Yigal Kassif

Evaluation of the impact of a quality improvement program and intensivist-directed ICU team on mortality after cardiac surgery.

OBJECTIVE Quality improvement is an important pursuit for critical care teams. DESIGN The authors performed an observational cohort study with historic control. SETTING Eight-bed cardiac surgery ICU in a tertiary university hospital. PARTICIPANTS A total of 4,866 patients undergoing cardiac surgery over a 6-year period between January 2005 and December 2010. INTERVENTIONS In this study, the influence of the introduction of a quality improvement program under the supervision of a newly appointed intensivist on patient outcomes after cardiac surgery was evaluated. Patients were further divided into three 2-year periods: Period I, 2005-2006, before appointment of an intensivist; Period II, 2007-2008, after appointment of an intensivist and initial introduction of a quality improvement program; and Period III, 2009-2010, after implementation of the program and introduction of Critical Care Information Systems. MEASUREMENTS AND MAIN RESULTS There were 1,633, 1,690, and 1,543 patients in each period, respectively. There was no significant difference in the severity of patient illness between the groups. Unadjusted in-hospital mortality decreased from 6.37% (104 patients) in Period I to 4.32% (73 patients) and 3.3% (51 patients) in Periods II and III, respectively (p< 0.01). CONCLUSIONS Appointment of an intensivist-directed team model and introduction of quality improvement interventions were associated with decreased mortality after cardiac surgery.

The impact of gender mismatching on early and late outcomes following heart transplantation: Gender mismatching impacts heart transplantation outcomes

The role of donor/recipient gender matching on the long‐term rejection process and clinical outcomes following heart transplantation (HT) outcomes is still controversial. We aim to investigate the impact of gender matching on early and long‐term outcome HT.

Tricuspid Valve Regurgitation after Orthotopic Heart Transplantation: Prevalence and Etiology

Background. Tricuspid valve regurgitation (TR) after orthotopic heart transplantation (OHT) is common. The aims of this study were to determine the prevalence of TR after OHT, to examine the correlation between its development and various variables, and to determine its outcomes. Methods. All 163 OHT patients who were followed up between 1988 and 2009 for a minimal period of 12 months were divided into those with no TR/mild TR and those with at least mild-moderate TR, as assessed by doppler echocardiography. These groups were compared regarding preoperative hemodynamic variables, surgical technique employed, number of endomyocardial biopsies, number of acute cellular rejections, incidence of graft vasculopathy, and clinical outcomes. Results. At the end of the followup (average 8.2 years) significant TR was evident in 14.1% of the patients. The development of late TR was found by univariate, but not multivariate, analysis to be significantly correlated with the biatrial surgical technique (P < 0.01) and the presence of graft vasculopathy (P < 0.001). TR development was found to be correlated with the need for tricuspid valve surgery but not with an increased mortality. Conclusions. The development of TR after OHT may be related to the biatrial anastomosis technique and to graft vasculopathy.

Severe hypothermia in myxoedema coma: A rewarming by extracorporeal circulation

Myxoedema coma is the most lethal manifestation of hypothyroidism. It represents a true medical emergency, especially in the case of cardiovascular instability. Extracorporeal circulation is usually used for rewarming and for providing cardiac support in patients with severe hypothermia and, in addition, cardiovascular instability. We report the case of an 84‐year‐old woman who presented to the ED with accidental hypothermia associated with myxoedema that was successfully managed by veno‐arterial extracorporeal blood rewarming. This case suggests that veno‐arterial extracorporeal rewarming appears to achieve a rapid and consistent rewarming rate and is less invasive and more readily available than cardiopulmonary bypass.

Comparison of patients with multivessel disease treated at centers with and without on-site cardiac surgery

Background: The regional needs and consolidation of cardiac surgery services (CSS) result in an increased number of stand‐alone interventional cardiology units. We aimed to explore the impact of a heart team on the decision making and outcomes of patients with multivessel coronary artery disease referred for coronary revascularization in stand‐alone interventional cardiology units. Methods: This prospective study included 1063 consecutive patients with multivessel disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography and percutaneous coronary intervention (PCI), with or without on‐site CSS. Results: Of the 1063 patients, 487 (46%) underwent coronary artery bypass grafting (CABG) and 576 (54%) underwent PCI. A higher proportion of patients underwent PCI in hospitals without on‐site CSS compared with those with on‐site CSS (65% vs 46%; P < .001). Furthermore, patients referred to CABG from hospitals without on‐site CSS had a significantly higher mean SYNTAX score compared with those who underwent CABG in centers with on‐site CSS (29 vs 26; P = .018). Multivariate logistic regression analysis consistently showed that the absence of on‐site cardiac surgery and a heart team was independently associated with a 2.5‐fold increased likelihood for predicting the referral of PCI rather than CABG (odds ratio, 2.54; 95% confidence interval, 1.8‐3.6). Conclusions: Patients with multivessel coronary artery disease treated in centers without on‐site cardiac surgery services receive a lower rate of appropriate guideline‐based intervention with CABG. These findings suggest that a heart team approach should be mandatory even in centers with stand‐alone interventional cardiology units.

Long-term Arm Morbidity after Radial Artery Harvesting for Coronary Bypass Operation

BACKGROUND The use of the radial artery (RA) in coronary bypass operations has become increasingly popular in recent years, but there is almost no documentation regarding the midterm and long-term arm complications. METHODS Between January 1 and December 31, 1998, 109 patients underwent operations for myocardial revascularization employing a pedicled RA as 1 of the coronary grafts. The patients were surveyed for subjective arm morbidities at 2 times during their follow-up: short term (mean, 7 months postoperatively; range, 0.3-14 months) and long term (mean, 49 months postoperatively; range, 46-57 months). RESULTS At the short-term follow-up, 33 (33.3%) of the patients had some complaints regarding the arm that was operated on, with 4 (4%) of the patients reporting arm disability with complaints that focused on pain (11, 11%), numbness (15, 15%), and parasthesias (12, 12%). At the longterm follow-up, only 9 patients (10.5%) still experienced some sort of inconvenience with the arm that was operated on, with 1 case of functional disability, 4 complaints (4.6%) of residual parasthesias, and 1 report (2.3%) each of pain or numbness. All but 2 of the patients with complaints at the short-term follow-up reported amelioration of symptoms at the long-term follow-up. CONCLUSION It appears that severe arm disability early after RA harvesting is likely to dissolve with time. Our favorable late follow-up results support the continuation of the employment of the RA as a conduit for coronary artery bypass grafting operations.

Thromboelastography during coronary artery bypass grafting surgery of severe hemophilia A patient - the effect of heparin and protamine on factor Viii activity.

&NA; Coronary artery bypass grafting surgery (CABG) in hemophilia patients is challenging. Thromboelastography (TEG) is useful to assess hemostasis perioperatively. A patient with severe hemophilia A underwent CABG with TEG studies. After factor VIII (FVIII) bolus dose, TEG was normalized. Following ‘on-pump’ heparinization, protamine administration revealed prolonged TEG-R and TEG-R with heparinase confirming it, whereas the activated clotting time was normal, suggesting low FVIII activity rather than excess of heparin. Another FVIII bolus yielded complete normalization of all TEG parameters. Data are compatible with in-vitro assays performed in our laboratory, showing that both heparin and protamine may impair measurable FVIII activity. The rational use of TEG measurements enabled more accurate hemostatic therapy application with regard to FVIII, heparin and protamine administration. Adopting this approach may lead to a better therapy tailoring for hemophilia patients undergoing CABG surgery.

Surgical Pericardiectomy for Constrictive Pericarditis: A Single Tertiary Center Experience

BACKGROUND  Although surgery is the sole therapeutic option for patients with constrictive pericarditis (CP), reports on high postoperative mortality rates have led to hesitant surgery referral. The aim of this study was to report the short- and long-term outcomes of surgical pericardiectomy (SP) from a large tertiary center. METHODS  Between January 2005 and January 2017, 55 consecutive patients underwent SP after comprehensive echocardiography, computed tomography, and hemodynamic studies. Detailed clinical, imaging, surgical techniques and follow-up outcomes were recorded. RESULTS  The most common etiology was idiopathic (n = 27, 49%) and 33 patients (60%) were in functional class 3/4. Sixteen patients (29%) underwent concomitant interventions during SP, and cardiopulmonary bypass (CPB) was used in these, as well as in four additional cases. Complete resection, independent of CPB, was achieved in 96%. One patient died during the index hospitalization, and four (7%) needed re-explorations due to bleeding. While 12 patients (22%) died during a mean follow-up of 52 ± 39 months, only 1 death was due to right heart failure. Functional class significantly improved (with a p-value < 0.001), diuretics were discontinued in all, and significant reductions of right atrial pressures were recorded. None of these outcomes differed as a result of concomitant interventions at the time of SP. CONCLUSION  Short- and long-term outcomes of SP, performed either alone or concomitantly with other procedures, indicate high safety and favorable clinical and hemodynamic efficacy for the treatment of CP.

Real-life characteristics and outcomes of patients who undergo percutaneous coronary intervention versus coronary artery bypass grafting for left main coronary artery disease: data from the prospective Multi-vessel Coronary Artery Disease (MULTICAD) Israeli Registry†

OBJECTIVES Left main coronary artery involvement in patients with multivessel coronary artery disease provides a poor prognosis. Although the main strategy for revascularization is by coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI) is being used with increased frequency. METHODS This prospective, 3-year follow-up study included 1063 consecutive patients with multivessel coronary artery disease enrolled between January and April 2013 from all 22 hospitals in Israel that perform coronary angiography and PCI. RESULTS Of the 1063 patients, 252 (24%) had left main coronary artery disease. Of them, 27% were treated by PCI and 73% by CABG. Factors associated with referral for PCI included older age [odds ratio (OR) 1.04; P = 0.021], renal impairment (OR 3.52; P = 0.006), prior PCI (OR 2.23; P = 0.041) and lower SYNTAX score (OR 1.05; P = 0.004). Kaplan-Meier survival analysis showed that after 3 years, all-cause mortality among left main coronary artery disease patients was significantly higher among those who underwent PCI versus CABG (26.9% vs 8.7%; P < 0.001). Multivariable analysis showed that PCI was associated with a >2-fold increased hazard for mortality compared with surgical revascularization (hazard ratio 2.13, 95% confidence interval 1.05-4.31; P = 0.036). CONCLUSIONS In real-life practice, clinical factors and a lower SYNTAX score affect the decision to perform PCI in left main coronary artery disease patients. Our findings suggest that CABG is associated with improved long-term survival compared to PCI in patients with left main coronary artery disease after adjustment for those factors.

Risk of Early, Intermediate, and Late Rejection Following Heart Transplantation: Trends Over the Past 25 Years and Relation to Changes in Medical Management Tertiary Center Experience: The Sheba Heart Transplantation Registry

To explore the trends in the risk for rejection following heart transplantation (HT) over the past 25 years, and their relation to changes in medical management.