Alex Zapolanski

Propensity matched analysis of bilateral internal mammary artery versus single left internal mammary artery grafting at 17-year follow-up: validation of a contemporary surgical experience.

OBJECTIVESnBilateral internal mammary arteries (BIMA) remains widely underutilized in coronary artery bypass grafting (CABG). Although prior research has demonstrated a long-term benefit of the use of BIMA over left internal mammary artery (LIMA)-only, validation of these results is lacking in a contemporary surgical experience. We compared complications and survival at 17-year follow-up in a large series of consecutive CABG patients from a single institution that underwent BIMA grafting with a propensity-matched group where LIMA only was used.nnnMETHODSnPropensity scores representing the estimated probabilities of patients receiving either BIMA or LIMA alone were developed based on 22 observed baseline covariates in a logistic regression model with procedure group as the dependent variable. The nearest-neighbour-matching algorithm with Greedy 5-1 Digit Matching was used to produce two patient cohorts of 928 patients each balanced for baseline factors. We compared 30-day morbidity and mortality, as well as long-term survival at 5-year intervals up to 17-year follow-up.nnnRESULTSnIn-hospital and 30-day mortality was 0.8% for the BIMA group and 1.1% for the LIMA-saphenous vein grafting (SVG). No significant difference was found in complications, mortality and/or length-of-stay between these two groups. Off-pump was done in 48.9% of BIMA cases and 51.3% of LIMA cases. Regardless of the types of grafts used, on-pump patients were more likely to have postoperative permanent strokes and longer postoperative lengths of stay. Use of the BIMA over LIMA-only had a statistically significant impact conferring a 10% survival advantage at 10-year and 18% at 15-year follow-up. The Kaplan-Meier survival curves comparing off-/on-pump BIMA and off-/on-pump LIMA-SVG patients demonstrated a 22% survival advantage for off-pump BIMA patients when compared with on-pump LIMA-SVG patients at 15-year follow-up.nnnCONCLUSIONSnPerioperative complications do not increase with the use of BIMAs. Long-term survival is optimized with off-pump CABG and BIMA grafting. The low morbidity and mortality rates in this series are likely due to the continuous evolution of technology and the adoption of less invasive options for CABG patients. A more widespread use of BIMAs in CABG patients would continue to improve the overall excellent short- and long-term results of this operation.

Quality, not volume, determines outcome of coronary artery bypass surgery in a university-based community hospital network

OBJECTIVESnThe present study examined the relationship between hospital and surgeon coronary artery bypass grafting procedural volume, mortality, morbidity, and National Quality Forum care processes in a university-based community hospital quality improvement program.nnnMETHODSnThe study population consisted of 2218 consecutive patients undergoing isolated coronary artery bypass grafting from 2007 to 2009 in a university-based quality improvement program that emphasizes involvement of all surgeons in the academic quality endeavor. The endpoints included operative mortality, major morbidity, and National Quality Forum-endorsed process measures as defined by the Society of Thoracic Surgeons. The procedural volume was analyzed as a categorical and continuous variable using general estimating equations, which accounted for clustering effects and which were adjusted for Society of Thoracic Surgeons risk scores and the propensity for operation in a low- versus high-volume program.nnnRESULTSnThe annual program volume ranged from 67 to 292 (median, 136; interquartile range, 88-224) and surgeon volume from 1 to 124 (median, 58; interquartile range, 30-89). The mortality rate among the hospitals was 0.47% to 2.23% (0.8% overall), and the observed/expected mortality ranged from 0 to 1.20 (0.41 overall). When comparing low-volume (<200 cases/year) and high-volume centers, no difference was found in the mortality (odds ratio [OR], 1.08; 95% confidence interval [CI], 0.46-2.54, P = .85), morbidity (OR, 1.34; 95% CI, 0.73-2.43), or any of the medication process measures. No difference was found in mortality (OR, 1.59; 95% CI, 0.81-3.13; P = .18), morbidity (OR, 1.20; 95% CI, 0.86-1.66; P = .28), or medication failure (OR, 0.57, 95% CI, 0.3-1.10; P = .10) between the high- and low-volume surgeons (<87). After adjustment for both the Society of Thoracic Surgeons risk score and the propensity score, no association was found for either hospital or surgeon volume with mortality or morbidity. However, a lack of compliance with National Quality Forum measures was highly predictive of morbidity (OR, 1.51; 95% CI, 1.18-1.93; P = .001), regardless of volume, even after adjustment for predicted risk.nnnCONCLUSIONSnIn the setting of a university-based community hospital quality improvement program, excellent surgical results can consistently be obtained even in relatively low-volume programs. The surgical outcomes were not associated with program or surgeon volume, but were directly correlated with the focus on quality as manifested by compliance with evidence-based quality standards. Meaningful university affiliation might represent a new quality paradigm for cardiac surgery in the community hospital setting.

The effects of using a radial artery in patients already receiving bilateral internal mammary arteries during coronary bypass grafting: 30-day outcomes and 14-year survival in a propensity-matched cohort

OBJECTIVESnRecent studies have demonstrated the superiority of bilateral internal mammary arteries (BIMAs) as conduit material for coronary artery bypass grafting (CABG) surgery. However, there is limited research on the effects of other graft conduits used in patients who require additional bypasses. The goal of this study was to evaluate the impact of the radial artery (RA) when used in conjunction with the BIMAs.nnnMETHODSnFrom the beginning of 2000 to the end of 2013, 4370 patients underwent CABG for three or more vessels at our institution. There were 568 and 183 patients who received BIMA + saphenous vein graft (SVG) and BIMA + radial ± SVG, respectively. Propensity matching was used to create a balanced cohort from these patients, which resulted in two groups of 183 patients. Thirty-day outcomes and long-term survival were compared between the two groups. Long-term follow-up was generated using the Social Security Death Index.nnnRESULTSnThere were no significant differences in preoperative characteristics. For 30-day outcomes, the BIMA + radial ± SVG group had more postoperative atrial fibrillation (24.6 vs 12.0%; P = 0.001) and a longer median postoperative length of stay (6 vs 5 days; interquartile range = 2; P = 0.016) than BIMA + SVG patients. There was no significant difference in long-term survival between the two groups over the 14-year period. However, before year 10, the BIMA + SVG group had a trend towards higher survival, whereas on follow-up after 10 years, there was a trend that favoured the BIMA + radial ± SVG patients. Cox regression analysis using a time-dependent covariate demonstrated that when the groups were split at 10 years, there was a statistically significant improvement in survival of the BIMA + radial ± SVG group [adjusted hazard ratio 0.254 95% confidence interval (CI) 0.062-0.977; P = 0.048] over BIMA + SVG patients between 10 and 14 years.nnnCONCLUSIONSnOverall, there were no statistically significant differences in survival between the BIMA + SVG and BIMA + radial ± SVG groups over the 14 years. However, further analysis demonstrated that while the BIMA + radial ± SVG group had a trend towards decreased survival before 10 years, use of the RA in conjunction with BIMAs was associated with significantly increased survival in the later years. A larger cohort of patients with longer follow-up is needed to assess the outcomes of CABG using BIMA + radial ± SVG.

Blood transfusion in cardiac surgery does increase the risk of 5‐year mortality: results from a contemporary series of 1714 propensity‐matched patients

Studies have found that cardiac surgery patients receiving blood transfusions are at risk for increased mortality during the first year after surgery, but risk appears to decrease after the first year. This study compared 5‐year mortality in a propensity‐matched cohort of cardiac surgery patients.

Balancing the benefits and risks of blood transfusions in patients undergoing cardiac surgery: a propensity-matched analysis

OBJECTIVESnPrior studies have found that cardiac surgery patients receiving blood transfusions are at risk for increased mortality and morbidity following surgery. It is not clear whether this increased risk occurs across all haematocrit (HCT) levels. The goal of this study was to compare operative mortality in propensity-matched cardiac surgery patients based on stratification of the preoperative HCT levels.nnnMETHODSnBetween 1 August 2004 and 30 June 2011, 3516 patients had cardiac surgery. One thousand nine hundred and twenty-two (54.5%) required blood transfusion during or after surgery. A propensity score for transfusion was developed based on 22 baseline variables. One thousand seven hundred and fourteen patients were matched: 857 in the transfusion group (TG) and 857 in the non-transfused control group (CG). Univariate analyses demonstrated that, after propensity matching, the groups did not differ on any baseline factors included in the propensity model. Operative mortality was defined as death within 30 days of surgery. Preoperative HCT was stratified into four groups: <36, 36-39, 40-42 and ≥ 43.nnnRESULTSnFor HCT <36%, 30-day mortality was higher in the TG than that in the CG (3.0 vs 0.0%). For HCT 36-39, operative mortality was similar between TG (1.1%, N = 180) and CG (0.8%, N = 361; P = 0.748). For HCT 40-42, operative mortality was significantly higher in the TG compared with that in the CG (1.9 vs 0%, N = 108 and 218, respectively; P = 0.044). For HCT of ≥ 43, there was a trend towards higher operative mortality in the TG vs the CG (2.0 vs 0%, N = 102 and 152, respectively; P = 0.083). Other surgical complications followed the same pattern with higher rates found in the transfused group at higher presurgery HCT levels. HCT at discharge for the eight groups were similar, with an average of 29.1 ± 1.1% (P = 0.117).nnnCONCLUSIONSnOur study indicates that a broad application of blood products shows no discernible benefits. Furthermore, patients who receive blood at all HCT levels may be placed at an increased risk of operative mortality and/or other surgical complications. Paradoxically, even though patients with low HCTs theoretically should benefit the most, transfusion was still associated with a higher complication and mortality rate in these patients. Our results indicate that blood transfusion should be used judiciously in cardiac surgery patients.

Impact of pump status and conduit choice in coronary artery bypass: A 15-year follow-up study in 1412 propensity-matched patients

OBJECTIVEnPrevious studies have demonstrated that bilateral internal mammary artery (BIMA) grafts lead to superior outcomes compared with single internal mammary artery grafts. This study examines whether cardiopulmonary bypass affects conduit-dependent outcomes of coronary artery bypass grafting (CABG) surgery.nnnMETHODSnFrom 1994 to 2013, a total of 6666 patients underwent isolated CABG surgery at our institution. Of these procedures, 3548 (53.2%) were performed off pump. A BIMA-saphenous vein graft (SVG) was used in 1544, and 5122 had left internal mammary artery-SVGs. These 2 conduit groups differed significantly in baseline characteristics. Propensity matching based on 22 preoperative variables and using a nearest-neighbor matching algorithm was used to make balanced cohorts, resulting in 2 groups of 1006. To account for the influence of pump status on conduit selection, a second propensity score was developed for pump use. These cases were matched to create 4 patient cohorts of 353 patients each (a total of 1412), balanced for both conduit use and pump status. Late mortality was determined using the Social Security Death Index.nnnRESULTSnNo difference was found in survival between patients receiving BIMA-SVGs on or off pump (78.9% vs 79.1%). BIMA-SVGs outperformed the left internal mammary artery-SVGs regardless of whether the procedure was performed off pump (73.9%) or on pump (69.9%).nnnCONCLUSIONSnThis study demonstrates that the use of cardiopulmonary bypass does not significantly affect the long-term outcomes in these patients as long as full revascularization is achieved. In addition, these results are consistent with prior research showing that the use of BIMAs produces better outcomes than use of a single internal mammary artery when performing CABG.

Effects of a protocol-based management of type A aortic dissections.

BACKGROUNDnAscending aortic dissections (AADs) require prompt diagnosis and surgical treatment. We present the results of implementing a multidisciplinary aortic dissection protocol on the outcomes of AAD treatment at a nonteaching hospital.nnnMETHODSnFrom January 2002-December 2013, 54 patients with the diagnosis of AAD were treated at our institution. Thirty-seven (68.5%) were male with a mean age of 62.3 y. Cardiogenic shock was present in 25.9% of patients. An AAD protocol, focused on educating physicians on presenting signs and symptoms, adequate triaging, and the need for immediate surgical intervention, was implemented, alongside the standardization of surgical treatment. We divided the cohort into two eras, based on AAD programs implementation in 2006, to better assess the impact of this protocol.nnnRESULTSnPatients from the early era had significantly longer time from Emergency Department to the operating room, more postoperative occurrence of prolonged ventilation, and a longer postoperative hospital stay at 8.7 ± 8 versus 3.1 ± 2.6 h (P = 0.002), 63% versus 18% (P = 0.002), and 63% versus 18% (P = 0.002), respectively. The overall mortality for the cohort was 9.3%, decreasing from 12.5% before 2006 to 7.9% after 2006.nnnCONCLUSIONSnThe implementation of a multidisciplinary aortic dissection protocol has resulted in faster diagnosis and transport of AAD cases from the emergency room to the operating room, improving outcomes. Our data support the concept that nonteaching institutions can deliver excellent care to patients with acute aortic emergencies.

Comparative genome-wide transcriptional analysis of human left and right internal mammary arteries

In coronary artery bypass grafting (CABG), the combined use of left and right internal mammary arteries (LIMA and RIMA) - collectively known as bilateral IMAs (BIMAs) provides a survival advantage over the use of LIMA alone. However, gene expression in RIMA has never been compared to that in LIMA. Here we report a genome-wide transcriptional analysis of BIMA to investigate the expression profiles of these conduits in patients undergoing CABG. As expected, in comparing the BIMAs to the aorta, we found differences in pathways and processes associated with atherosclerosis, inflammation, and cell signaling - pathways which provide biological support for the observation that BIMA grafts deliver long-term benefits to the patients and protect against continued atherosclerosis. These data support the widespread use of BIMAs as the preferred conduits in CABG.

A 37-Year-Old Smeloff-Cutter Aortic Valve

We describe the case of a 64-year-old woman with mitral insufficiency that had undergone an aortic valve replacement with a Smeloff-Cutoff prosthesis (Cutter Laboratories, Berkeley, CA) 37 years ago. She underwent both aortic and mitral valve replacement. The patients Smeloff-Cutter aortic valve was unchanged. This case demonstrates the longest durability for the Smeloff-Cutter aortic prosthesis reported in the literature.

Intracardiac juvenile xanthogranuloma with presentation in adulthood.

Juvenile xanthogranuloma is the most frequent type of non-Langerhans cell histiocytosis. It most commonly presents in infancy and early childhood; manifesting as cutaneous lesions on the head, neck, and trunk that suddenly appear and usually undergo spontaneous regression. Extracutaneous involvement, although rare, may occur along with the cutaneous form or in isolation. It most frequently involves the eye, deep subcutaneous tissues, lung, and liver. Involvement of the heart is exceptionally rare, with only seven reports found in the English literature, all affecting infants. We present the first report of an intracardiac juvenile xanthogranuloma in an adult.