Michael P. Robich

del Nido versus Buckberg cardioplegia in adult isolated valve surgery

BACKGROUND del Nido solution is a non-glucose-based, single-dose cardioplegic solution with few data supporting its safety in adults. We hypothesized that it and Buckberg solution offer myocardial protection of equivalent safety for isolated adult valve surgery. METHODS Adult patients undergoing primary isolated aortic or mitral valve surgery with del Nido or Buckberg solution from January 2010 to September 2013 were 1:1 propensity matched (85 aortic valve, 110 mitral valve), and outcomes were compared. RESULTS After aortic valve operations, no hospital deaths occurred, and troponin T levels (median 0.19 ng · mL(-1) for del Nido vs 0.21 ng · mL(-1) for Buckberg) were similar, with no statistically significant change in left ventricular ejection fraction (P = .4). Aortic clamp, bypass, and operating room times were shorter with del Nido solution (44 ± 14 vs 56 ± 19; 56 ± 18 vs 70 ± 24; and 285 ± 44 vs 308 ± 61 minutes, respectively; P < .0001). Peak intraoperative glucose levels (170 ± 31 vs 240 ± 41 mg · dL(-1); P < .0001) and postoperative insulin-drip requirements (46% vs 82%; P < .0001) were lower. After mitral operations, there were no hospital deaths and no statistically significant cardioplegia-specific changes in troponin T levels (median 0.37 ng · mL(-1) for del Nido vs 0.4 ng · mL(-1) for Buckberg) or postoperative left ventricular ejection fraction (P = .13). We found no clear time differences with del Nido solution in mitral cases, but intraoperative glucose levels and postoperative insulin-drip requirements (184 ± 37 vs 250 ± 60 mg · dL(-1) and 50% vs 67% mg · dL(-1), respectively; P = .009) were lower. CONCLUSIONS del Nido solution can be used safely and effectively as an alternative to Buckberg solution in adult isolated valve surgery and is associated with lower insulin requirements and potential time and cost savings.

Ventricular septal rupture complicating acute myocardial infarction: a contemporary review.

Ventricular septal rupture (VSR) after acute myocardial infarction is increasingly rare in the percutaneous coronary intervention era but mortality remains high. Prompt diagnosis is key and definitive surgery, though challenging and associated with high mortality, remains the treatment of choice. Alternatively, delaying surgery in stable patients may provide better results. Prolonged medical management is usually futile, but includes afterload reduction and intra-aortic balloon pump placement. Using full mechanical support to delay surgery is an attractive option, but data on success is limited to case reports. Finally, percutaneous VSR closure may be used as a temporizing measure to reduce shunt, or for patients in the sub-acute to chronic period whose comorbidities preclude surgical repair.

Trends in blood utilization in United States cardiac surgical patients.

We sought to determine whether publication of blood conservation guidelines by the Society of Thoracic Surgeons in 2007 influenced transfusion rates and to understand how patient‐ and hospital‐level factors influenced blood product usage.

Outcomes of patients with human immunodeficiency virus infection undergoing cardiovascular surgery in the United States

INTRODUCTION Advances in highly active antiretroviral therapy have dramatically improved the lifespan of patients infected with human immunodeficiency virus (HIV). We sought to examine the impact of HIV status on outcomes in patients undergoing cardiovascular surgery. METHODS We identified 5,621,817 patients who underwent coronary artery bypass graft (CABG), valve, aortic, or other cardiovascular surgery between 1998 and 2009 from the Nationwide Inpatient Sample. Of these, 9771 (0.17%) patients were seropositive for HIV. Using multivariable logistic regression modeling and 1:1 propensity-score matching, we determined the influence of HIV infection on outcomes. RESULTS The percentage of HIV+ patients undergoing cardiovascular surgery increased significantly from 0.09% to 0.23%. HIV+ patients were more often male, black, younger than 55 years of age, and on Medicaid, and they were more likely to undergo valve and other cardiovascular surgeries, but less likely to have CABG. Among propensity-matched pairs, patients with HIV were at no increased risk for in-patient mortality. HIV+ patients were more likely to receive a blood transfusion and have any postoperative complication. Patients with HIV were less likely to have a postoperative stroke. Rates of pneumonia, renal complications, and wound infection were similar between the groups. The median length of stay and mean total cost were not different between the groups. Factors that predicted in-hospital death in HIV+ patients included metastatic cancer, coagulopathy, renal failure, and aortic, other, or combined surgical procedure. CONCLUSIONS Cardiovascular surgery can be performed safely on patients with HIV with no increased hospital mortality and only minimal increased need for blood transfusion.

Hospitalization before surgery increases risk for postoperative infections

OBJECTIVES Exposure to a health care facility before surgery may increase risk for postoperative infections. Our objectives were to (1) determine whether the prevalence of postoperative infections was higher among patients who were hospitalized before cardiac surgery, (2) identify risk factors for infection, and (3) evaluate in-hospital outcomes. METHODS A total of 32,707 patients underwent cardiac surgery from January 1, 2000, to January 1, 2011. Forty percent (13,107) were hospitalized before their surgery date or were transfers from other health care facilities, and 60% (19,600) were same-day admissions. The primary outcome consisted of a composite infection: pneumonia, sepsis, surgical site infection, and urinary tract infection. The secondary outcome was in-hospital death. The propensity method was used to compare infectious complications and mortality between groups. RESULTS Overall infectious complications occurred in 2327 patients (7.1%). Overall composite and individual infections decreased over the study period (P for trend <.0001). Among 7814 propensity-matched pairs, 522 infections (6.7%) occurred in the same-day admission group versus 676 (8.7%) in the prior hospitalization group, P<.0001. In-hospital mortality was 1.5% (n=120) for the same-day admission group versus 2.8% (n=221) for the prior hospitalization group (P<.0001). CONCLUSIONS Although the risk of infection decreased over time, the relationship between exposure to a health care facility before surgical intervention and higher infection risk remained substantial. Further investigation into processes of care surrounding infection control is necessary to reduce postoperative infections and associated morbidity.

The most important lessons I learned in training

From the Cardiovascular Institute, Maine Medical Center, Portland, Me. Disclosures: M.P.R. is a surgical proctor and invited lecturer for the Perceval aortic valve prosthesis, LivaNova. Received for publication Dec 15, 2016; revisions receivedMarch 6, 2017; accepted for publication April 12, 2017. Address for reprints: Michael P. Robich, MD, 818 Congress St, Portland, ME 04102 (E-mail: mrobich@ mmc.org). J Thorac Cardiovasc Surg 2017;-:1-2 0022-5223/

Prolonged Effect of Postoperative Infectious Complications on Survival After Cardiac Surgery

36.00 Copyright 2017 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2017.04.027

Comparative effectiveness of coronary artery bypass grafting versus percutaneous coronary intervention in a real-world Surgical Treatment for Ischemic Heart Failure trial population

BACKGROUND Whether patients having infections after cardiac surgery are at a survival disadvantage after hospital discharge is unclear. Our objectives were (1) to identify characteristics of such patients and (2) to determine whether this complication is associated with increased mortality beyond hospital discharge. METHODS In all, 30,414 patients were discharged after isolated coronary artery bypass grafting, valve, ascending aorta repair, or combined procedures from January 2000 to January 2011. Surgical site infection, septicemia, pneumonia, and urinary tract infection occurred in 1,868 patients (6.1%). Propensity matching was used to account for differences in perioperative characteristics and postoperative in-hospital events between these patients and those not having postoperative infections, to give 1,593 propensity-matched pairs. Time-related mortality and instantaneous risk were compared. RESULTS Surgical site infection occurred in 122 patients (0.40%), sternal wound infection in 263 (0.86%), septicemia in 656 (2.2%), urinary tract infection in 853 (2.8%), and pneumonia in 513 (1.7%). Infections were associated with older age, female sex, larger body mass index, and multiple comorbidities. Among 1,593 propensity-matched pairs, postdischarge survival at 6 months and at 1, 5, and 10 years, respectively, was 89%, 86%, 67%, and 45% for patients without infections, and 86%, 83%, 63%, and 43% (p = 0.008) for patients with infections. Survival differences resulted from a higher, but gradually declining, early instantaneous risk during the first year after surgery. Elevated risk was of shorter duration for surgical site infections than for other infections. CONCLUSIONS Postoperative infection is associated with a high-risk patient profile, and risk of death is elevated early after hospital discharge. Reasons for this prolonged effect are unclear.

Predictors of Career Choice Among Cardiothoracic Surgery Trainees

Objective There are no prospective randomized trial data to guide decisions on optimal revascularization strategies for patients with multivessel coronary artery disease and reduced ejection fraction. In this analysis, we describe the comparative effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in this patient population. Methods A multicenter, retrospective analysis of all CABG (n = 18,292) and PCIs (n = 55,438) performed from 2004 to 2014 among 7 medical centers reporting to the Northern New England Cardiovascular Disease Study Group. After applying inclusion and exclusion criteria from the Surgical Treatment for Ischemic Heart Failure trial, there were 955 CABG and 718 PCI patients with an ejection fraction ≤ 35% and 2‐ or 3‐vessel disease. Inverse probability weighting was used for risk adjustment. The primary end point was all‐cause mortality. Secondary end points included rates of 30‐day mortality, stroke, acute kidney injury, and incidence of repeat revascularization. Results The median duration of follow‐up was 4.3 years (range, 1.59‐6.71 years). CABG was associated with improved long‐term survival compared with PCI after risk adjustment (hazard ratio, 0.59; 95% confidence interval, 0.50‐0.71; P < .01). Although CABG and PCI had similar 30‐day mortality rates (P = .14), CABG was associated with a higher frequency of stroke (P < .001) and acute kidney injury (P < .001), whereas PCI was associated with a higher incidence of repeat revascularization (P < .001). Conclusions Among patients with reduced ejection fraction and multivessel disease, CABG was associated with improved long‐term survival compared with PCI. CABG should be strongly considered in patients with ischemic cardiomyopathy and multivessel coronary disease.

Rab27a Regulates Human Perivascular Adipose Progenitor Cell Differentiation

BACKGROUND The impact of factors influencing career choice by cardiothoracic surgery (CTS) trainees remains poorly defined in the modern era. We sought to examine the associations between CTS trainee characteristics and future career aspirations. METHODS The 2012 Thoracic Surgery In-Training Examination survey results were used to categorize responders according to career interest: congenital, adult cardiac, mixed cardiac/thoracic, and general thoracic surgery. Univariate and multivariable analyses were used to identify and analyze characteristics associated with career interest categories. RESULTS With a 100% response rate, 300 responses from trainees in programs accredited by the Accreditation Council for Graduate Medical Education were included in the analysis. Multinomial logistic regression identified three factors associated with career choice in CTS: level of training (p < 0.001), type of training pathway (p < 0.001), and primary motivating factor to pursue CTS (p = 0.002). Trainees interested in general thoracic surgery were more likely to commit to CTS during their senior years of general surgery training and were more likely to enroll in 2-year or 3-year traditional fellowships, whereas individuals pursuing adult or congenital cardiac surgery were more likely to commit earlier during training and were more commonly interested in 6-year integrated or joint training pathways. Moreover, trainees interested in general thoracic surgery were predominantly influenced by early mentorship (p = 0.025 vs adult cardiac), and trainees interested in adult cardiac surgery were more likely to be influenced by types of operations (p = 0.047 vs general thoracic). CONCLUSIONS Career choice in CTS appears strongly associated with level of training, exposure to mentors, and training paradigm. These results demonstrate the importance of maintaining all four currently approved training pathways to retain balance and diversity in future CTS practices.