Robert H. Habib

Worldwide Trends in Multi-arterial Coronary Artery Bypass Grafting Surgery 2004-2014: A Tale of 2 Continents

Recent evidence shows that multi-arterial coronary artery bypass grafting (MABG) based on bilateral internal thoracic (BITA) or left internal thoracic (LITA) and radial artery (RA) improves long-term outcomes compared with single arterial coronary artery bypass grafting (SABG) (LITAu2009+u2009saphenous vein graft). How this evidence affected the worldwide use of MABG, if at all, is not well defined. Accordingly, we report 10-year temporal trends of MABG utilization from 2 continents. A study population of 1,683,434 non-emergent, primary, isolated LITA-based coronary artery bypass grafting (CABG) (≥2 grafts) patients was derived from the Society of Thoracic Surgeons (STS) (1,307,528 (79.5%) of 1,644,388 isolated CABG; total 1179 centers) and the Australia New Zealand Cardiothoracic (ANZ) Databases (34,213 (87%) of 39,046 isolated CABG; 24 centers) between 2004 and 2014. Patients were excluded based on the following: (1) no LITA, (2) if arterial grafts were other than RA or ITA, or (3) if grafting data were missing. The 3 MABG groups were LITAu2009+u2009RA, BITA, and BITAu2009+u2009RA, each with or without supplemental vein grafts. Grafting trends and their associated patient demographics were analyzed. SABG (89.3% STS, 51.4% ANZ) was the most common grafting strategy. MABG was most frequently accomplished by LITAu2009+u2009RA: (STS: 6.1%; ANZ: 42.6%), followed by BITA: (STS: 4.1%; ANZ: 4.3%), while ≥3 (BITAu2009+u2009RA) was rare in the STS (0.5%), but more common in ANZ (5.9%). In the STS, between 2004 and 2014, SABG rates systematically increased from 85.2% to 91.7%, BITA grafting was essentially unchanged from 3.6% to 4.3%, while RA use decreased systematically from 10.5% to 3.7%. In the ANZ, SABG rates increased from 17.3% to 51.4%, BITA grafting decreased from 6.3% to 3.6%, while RA grafting decreased from 65.8% to 39.0%. Compared with SABG patients, BITA patients were younger (STS: median age 59 vs 66, Pu2009<u20090.001; ANZ: mean age 62 vs 68, Pu2009<u20090.001), predominately male (STS: 84% vs 73%, Pu2009<u20090.001; ANZ: 86% vs 79%, Pu2009<u20090.001), less obese (body mass indexu2009>30u2009kg/m2) in STS (37% vs 42%, Pu2009<u20090.001), more obese in ANZ (33% vs 32%, Pu2009=u20090.001), and less diabetic (STS: 26% vs 43%, Pu2009<u20090.001; ANZ: 25% vs 37%, Pu2009<u20090.001), whereas RA patients were intermediate in age (STS: 61; ANZ: 65), in male sex (STS: 82%; ANZ: 81%), in the prevalence of diabetes (STS: 40%; ANZ: 34%), and were most obese (STS: 47%; ANZ: 34%). A decade-long analysis of STS data reveals a counterintuitive decline in the use (driven by decreasing RA use) of MABG: a potentially superior grafting strategy compared with SABG. In contra distinction, the smaller but growing ANZ data document a distinctly different CABG practice pattern, with a higher MABG utilization rate, but a similarly declining RA use. The reasons for these practice patterns and declining MABG are likely diverse and require further assessment.

The Society of Thoracic Surgeons National Database 2016 Annual Report

The art and science of outcomes analysis, quality improvement, and patient safety continue to evolve, and cardiothoracic surgery leads many of these advances. The Society of Thoracic Surgeons (STS) National Database is one of the principal reasons for this leadership role, as it provides a platform for the generation of knowledge in all of these domains. Understanding these topics is a professional responsibility of all cardiothoracic surgeons. Therefore, beginning in January 2016, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides a summary of the status of the STS National Database as of October 2016 and summarizes the articles about the STS National Database that appeared in The Annals of Thoracic Surgery 2016 series, Outcomes Analysis, Quality Improvement, and Patient Safety.

The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2017 Update on Research

The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) is the largest congenital and pediatric cardiac surgical clinical data registry in the world. It contains data pertaining to more than 435,000 total operations. The most recent biannual feedback report to participants (Spring 2017, Report of the Twenty-Sixth Harvest) included analysis of data submitted from 127 hospitals in North America. That represents nearly all centers performing pediatric and congenital heart operations in the United States and Canada. As an unparalleled platform for assessment of outcomes and for quality improvement activities in the subspecialty of surgery for pediatric and congenital heart disease, the STS CHSD continues to be a primary data source for clinical investigations and for research and innovations related to quality measurement. In 2016, several major original publications reported analyses of data in the CHSD pertaining to various processes of care, including assessment of variation across centers and associations between specific practices, patient characteristics, and outcomes. Additional publications reported the most recent development, evaluation, and application of metrics for quality measurement and reporting of pediatric and congenital heart operation outcomes and center level performance. Use of the STS CHSD for outcomes research and for quality measurement continues to expand as database participation has grown to include nearly all centers in North America, and the available wealth of data in the database continues to grow. This article reviews outcomes research and quality improvement articles published in 2016 that are based on STS CHSD data.

The Society of Thoracic Surgeons Congenital Heart Surgery Database: 2016 Update on Research

The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD) is the largest congenital and pediatric cardiac surgical clinical data registry in the world. With more than 400,000 total operations from nearly all centers performing pediatric and congenital heart operations in North America, the STS CHSD is an unparalleled platform for clinical investigation, outcomes research, and quality improvement activities in this subspecialty. In 2015, several major original publications reported analyses of data in the CHSD pertaining to specific diagnostic and procedural groups, age-defined cohorts, or the entire population of patients in the database. Additional publications reported the most recent development, evaluation, and application of metrics for quality measurement and reporting of pediatric and congenital heart operation outcomes. This use of the STS CHSD for outcomes research and for quality measurement continues to expand as database participation and the available wealth of data in it continue to grow. This article reviews outcomes research and quality improvement articles published in 2015 based on STS CHSD data.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2016 Update on Research.

The Society of Thoracic Surgeons Adult Cardiac Database (ACSD) is an international voluntary effort that is the foundation of our specialtys efforts in clinical performance assessment and quality improvement. Containing nearly 6,000,000 patient records, thexa0ACSD is a robust resource for clinical research. Seven major original publications and four review articles were generated from the ACSD in 2015. The risk-adjusted outcome analyses and quality measures reported in these studies have made substantial contributions to inform daily clinical practice. This report summarizes the ACSD-based research efforts published inxa02015.

Operative Outcomes of Multiple-Arterial Versus Single-Arterial Coronary Bypass Grafting

BACKGROUNDnMore than 90% of coronary artery bypass grafting (CABG) is performed with a single-arterial bypass graft (SABG), based on the left internal thoracic artery (ITA) with supplemental vein grafts. This practice, often justified by safety concerns with multiple-arterial grafting (MABG), defies evidence of improved late survival achieved with bilateral ITA (BITA-MABG) or left ITA plus radial artery (RA-MABG). We hypothesized that MABG and SABG are equally safe.nnnMETHODSnWe analyzed The Society of Thoracic Surgeons National Database (2004 to 2015) to assess the operative safety of BITA-MABG (nxa0= 73,054) and RA-MABG (nxa0= 97,623) vs SABG (nxa0= 1,334,511). Primary end points were operative (30-day or same hospitalization) mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios (AOR) and 95% confidence intervals (CIs) were derived from by logistic regression with sensitivity analyses in multiple subcohorts including MABG use rate.nnnRESULTSnSABG (73.8% men; median age, 66 years), BITA-MABG (85.1% men; median age, 59 years), and RA-MABG (82.5% men; median age, 61 years) showed distinctly different patient characteristics. Compared with SABG (1.91% OM; 0.73% DSWI), observed OM was lower for BITA-MABG (1.19%, p < 0.001) and RA-MABG (1.19%, p < 0.001). DSWI was higher among BITA-MABG (1.08%, p < 0.001) and similar for RA-MABG (0.71%, pxa0= 0.55). BITA-MABG showed marginally increased, likely not clinically significant, OM (AOR, 1.14; 95% CI, 1.00 to 1.30; pxa0= 0.05) and doubled DSWI (AOR, 2.09; 95% CI, 1.80 to 2.43; p < 0.001). RA-MABG had similar OM (AOR, 1.01; 95% CI, 0.89 to 1.15; pxa0= 0.85) and DSWI (AOR, 0.97; 95% CI, 0.83 to 1.13; pxa0= 0.70). Results were consistent across multiple subcohorts. A U-shaped OM vs BITA use relation was documented, with worse OM at hospitals with low (<5%: AOR, 1.38; 95% CI, 1.18 to 1.61; p < 0.001) and high (≥40%: AOR, 1.31; 95% CI, 1.00 to 1.70; pxa0= 0.049) BITA use.nnnCONCLUSIONSnMABG in the United States is associated with OM comparable to SABG and increased DSWI risk with BITA-MABG. Our findings highlight the importance of surgeon and institutional experience and careful patient selection for BITA-MABG. Our short-term results should not in any way dissuade the use of MABG, given its well-established long-term survival advantage.

Differential effects of operative complications on survival after surgery for primary lung cancer

Objective: Complications adversely affect survival after lung cancer surgery. We tested the hypothesis that effects of complications after lung cancer surgery on survival vary substantially across the spectrum of postoperative complications. Methods: The Society of Thoracic Surgeons General Thoracic Surgery Database was linked to Medicare data for lung cancer resections from 2002 through 2013. Linkage was achieved for 29,899 patients. A survival model was created that included operative complications as explanatory variables and adjusted for relevant baseline covariates. Because of violation of the proportional hazard assumption, we used time‐varying coefficient Cox modeling for the complication variables. Results: Median patient age was 73 years, and 48% were male. Procedures performed were lobectomy in 69%, wedge in 17%, segmentectomy in 7%, bilobectomy in 3%, pneumonectomy in 3%, and sleeve lobectomy in 1%. Most frequent complications were atrial arrhythmia (14%), pneumonia (4.3%), reintubation (3.8%), delirium (2%), and acute kidney injury (1.4%). In the early period (0‐90 days), 12 complications are associated with worse survival. From 3 to 18 months after surgery, only 4 complications are associated with survival: delirium, blood transfusion, reintubation, and pneumonia. After 18 months, only sepsis and blood transfusion are associated with a significant late hazard. Conclusions: Our analysis confirmed the presence of differential magnitude and time‐varying effects on survival of individual complications after lung cancer surgery. We conclude that the derived time‐dependent hazard ratios can serve as objective weights in future models that enhance performance measurement and focus attention on prevention and management of complications with greatest effects.

Optimal management of radial artery grafts in CABG: Patient and target vessel selection and anti-spasm therapy

The current literature on radial artery grafting is reviewed focusing on the optimal deployment of radial artery grafts in coronary artery bypass surgery with specific attention to the selection of patients and target vessels for radial artery grafting.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2017 Update on Research

Containing more than 6 million cumulative operative records and accounting for 90% to 95% of adult cardiac surgery performed in the United States, The Society of Thoracic Surgeons Adult Cardiac Surgery Database is an invaluable resource for performance assessment, quality improvement, and clinical research. This article reviews the seven major research efforts published in 2016 that utilized the Adult Cardiac Surgery Database. Two studies evaluated national trends in clinical practice, three assessed the effect of several risk factors on postoperative morbidity and mortality, and two developed new models to evaluate quality of care. The findings of these studies have enhanced clinical practice and delineated areas for future quality improvement research.

Effectiveness of radial artery–based multiarterial coronary artery bypass grafting: Role of body habitus

Background: The multiarterial grafting survival advantage noted in the overall population undergoing coronary artery bypass grafting is not well defined in the obese. We investigated the early to late survival effects of the radial artery in left internal thoracic artery–based multiarterial bypass grafting (radial artery‐multiarterial bypass grafting) versus single arterial bypass grafting (left internal thoracic artery‐single arterial bypass grafting) in obese patients. Methods: We analyzed 15‐year Kaplan–Meier survival in 6102 patients receiving primary, left internal thoracic artery–based coronary artery bypass grafting with 2 or more grafts divided into body mass index groups: nonobese (<30 kg/m2) and all‐obese, comprised of mildly obese (30‐35 kg/m2) and morbidly obese (>35 kg/m2). Risk‐adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of radial artery‐multiarterial bypass grafting versus left internal thoracic artery‐single arterial bypass grafting were derived via Cox regression and applied separately for early (<0.5 years), intermediate (0.5‐5 years), and late (5‐15 years) follow‐up in each body mass index cohort. Propensity score matching between radial artery‐multiarterial bypass grafting and left internal thoracic artery‐single arterial bypass grafting cohorts within the body mass index groups was performed as a corroborating analysis. Results: Radial artery‐multiarterial bypass grafting was more frequently used in obese patients who were younger (62 ± 10 years; mild/morbid: 45.4%/54.4% radial artery‐multiarterial bypass grafting) compared with nonobese patients (66 ± 10 years; 37.4% radial artery‐multiarterial bypass grafting). Unadjusted 15‐year survival was significantly better for radial artery‐multiarterial bypass grafting in all body mass index groups. Multivariate analysis showed a survival benefit of radial artery‐multiarterial bypass grafting over the entire 0‐ to 15‐year study period in the all‐obese cohort (HR, 0.85; 95% CI, 0.74‐0.98) and was more pronounced in the mildly obese (HR, 0.79; 95% CI, 0.66‐0.96) versus morbidly obese (HR, 0.88; 95% CI, 0.69‐1.13). The radial artery‐multiarterial bypass grafting survival benefit was realized between 0.5 and 5 years postoperatively and was comparable for all‐obese (HR, 0.69; 95% CI, 0.51‐0.94) and nonobese (HR, 0.68; 95% CI, 0.52‐0.88) groups. Propensity score matching was confirmatory. Conclusions: Radial artery‐multiarterial bypass grafting confers a long‐term survival advantage in both obese and nonobese patients.