for left anterior descending artery (LAD) grafting has been a cornerstone of coronary artery bypass grafting surgery (CABG). However, for some patients whose LIMA cannot be used, surgeons have to choose other conduit materials to revascularize the LAD. The purpose of this study was to explore the differences in different conduit materials used for LAD in terms of parameters measured by transit-time flow measurement (TTFM) and the early graft patency detected by computed tomography angiography.MethodsWe retrospectively collected the data of 410 patients who underwent isolated primary OPCAB with intraoperative TTFM data. According to the strategy of the LAD revascularization, 410 patients were assigned to three groups: a left internal mammal artery (LIMA) group (n = 333), a right IMA (RIMA) group (n = 34) and a great saphenous vein (SVG) group (n = 43). The baseline and perioperative blood parameters were compared for the three groups, as well as the early graft patency rates.ResultsCompared with the LIMA-LAD group, the SVG-LAD group had a significantly higher mean graft flow volume (MGF) (37.15 ± 23.29 vs 29.71 ± 20.94 ml/min, P = 0.036), however, had a lower value of pulse index (PI) (2.07 ± 0.62 vs 2.65 ± 1.01, P<0.001). There was no significant difference between the two groups in terms of DF (P>0.05). Compared with the RIMA-LAD group, the SVG-LAD group just had a lower value of PI (2.07 ± 0.62 vs 2.56 ± 0.96, P = 0.029). However, there was no significant difference between the two groups in terms of MGF and DF (P>0.05). Compared with the LIMA-LAD group, the RIMA-LAD group had a slightly lower value of DF (70.76 ± 11.87 vs 74.06 ± 7.09, P = 0.018), while there was no difference in terms of MGF and PI between the two groups (P>0.05). The patency rate of the LIMA-LAD group was 98.72% (309/313), that of RIMA-LAD group was 97.06% (33/34), and that of SVG-LAD group was 100%. There was no difference among the three groups in patency rate (P = 0.405).ConclusionsSVG-LAD has a higher intraoperative MGF and a lower value of the PI than both LIMA-LAD and RIMA-LAD. RIMA has a higher preoperative blood flow and a lower value of the PI than LIMA; however, there were no significant difference between RIMA grafted to LAD and LIMA grafted to LAD in terms of MGF, PI and DF. In situ skeletonized RIMA did not increase blood flow compared to pedicled LIMA.

Evaluation of post-operative development of mediastinitis in patients undergoing isolated coronary artery bypass grafting surgery: A single-center experience.

In this study, we aimed to evaluate mediastinitis cases developed after isolated coronary artery bypass graft surgery performed by median sternotomy to determine the causative microorganisms, risk factors, and clinical features. Between March 2009 and December 2018, a total of 44 patients (32 males and 12 females; mean age 62.84±6.951 years; range, 46-78 years) who underwent isolated coronary artery bypass grafting surgery with median sternotomy and developed mediastinitis postoperatively were included in the studying our cardiovascular surgery (CVS) department. Patients demographic information, comorbidities, habits, pre-operative hospital stay, elective or emergency surgery, perioperative internal mammary artery use, perioperative blood or blood product, operation and cardiopulmonary bypass times, suitability of antibiotic prophylaxis, medical and surgical treatment, clinical data, and laboratory results were retrospectively analyzed. Purulent discharge cultures obtained directly from the mediastinal space and microbiological examination notes made from the material obtained from the surgical site or surgical repair were recorded. In isolated coronary artery bypass grafting surgery performed over a period of approximately 10 years, the rate of mediastinitis was 1%. There was no statistically significant difference between patients with and without mediastinitis in terms of age, sex, smoking habits, duration of operation and cardiopulmonary bypass, and intraoperative blood transfusion. The presence of diabetes mellitus and high mean body mass index was significantly higher in patients with mediastinitis compared to those without. Mediastinitis was diagnosed in 38 (86.3%) patients in the 1st month, 5 (11.3%) in the first 3 months, and 1 (2.2%) in the 1st year. Twenty-five (56.9%) Gram-positive bacteria, 13 (29.6%) Gram-negative bacteria, and 1 (2.3%) fungi were the microorganisms grown in purulent discharge cultures. Pathogen microorganisms could not be produced in 5 (11.4%) cases. The three most commonly isolated agents were methicillin-resistant coagulase-negative staphylococci (MRCNS) (50%), Escherichia coli (9.1%), and Klebsiella pneumoniae (6.8%). Attention should be paid to surgical site infection in patients undergoing CVS. Following discharge, follow-up is important and empirical treatment should be determined by considering the presence of MRCNS as the leading infectious agent in our hospital when infection occurs.

Prevention of Sternal Dehiscence Following Use of Bilateral Internal Mammary Arteries in OPCAB

Purpose: We harvested bilateral Internal Mammary Arteries and made LIMA-RIMA Y in all the patients undergoing OPCAB at our center irrespective of the presence or absence of various risk factors for sternal dehiscence. The purpose of this study was to find an effective way of sternal closure in patients undergoing OPCAB with both the Internal Mammary Arteries harvested for grafting. Method: The patients who did not have any risk factors were placed in group I and all of them had a standard six wire closure of sternotomy. The patients having any risk factors were placed in group II. The patients in group II were randomized by including every alternate patient from group II to subgroup II A and every other alternate patient from group II to subgroup II B. Patients in subgroup II A again had a standard closure of sternotomy while in patients of subgroup II B bilateral Robiscek repair and four-five interlocking figure of eight wires were used for closure of sternotomy. Results: The patients who had risk factors for sternal dehiscence had higher risk for sternal dehiscence as compared to patients without any risk factors if bilateral Internal Mammary Arteries were harvested for OPCAB. But if we used bilateral Robiscek repair with four to five interlocking figure of eight wires for sternal closure then the rate of sternal complications in the patients with risk factors for sternal dehiscence was not more than the patients without risk factors. Conclusion: We can harvest bilateral Internal Mammary Arteries for OPCAB without fear of sternal complications even in patients with high risk for sternal dehiscence if we use bilateral Robiscek repair with four to five interlocking figure of eight wires for sternal closure.

Comparison of Long-Term Outcomes of Patients Having Surgical Aortic Valve Replacement With Versus Without Simultaneous Coronary Artery Bypass Grafting

Coronary artery disease is a common co-morbidity of aortic stenosis. When needed, adding coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) is the standard treatment method, but the impact of concomitant CABG on long-term outcomes is uncertain. We compared long-term outcomes of SAVR patients with and without CABG. Hospital survivors aged ≥50 years discharged after SAVR ± CABG in Finland between 2004 and 2014 (n = 6,870) were retrospectively studied using nationwide registries. Propensity score matching (1:1) was used to identify patients with comparable baseline features (n = 2,188 patient pairs, mean age 73 years). The end points were postoperative 10-year major adverse cardiovascular outcome (MACE), all-cause mortality, stroke, major bleeding, and myocardial infarction. Median follow-up was 6 years. Cumulative MACE rate (39.5% vs 35.6%; hazard ratio [HR] 1.04; p = 0.677) and mortality (32.7% vs 31.0%; HR 1.03; p = 0.729) after SAVR were comparable with or without CABG. Myocardial infarction was more common in patients with CABG (13.4% vs 6.9%; HR 1.47; p = 0.0495). Occurrence of stroke (15.1% vs 13.5%; p = 0.998) and major bleeding (20.0% vs 21.9%; p = 0.569) were comparable. There was no difference in gastrointestinal (8.1% vs 10.3%; p = 0.978) or intracranial bleeds (6.0% vs 5.5%; p = 0.794). The use of internal mammary artery in CABG did not have an impact on the results. In conclusion, matched patients with and without concomitant CABG had comparable long-term MACE, mortality, stroke, and major bleeding rates after SAVR. In conclusion, our results indicate that need for concomitant CABG has limited impact on long-term outcomes after initially successful SAVR.

Revascularização híbrida na doença coronária multiarterial: qual é o verdadeiro papel da técnica?

ABSTRACT The best treatment option for patients with complex multivessel coronary artery disease remains uncertain. In association with optimal medical therapy, coronary artery bypass graft surgery and percutaneous coronary intervention have been compared over the past decades. Hybrid coronary revascularization applies the best of both strategies, aiming at complete revascularization and lower rates of major adverse cardiovascular events. The technique comprises the use of left internal mammary artery connected to the left anterior descending artery, combining off pump and minimally [...]

P4581Outcome of surgical revascularization for coronary artery disease after 30 years

Abstract Objective We report the long-term outcome of surgical revascularization in patients with coronary artery disease. Methods The institutional trial on Coronary Artery Disease and Surgical Therapy: Long-term Follow-up, is a 30-year follow-up study of 2728 patients with coronary artery disease who underwent surgical revascularization from April 1986 to December 1988. One-vessel coronary artery disease was found in 234 patients while 2 and 3-vessel diseases were found in 1021 and 1463 patients, respectively. Survival was analyzed according to age, gender, ejection fraction, and number of arterial and vein grafts (2165 males, mean age at coronary revascularization 59.4±8.8 years). Results Mean duration of follow-up was 30.6±1.2 years. Overall survival at this time point was 24.1%. Age–stratified survival was observed higher (40%) in those patients &lt;50 years of age at that time of surgery compared to the other age groups, i.e. 50–59: 20%, 60–69: 10% and &gt;70: 5% (p&lt;0.001). Women had increased early mortality, hence have poorer survival (12%) than men (18%). However, when age (women=median 64.7, men=58.4, years) was considered between gender, no significant difference (p=0.13) in survival was observed. Interestingly, survival rate of patients with ejection fraction of &lt;30% (n=826) was 6% which obviously fared well compared with 18% of those with ejection fraction of &gt;30% (n=1902) at the time of coronary surgery. There was no significant difference between the use of a single internal mammary artery (IMA) [left or right] graft and use of 2 arterial grafts (combined left and right IMA or IMA and radial artery) on long-term survival (p=0.014). However, the use of an arterial graft combined with vein grafts are favorable (p&lt;0.001). Conclusion The findings in this study showed that after a relatively long-term follow-up, age-based survival was similar compared to the general population. Female gender demonstrated poorer survival than men. However, when this is adjusted for age, no significant difference was shown. Interestingly, several patients with severely reduced ejection fraction, considered inoperable by many cardiac surgeons and cardiologists at the time of revascularization have survived for &gt;30 years. Use of one internal mammary artery graft demonstrated better survival than use of only vein grafts. Noteworthy is that the sole use of vein grafts may also lead to an acceptable long-term survival.

Saphenous vein grafts in contemporary coronary artery bypass graft surgery.

Myocardial ischaemia resulting from obstructive coronary artery disease is a major cause of morbidity and mortality in the developed world. Coronary artery bypass graft (CABG) surgery is the gold-standard treatment in many patients with complex multivessel coronary artery disease or left main disease. Despite substantial improvements in the outcome of patients undergoing CABG surgery in the past decade, graft patency remains the 'Achilles' heel' of this procedure. Whereas the use of the left internal mammary artery as a conduit is associated with the highest 10-year patency rate (>90%), saphenous vein grafts - the most commonly used conduit in CABG surgery - fail in 40-50% of treated patients by 10 years after surgery. Vein graft disease (VGD) and failure result from complex pathophysiological processes that can lead to complete occlusion of the graft, affecting long-term clinical outcomes. Optimal harvesting techniques, intraoperative preservation strategies and intraoperative patency control have important roles in the prevention of VGD. In addition, several studies published in the past decade have reported similar mid-term patency rates between vein grafts and arterial grafts when veins are used as a composite graft based on the internal mammary artery. In this Review, we present the latest evidence on the utilization of saphenous vein grafts for CABG surgery and provide an overview of the current practices for the prevention of VGD and vein graft failure.

Professional Society Leadership in Health Care Quality: The Society of Thoracic Surgeons Experience

The STS quality program is overseen by the STS Council on Quality, Research, and Patient Safety, which has four components. The Workforce on Research Development, in collaboration with the STS Research Center, coordinates clinical research based on the STS National Database, all of which is focused on improving clinical outcomes. The Workforce on Evidence Based Surgery develops clinical practice guidelines and expert consensus documents to foster the use of best practices. The Workforce on Patient Safety disseminates high-reliability practices from within and outside health care to improve the safety of cardiothoracic surgical care. The Workforce on National Databases consists of four subspecialty registries (adult cardiac, congenital cardiac, general thoracic, mechanical circulatory support [Intermacs and Pedimacs]) and multiple functionally oriented task forces (Quality Measurement, Quality Initiatives, Public Reporting, Informatics, Patient-Reported Outcomes, and Aortic Surgery). Between 1998 and 2016, the rates of coronary artery bypass grafting surgery adverse outcomes decreased substantially, including operative mortality (-31.3%), renal failure (-56.3%), stroke (-43.5%), reoperation (-65.7%), and sternal infection (-50.0%). Comparable increases in process measure compliance included internal mammary artery use (32%), preoperative beta-blocker use (83.1%), discharge antiplatelet drugs (22.9%), discharge antilipid drugs (78.6%), and discharge beta-blockers (54.1%). The STS quality program has achieved remarkable, continuing improvements in patient safety and quality over several decades. The components of this program can be replicated by other health care professional societies to advance quality and safety for their patient populations.

How do surgeons decide? Conduit choice in coronary artery bypass graft surgery in the UK†.

Conduits used in coronary artery bypass grafting may have significant impact on outcomes, but evidence is mixed and there is large variation in practice. This study provides insights into the opinions of the UK surgeons on conduit use and their decision-making processes. A questionnaire was created using the Ottawa Decision Support Framework to elicit the importance that surgeons placed on bilateral internal mammary artery grafting, skeletonization, total arterial revascularization and sequential anastomoses on a scale of 1-10. Scores ≥8 were deemed 'important' and ≤3 'not important'. Surgeons were asked to specify changes to practice in frail patients or emergencies. Additional questions included conduit type used, factors affecting decision-making and vein harvesting methods. Questionnaires were administered in person with data analysed centrally. Ninety-seven consultant cardiac surgeons from 25 centres responded. Thirty-two percent surgeons routinely used radial arteries and 36% used right internal mammary artery. High-quality evidence contributed most to decision-making receiving a total of 328/960 points, with consultant experience being the second (255/960 points). There was a bimodal distribution of perceived importance of bilateral internal mammary artery use, with 29 (30%) 'important' and 'not important' scores each. 23% of surgeons found total arterial revascularization important. Most surgeons (64%) preferred pedicled mammary arteries. Twenty-six percent of surgeons considered sequential grafting to be important. Low uptake of total arterial revascularization and bilateral internal mammary artery among the UK consultants may be due to the lack of high-quality evidence demonstrating a significant benefit. It is also possible that reluctance to use certain conduits may stem from low levels of exposure to conduits or inadequate training, particularly given the importance of consultant experience on decision-making.

Indications and contra-indications for minimally invasive mitral valve surgery

A minimally invasive access through right mini-thoracotomy (MT) for mitral valve surgery (MIMVS) is indicated in all cases except those which cannot be safely addressed by this approach, i.e., in particular major annular calcification (MAC). Other conditions to be regarded as contraindications generally either impose an increased risk of complications compared to the standard approach (e.g., severe aorto-iliac atherosclerosis) or may simply jeopardize the results of MIMVS (any co-morbidity imposing an elevated surgical risk). Partial sternotomy (PS) represents an alternative less invasive approach for cases when MT is not feasible including severe MAC, concomitant aortic valve replacement (AVR) and selected indications for coronary artery bypass graft (CABG). Full sternotomy may be reserved for multiple bypass grafting, use of left internal mammary artery (LIMA), right internal mammary artery (RIMA) and reoperations when a MT approach is not appealing.

Surgeon-Specific Quality Monitoring System for Coronary Artery Bypass Grafting

We developed a multidimensional quality monitoring system using an electronic health care records-derived database, and mobile-based reports for individual cardiovascular surgeons. This study included surgeons who performed coronary artery bypass graft surgery at a single center in China from January to December 2015. Patient data were automatically derived from structured electronic health records. Surgeon-specific quality measures included inhospital mortality and morbidity, transfusion-free procedure, use of internal mammary artery, postoperative length of stay, and hospitalization cost. The"technique for order of preference by similarity to ideal solution" method was used to create a composite quality measure and rank surgeons on performance. Surgeons were rated into three categories: the top 20%, middle 20% to 80%, and the bottom 20%. Quality data were delivered to surgeons through mobile-based reports. Forty surgeons performed 4,288 coronary artery bypass graft surgeries in 2015. For surgeons in the top, middle, and bottom performance categories, there was a trend of increase in risk adjusted inhospital morbidity rate (2.66%, 2.89%, and 3.07%, respectively; p= 0.5101). There were significant differences in the use of internal mammary artery (94.65%, 95.8%, 90.14%, respectively; p < 0.0001), risk-adjusted postoperative length of stay (7.01 days, 7.99 days, and 8.69 days, respectively; p < 0.0001), and hospitalization cost(81.27 thousand yuan, 88.36 thousand yuan, and 102.77 thousand yuan, respectively; p < 0.0001). We developed a surgeon-specific quality monitoring system using structured electronic health records-derived database, multidimensional measures, and mobile-based reporting. This system will facilitate quality reporting and peer comparison, and strengthen the effect of quality improvement.

Off-pump coronary artery bypass in octogenarians: results of a statewide, matched comparison.

Off-pump coronary artery bypass grafting (OPCAB) may have advantages in the elderly. Although proven safe, it remains unclear whether OPCAB provides a short-term survival benefit in octogenarians. We sought to compare outcomes using propensity matching between OPCAB and conventional surgery in a statewide database. We identified all octogenarians (≥ 80years) who underwent isolated coronary artery bypass grafting (CAB) at 10 different centers in the state of Maryland from July 2011 to June 2016. We separated patients into two groups: OPCAB and on-pump coronary artery bypass (ONCAB). Patients were assigned propensity scores with a semi-parsimonious logistic regression model and matched 1:1 by the nearest-neighbor principle. A revascularization ratio was determined between the number of distal grafts sewn and number of diseased coronaries (≥ 50% stenosis). In total, 926 octogenarians underwent isolated CAB (8.2% of all CAB): 798 (86%) had ONCAB and 128 (14%) had OPCAB. Propensity matching yielded 128 well-matched pairs. Operative mortality was similar between groups (OPCAB 5.5% vs ONCAB 3.1%, p = 0.364). Rates of complications were similar between groups. OPCAB patients had a lower revascularization ratio (0.92 vs 1.15, p < 0.001), but more frequent use of left internal mammary artery (97 vs 89%, p = 0.017), and decreased intraoperative transfusion rates (33 vs 63%, p < 0.001). In comparing outcomes among octogenarians across the state of Maryland, OPCAB and ONCAB had similar mortality and morbidity. However, OPCAB was associated with a lower revascularization ratio. Thus, our results demonstrate no short-term survival benefit of OPCAB over ONCAB in octogenarians.