Trends, Predictors, and Outcomes of Temporary Mechanical Circulatory Support for Postcardiac Surgery Cardiogenic Shock.

Postcardiac surgery cardiogenic shock (PCCS) is seen in 2% to 6% of patients who undergo cardiac surgery. There are limited large-scale data on the use of mechanical circulatory support (MCS) in these patients. This study sought to evaluate the in-hospital mortality, trends, and resource utilization for PCCS admissions with and without MCS. A retrospective cohort of PCCS between 2005 and 2014 with and without the use of temporary MCS was identified from the National Inpatient Sample. Admissions for permanent MCS and heart transplant were excluded. Propensity-matching for baseline characteristics was performed. The primary outcome was in-hospital mortality and secondary outcomes included trends in use, hospital costs and lengths of stay. In the period between 2005 and 2014, there were 132,485 admissions with PCCS, with 51.3% requiring MCS. The intra-aortic balloon pump was the predominant device used with a steady increase in other devices. MCS use for more frequent in younger patients, males and those with higher co-morbidity. There was a decrease in MCS use across all demographic categories and hospital characteristics over time. Older age, female sex, previous cardiovascular morbidity and MCS use were independently predictive of higher in-hospital mortality. In 6,830 propensity-matched pairs, PCCS admissions that required MCS use, had higher in-hospital mortality (odds ratio 2.4; p<0.001), higher hospital costs ($98,759 ± 907 vs $81,099 ± 698; p<0.001) but not a longer length of stay compared with those without MCS use. In conclusion, in patients with PCCS, this study noted a steady decrease in MCS use. Use of MCS identified PCCS patients at higher risk for in-hospital mortality and greater resource utilization.

Comparison of Automated Titanium Fasteners to Hand-Tied Knots in Open Aortic Valve Replacement.

OBJECTIVE: Aortic cross-clamp and cardiopulmonary bypass times are independent predictors of postoperative morbidity and mortality. Reducing ischemic times with automated titanium fasteners may improve surgical outcomes. This study compared operative times and costs of titanium fasteners versus hand-tied knots for prosthesis securement in open aortic valve replacement. METHODS: A randomized control trial was conducted during a 16-month period at a single university medical center. Patients undergoing elective aortic valve replacement were randomized to the titanium fastener (n = 37) or hand-tied groups (n = 36). Knotting, aortic cross-clamp, cardiopulmonary bypass, and total operating room times were recorded. Hospital charges were also calculated for these procedures. RESULTS: Baseline characteristics, concomitant procedures, prosthetic valve size, and sutures were similar between groups. The titanium fastener group had significantly reduced knotting (7.4 vs. 13.0 minutes, P < 0.001), aortic cross-clamp (69 vs. 90 minutes, P < 0.05), cardiopulmonary bypass (86 vs. 114 minutes, P < 0.05), and total operating room times (234 vs. 266 minutes, P < 0.05). Intraoperative complications occurred more frequently in the hand-tied group compared with the titanium fastener group. Postoperative complications were similar between groups. Operating room costs were significantly higher in the titanium fastener group (US $10,428 vs. US $9671, P = 0.01). Hospitalization costs did not differ significantly between the titanium fastener and hand-tied group (US $23,987 vs. US $21,068, P = 0.12). CONCLUSIONS: Titanium fastener use was associated with shorter knotting, aortic cross-clamp, cardiopulmonary bypass, and operating room times and fewer intraoperative complications in open aortic valve replacement, without significantly increasing hospitalization cost.

Low tidal volume mechanical ventilation against no ventilation during cardiopulmonary bypass heart surgery (MECANO): study protocol for a randomized controlled trial.

BACKGROUND: Postoperative pulmonary complications are a leading cause of morbidity and mortality after cardiac surgery. There are no recommendations on mechanical ventilation associated with cardiopulmonary bypass (CPB) during surgery and anesthesiologists perform either no ventilation (noV) at all during CPB or maintain low tidal volume (LTV) ventilation. Indirect evidence points towards better pulmonary outcomes when LTV is performed but no large-scale prospective trial has yet been published in cardiac surgery. DESIGN: The MECANO trial is a single-center, double-blind, randomized, controlled trial comparing two mechanical ventilation strategies, noV and LTV, during cardiac surgery with CPB. In total, 1500 patients are expected to be included, without any restrictions. They will be randomized between noV and LTV on a 1:1 ratio. The noV group will receive no ventilation during CPB. The LTV group will receive 5 breaths/minute with a tidal volume of 3 mL/kg and positive end-expiratory pressure of 5 cmH2O. The primary endpoint will be a composite of all-cause mortality, early respiratory failure defined as a ratio of partial pressure of oxygen/fraction of inspired oxygen <200 mmHg at 1 hour after arrival in the ICU, heavy oxygenation support (defined as a patient requiring either non-invasive ventilation, mechanical ventilation or high-flow oxygen) at 2 days after arrival in the ICU or ventilator-acquired pneumonia defined by the Center of Disease Control. Lung recruitment maneuvers will be performed in the noV and LTV groups at the end of surgery and at arrival in ICU with an insufflation at +30 cmH20 for 5 seconds. Secondary endpoints are those composing the primary endpoint with the addition of pneumothorax, CPB duration, quantity of postoperative bleeding, red blood cell transfusions, revision surgery requirements, length of stay in the ICU and in the hospital and total hospitalization costs. Patients will be followed until hospital discharge. DISCUSSION: The MECANO trial is the first of its kind to compare in a double-blind design, a no-ventilation to a low-tidal volume strategy for mechanical ventilation during cardiac surgery with CPB, with a primary composite outcome including death, respiratory failure and postoperative pneumonia. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03098524 . Registered on 27 February 2017.

Results of the 2015 Perfusionist Salary Study.

Presently, there exists no published valid and reliable salary study of clinical perfusionists. The objective of the 2015 Perfusionist Salary Study was to gather verifiable employee information to determine current compensation market rates (salary averages) of clinical perfusionists working in the United States. A salary survey was conducted between April 2015 and March 2016. The survey required perfusionists to answer questions about work volume, scheduling, and employer-paid compensation including benefits. Participants were also required to submit a de-identified pay stub to validate the income they reported. Descriptive statistics were calculated for all survey questions (e.g., percentages, means, and ranges). The study procured 481 responses, of which 287 were validated (i.e., respondents provided income verification that matched reported earnings). Variables that were examined within the validated sample population include job title, type of institution of employment, education level, years of experience, and geographic region, among others. Additional forms of compensation which may affect base compensation rates were also calculated including benefits, call time, bonuses, and pay for ancillary services (e.g., extracorporeal membrane oxygenation and ventricular assist device). In conclusion, in 2015, the average salary for all perfusionists is $127,600 with 19 years' experience. This research explores the average salary within subpopulations based on other factors such as position role, employer type, and geography. Information from this study is presented to guide employer compensation programs and suggests the need for further study in consideration of attrition rates and generational changes (i.e., perfusionists reaching retirement age) occurring alongside the present perfusionist staffing shortage affecting many parts of the country.

[Alternatives to heparin and protamine anticoagulation for cardiopulmonary bypass in cardiac surgery]. / Les différentes alternatives d'anticoagulation au couple héparine/protamine en chirurgie cardiaque sous circulation extra-corporelle.

PURPOSE: Heparin anticoagulation followed by protamine reversal is commonly used in cardiopulmonary bypass (CPB) cardiac procedures, but this strategy has some limitations. The primary objective of this study was to determine the reliable alternatives for anticoagulation during CPB for cardiac surgery. For each drug proposed, the secondary objectives were to outline the main advantages and disadvantages, to propose a therapeutic protocol, and to provide a cost-benefit analysis. SOURCE: A systematic review of the literature was performed between September 2012 and December 2013. It was based on the protocol established by the "Cochrane collaboration Handbook". Twenty articles were analyzed. The Thériaque database from the University Hospital of Grenoble made the economic analysis possible. PRINCIPAL FINDINGS: Seven alternative anticoagulation strategies were considered: danaparoid sodium, lepirudin, argatroban, bivalirudin, ancrod, idraparinux, and EP217609. Danaparoid sodium has issues with individual variability. Several studies (EVOLUTION-ON, CHOOSE-ON) proposed a reliable therapeutic protocol for bivalirudin. Ancrod resulted in an increase in the transfusion of blood products. Direct thrombin inhibitors offer a promising alternative. EP217609 is a synthetic anticoagulant currently undergoing Phase IIa clinical trials. It is an indirect inhibitor of factor Xa, a direct inhibitor of free and bound thrombin, and can be neutralized by avidin. CONCLUSIONS: The ideal anticoagulation strategy for cardiac surgery with CPB does not exist. Heparin and protamine remain the gold standard for anticoagulation therapy. To date, bivalirudin is the most promising molecule despite its high cost and lack of a readily available antagonist.

The fate at mid-term follow-up of the on-pump vs. off-pump coronary artery bypass grafting surgery.

AIMS: To evaluate the fate of on-pump coronary artery bypass grafting (ON-pump CABG) vs. off-pump coronary artery bypass grafting (OP-CABG) surgery at mid-term follow-up. METHODS: From January 2008 to December 2010, 369 patients underwent surgical myocardial revascularization by means of OP-CABG techniques (n = 166) or with ON-pump CABG (n = 203). Data of the two groups of patients were retrospectively analyzed. RESULTS: As compared with OP-CABG, in the ON-pump CABG patients, mean value of Logistic EuroSCORE (8.1 ± 7.8% vs. 6.2 ± 5.9%, P = 0.04), more extended coronary disease (2.7 ± 0.5 vs. 2.5 ± 0.7 diseased vessels/patient, P < 0.001) consequently requiring greater number of grafts/patient (2.9 ± 0.9 vs. 2.3 ± 0.9, P < 0.0001), and emergency surgery (12 vs. 6%, P = 0.03) were more frequently observed. Operative mortality was 1.9% in ON-pump CABG vs. 1.2% in OP-CABG (P = 0.6) and incidence of stroke 2.46 vs. 1.81% (P = 0.7). The incidence of stroke was reduced at 1.2% when OP-CABG PAS-Port 'clamp-less' technique was used.Intraoperatively, costs per patient were higher for OP-CABG vs. ON-pump CABG (1.930,00 +1.050,00 €, if PAS-port system was included, vs. 1.060,00 € for ON-pump surgery). ICU stay (1.9 ± 1.0 days vs. 1.4 ± 0.7 days) and total postoperative in-hospital stay (5.3 ± 3.3 days vs. 5.5 ± 3.5 days) were similar in both groups.At 4 years, survival (91 ± 13% in the ON-pump CABG vs. 84 ± 19% in the OP-CABG), freedom from major adverse cardiac events (composite end-point of all-cause death, myocardial infarction, and repeat coronary revascularization of the target lesion) (82 ± 9% vs. 76 ± 14%), and major adverse cardiac and cerebrovascular events (80 ± 11% vs. 72 ± 16%) were not significantly different. Freedom from late cardiac death was slightly significant higher after ON-pump CABG (98 ± 4% vs. 90 ± 10%, P = 0.05). CONCLUSION: Mid-term freedom from composite end-points is similar after ON-pump CABG and OP-CABG. Freedom from cardiac death appears to be better after ON-pump CABG. OP-CABG needs for more expensive surgical technique. OP-CABG performed by an experienced surgical team using 'clamp-less' techniques can be an effective strategy in reducing postoperative stroke.

On-pump versus off-pump coronary artery bypass surgery: cost-effectiveness analysis alongside a multisite trial.

BACKGROUND: Questions have been raised about the costs and outcomes for patients receiving on-pump and off-pump coronary artery bypass graft surgery. As part of the Department of Veterans Affairs Randomized On/Off Bypass (ROOBY) multisite trial, a cost-effectiveness analysis was performed to compare on-pump versus off-pump patients' quality-adjusted life-years and costs at 1 year. METHODS: One-year outcomes and costs (standardized to 2010 dollars) were estimated in multivariate regression models, controlling for site and baseline patient factors. The 1-year incremental cost-effectiveness analysis ratio with 95% confidence intervals was calculated using bootstrapping. RESULTS: Eighteen centers randomly assigned 2,203 participants to on-pump (n=1,099) versus off-pump (n=1,104) coronary artery bypass graft surgery. Both groups' quality of life improved significantly after surgery (p<0.01) compared with baseline, but no differences were found between treatment groups. Adjusted cost of the index coronary artery bypass graft surgery hospitalization was $36,046 on-pump and $36,536 off-pump (p=0.16). At 1 year, on-pump adjusted cost was $56,023 versus $59,623 off-pump (p=0.046). Off-pump-to-on-pump conversions after first distal anastomosis (4.8%) had significantly higher 1-year costs. Excluding conversions, there were no significant differences between treatments for index hospitalization or 1-year total costs. CONCLUSIONS: At 1 year, off-pump coronary artery bypass graft surgery was more expensive than on-pump when late off-pump-to-on-pump conversions were included. Excluding late conversions, there was no difference in quality-adjusted life-years or costs. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT00032630; http://clinicaltrials.gov/ct2/show/NCT00032630.

Preoperative risk stratification models fail to predict hospital cost of cardiac surgery patients.

BACKGROUND: Preoperative risk stratification models have previously been suggested to predict cardiac surgery unit costs. However, there is a lack of consistency in their reliability in this field. In this study we aim to test the correlation between the values of six commonly known preoperative scoring systems and evaluate their reliability at predicting unit costs of cardiac surgery patients. METHODS: Over a period of 14 months all consecutive adult patients undergoing cardiac surgery on cardiopulmonary bypass were prospectively classified using six preoperative scoring models (EuroSCORE, Parsonnet, Ontario, French, Pons and CABDEAL). Transplantation patients were the only patients we excluded. Total hospital costs for each patient were calculated independently on a daily basis using the bottom up method. The full unit costs were calculated including preoperative diagnostic tests, operating room cost, disposable materials, drugs, blood components as well as costs for personnel and fixed hospital costs. The correlation between hospital cost and the six models was determined by linear regression analysis. Both Spearman's and Pearson's correlation coefficients were calculated from the regression lines. An analysis of residuals was performed to determine the quality of the regression. RESULTS: A total of 887 patients were operated on for CABG (n = 608), valve (n = 142), CABG plus valve (n = 100), thoracic aorta (n = 33) and ventricular assist devices (n = 4). Mean age of the patients was 68.3±9.9 years, 27.6% were female. 30-day mortality rate was 4.1%. Correlation between the six models and hospital cost was weak (Pearson's: r < 0.30; Spearman's: r < 0.40). CONCLUSION: The risk stratification models in this study are not reliable at predicting total costs of cardiac surgical patients. We therefore do not recommend their use for this purpose.

Intraoperative use of low-dose recombinant activated factor VII during thoracic aortic operations.

BACKGROUND: Numerous studies have supported the effectiveness of recombinant activated factor VII (rFVIIa) for the control of bleeding after cardiac procedures; however safety concerns persist. Here we report the novel use of intraoperative low-dose rFVIIa in thoracic aortic operations, a strategy intended to improve safety by minimizing rFVIIa exposure. METHODS: Between July 2005 and December 2010, 425 consecutive patients at a single referral center underwent thoracic aortic operations with cardiopulmonary bypass (CPB); 77 of these patients received intraoperative low-dose rFVIIa (≤60 µg/kg) for severe coagulopathy after CPB. Propensity matching produced a cohort of 88 patients (44 received intraoperative low-dose rFVIIa and 44 controls) for comparison. RESULTS: Matched patients receiving intraoperative low-dose rFVIIa got an initial median dose of 32 µg/kg (interquartile range [IQR], 16-43 µg/kg) rFVIIa given 51 minutes (42-67 minutes) after separation from CPB. Patients receiving intraoperative low-dose rFVIIa demonstrated improved postoperative coagulation measurements (partial thromboplastin time 28.6 versus 31.5 seconds; p=0.05; international normalized ratio, 0.8 versus 1.2; p<0.0001) and received 50% fewer postoperative blood product transfusions (2.5 versus 5.0 units; p=0.05) compared with control patients. No patient receiving intraoperative low-dose rFVIIa required postoperative rFVIIa administration or reexploration for bleeding. Rates of stroke, thromboembolism, myocardial infarction, and other adverse events were equivalent between groups. CONCLUSIONS: Intraoperative low-dose rFVIIa led to improved postoperative hemostasis with no apparent increase in adverse events. Intraoperative rFVIIa administration in appropriately selected patients may correct coagulopathy early in the course of refractory blood loss and lead to improved safety through the use of smaller rFVIIa doses. Appropriately powered randomized studies are necessary to confirm the safety and efficacy of this approach.

Comparing cost aspects of coronary artery bypass graft surgery with coronary artery stenting.

Randomized trials have compared revascularization of coronary artery disease by coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI). CABG is an expensive treatment. However, it manages to improve quality of life, restore general well being, and alleviate symptoms of patients. Coronary stents have improved the safety and durability of PCI. Nonetheless, stenting remains limited by a relatively high in-stent restenosis and thrombosis rate. The costs and cost-effectiveness for these different treatment modalities are relevant issues because cardiovascular disease and its management are prime targets for cost reduction initiatives. There is a debate as to which is the optimal treatment strategy as well as to the cost-effectiveness comparing CABG and PCI. This review provides an overview of cost-effectiveness of CABG compared with PCI. PCI has high costs due to the need for subsequent revascularization procedures, with absence of mortality and survival benefit compared with CABG. Despite the relative lower initial costs of PCI in the first year, PCI is not a cost-effective intervention in comparison with CABG. However, the studies undertaken to date have predominantly been short term and provide a very limited evidence base by which to assess the cost-effectiveness of modern clinical practice. It seems that in longer term, the benefits of CABG may exceed those of stenting and the difference in net cost may be in favour of CABG as the risk of repeat revascularization still increases with PCI regardless of the use of DES. However, to date no long-term data are available in cost-effectiveness between CABG and PCI. The 5-year outcome of the ongoing SYNTAX trial is essential and might therefore provide new insights into the comparison of cost-effectiveness between CABG and DES PCI.

Is a fully heparin-bonded cardiopulmonary bypass circuit superior to a standard cardiopulmonary bypass circuit?

A best-evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Is a fully heparin bonded cardiopulmonary bypass circuit superior to a standard cardiopulmonary bypass circuit?' Altogether more than 792 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated (Table 1). The studies analysed show that perfusion with heparin-coated and heparin-polymer-coated bypass does not increase the risk of adverse effects but reduces blood loss, re-operation rates, ventilation time, length of intensive care unit (ICU) and hospital stay and is also associated with improved biocompatibility, as evidenced by platelet preservation, reduced leucocyte and complement activation, and proinflammatory cytokine production. The various coated circuits have comparable biocompatibility as evaluated by a range of inflammatory markers and clinical outcomes. Three studies documented a significant decrease in post-operative blood loss (P = 0.001-0.54) and a meta-analysis found that perfusion with a heparin-bonded circuit resulted in a reduction in blood transfusion requirements (20%), ventilation time (P < 0.01), length of time in the ICU (P < 0.01) and also hospital stay (P = 0.02). Two studies found reduced levels of polymorphonuclear elastase (P < 0.018-0.001) and two trials concluded that the use of heparin-coated circuits in combination with low-dose systemic heparin (activated clotting time >250) resulted in the greatest clinical benefit and improvement in inflammation. One study documented significant platelet preservation with the use of third-generation heparin-polymer-bonded circuits (P ≤ 0.05). We conclude that despite heparin-bonded and newer third-generation heparin-polymer-bonded cardiopulmonary bypass circuits having a greater cost per person, their improved clinical outcomes and biocompatibility in patients undergoing cardiac surgery make them a preferable option to standard non-heparin-bonded circuits.

Is off-pump coronary artery bypass grafting superior to conventional bypass in octogenarians?

OBJECTIVE: Selected patients appear to benefit from off-pump coronary artery bypass compared with conventional coronary artery bypass with cardiopulmonary bypass. It is unknown whether elderly patients undergoing isolated coronary artery bypass grafting operations derive any benefit when performed off-pump. We hypothesized that off-pump coronary bypass offers a greater operative benefit to elderly patients when compared with conventional coronary artery bypass. METHODS: A total of 1993 elderly patients (age ≥ 80 years) underwent isolated, primary coronary artery bypass graft operations at 16 different statewide centers from 2003 to 2008. Patients were stratified into 2 groups: conventional coronary artery bypass (n = 1589, age = 82.5 ± 2.4 years) and off-pump bypass (n = 404, age = 83.0 ± 2.4 years). Preoperative risk, intraoperative findings, postoperative complications, and costs were evaluated. RESULTS: Patients undergoing off-pump bypass grafting were marginally older (P = .001) and had higher rates of preoperative atrial fibrillation (14.6% vs 10.0%; P = .01) and New York Heart Association class IV heart failure (29.7% vs 21.1%; P < .001) than did those having conventional coronary bypass grafting. Other patient risk factors and operative variables, including Society of Thoracic Surgeons predicted risk of mortality, were similar in both groups (P = .15). Compared with off-pump bypass, conventional coronary bypass incurred higher blood transfusion rates (2.0 ± 1.7 units vs 1.6 ± 1.9 units; P = .05) as well as more postoperative atrial fibrillation (28.4% vs 21.5%; P = .003), prolonged ventilation (14.7% vs 11.4%; P = .05), and major complications (20.1% vs 15.6%; P = .04). Importantly, postoperative stroke (2.6% vs 1.7%; P = .21), renal failure (8.1% vs 6.2%; P = .12), and postoperative length of stay (P = .41) were no different between groups. Despite more complications in patients having conventional bypass, operative mortality (P = .53) and hospital costs (P = .43) were similar to those of patients having off-pump procedures. CONCLUSIONS: Performance of coronary artery bypass grafting among octogenarian patients is safe and effective. Off-pump coronary artery bypass confers shorter postoperative ventilation but equivalent mortality to conventional coronary artery bypass. Off-pump coronary artery bypass was associated with a reduction in the composite incidence of major complications in unadjusted and adjusted analyses and should be considered an acceptable alternative to conventional bypass for myocardial revascularization in elderly patients.

Variations in the application of various perfusion technologies in Great Britain and Ireland--a national survey.

In an attempt to reduce the negative sequelae of cardiopulmonary bypass (CPB), a variety of new technologies have been created. This study investigates variations in the application of these technologies throughout Great Britain and Ireland (GB & I). All perfusion departments within GB & I were surveyed about equipment and technologies used in CPB. Eighty-five percent of units use a standard arterial line filter in all cases. Forty percent of units occasionally use leukocyte-depleting filters in various sites within the circuit. Sixteen percent always use some element of heparin-bonded circuit, but 62% never use them. Twenty-five percent use solely rotary pumps, 18% use solely centrifugal pumps, and 56% use both. Finally, 20% are now using minimal extracorporeal circulation in certain clinical scenarios. These decisions are most frequently affected by clinician preference and cost. This survey has highlighted significant variation in the utilization of various technologies used in CPB. While some variation between centers is to be expected, as innovative technologies are adopted at varying rates, surveys such as this are useful for alerting clinicians to gaps between evidence-based knowledge and clinical practice.

Five years follow-up after Y-graft arterial revascularization: on pump versus off pump; prospective clinical trial.

OBJECTIVES: We report our comparative experience of on-pump and off-pump full arterial coronary artery bypass grafting (CABG) using both internal mammary arteries (IMAs) anastomosed as a Y-graft. METHODS: A single-center clinical study was conducted prospectively between January 2003 and May 2008. It compared the short- and mid-term clinical outcomes of on- and off-pump arterial revascularization where the left internal mammary artery (LIMA) was anastomosed to the left anterior descending (LAD) artery while the free right internal mammary artery (RIMA) graft taking off from the LIMA was used to bypass different coronary targets. RESULTS: One hundred and ninety-two patients were divided into 77 on-pump and 115 off-pump procedures based on the intention to treat. The mean age in both groups was 60.2+/-11.7 and 68.1+/-10.6 years, respectively (P<0.05). Mean predictive logistic EuroSCORE was 3.5+/-6.7% for the on-pump group and 7.3+/-8.6% for the off-pump group (P<0.0001). Mean number of distal anastomoses were 2.7+/-0.6 (group ON) and 2.5+/-0.6 (group OFF) (P=NS). Postoperative mortality was two patients (2.6%) in the on-pump group and four patients (3.4%) in the off-pump group (P=0.63). No major adverse cardiac event, no stroke and no late death were reported during the follow-up that averaged 36.5+/-18.6 months. Angina recurrence was three patients (2.6%) in off-pump and two patients (3.5%) in on-pump group (P=NS). CONCLUSIONS: The use of a free RIMA as Y-graft from the LIMA performed off pump eradicates aortic manipulations and provides complete revascularization to high-risk patients with mortality similar to the one of a lower risk population operated on pump. The morbidity and cost was lower in the off-pump group. This advocates for the widespread usage of the technique in high-risk patients.

Costs associated with hospital-acquired bacteraemia in an Indian hospital: a case-control study.

Studies from around the world have shown that hospital-acquired infections increase the costs of medical care, morbidity and mortality. The aim of this study was to determine cost and attributable mortality associated with hospital-acquired bacteraemia in a tertiary care centre in India. This was a retrospective case-control, cost utility analysis set in the cardiothoracic unit of a 200-bedded tertiary care cardiac hospital. Cases included adult patients who underwent coronary artery bypass graft and/or valve replacement surgery who developed bacteraemia (indicated by positive blood cultures) during postoperative stay (N=24). Controls were age- and sex-matched adult patients who underwent similar procedures but who did not develop bacteraemia (N=48). Data were collected from patient medical records and other administrative databases for cost analysis. Prolongation of hospital stay, attributable mortality and extra costs associated with hospital-acquired bacteraemia were analysed. Statistical analysis was done using Fisher's exact test and unpaired t-test. Patients with hospital-acquired bacteraemia experienced a significantly longer total hospital stay [mean: 22.9 days; 95% confidence interval (CI): 17.2-28.6; P<0.0001], significantly longer ICU stay (mean: 11.3 days; 95% CI: 9.0-13.6; P<0.0001), a significantly higher mortality (mean: 54%; P<0.0001) and cost significantly more (mean: US $14,818; 95% CI: 10,663-18,974; P<0.0001) than controls. We conclude that hospital-acquired bacteraemia significantly increases mortality and costs of hospitalisation in lower income developing countries. Our study demonstrates that costs associated with HAIs are similar between developing and developed countries. Better infection control planning and infrastructure may offset some of these costs.

Minimally invasive, minimally reimbursed? Anesthesia for endoscopic cardiac surgery is not reflected adequately in the german diagnosis-related group system.

OBJECTIVES: In the German diagnosis-related group (G-DRG) system, hospital reimbursement for anesthesia is linked to specific surgical procedures, irrespective of case duration. Accordingly, costs of innovative procedures, such as endoscopic cardiac surgery, may be underreimbursed. The authors assessed to what extent anesthesia costs for endoscopic cardiac surgery are reimbursed with the G-DRG system. DESIGN: Retrospective analysis. SETTING: University hospital. PARTICIPANTS: Eighty-four patients were studied undergoing general anesthesia for minimally invasive endoscopic port-access intracardiac surgery (n = 42) or conventional "open" surgery (n = 42) for similar indications. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors measured anesthesia staffing time, costs, and reimbursement for endoscopic cardiac surgery and compared results with data from a matched group undergoing conventional surgery. Endoscopic surgery increased anesthesia staffing time per case by 521 minutes (977 minutes +/- 177 v 456 +/- 92, mean +/- standard deviation, p = 0.0001) and costs by approximately 200%. Anesthesia duration increased by 152 minutes (503 minutes +/- 89 v 351 +/- 69, p = 0.0001). In contrast, staffing reimbursement did not increase at the time of the patient's surgery (euro500/case [446-569] v 492 [452-508], p = 0.75, median [interquartile range]) or with the 2007 G-DRG matrix (euro548/case [463-559] v 503 [503-568], p = 0.48). Cost recovery was only 66% +/- 17.4% and 72.7 +/- 38.9 in the 2007 G-DRG matrix, respectively. CONCLUSIONS: It was shown that (1) endoscopic cardiac surgery consumed more anesthesia resources and was underreimbursed both relative to actual costs and to conventional surgery, (2) costs for such anesthesia services were inappropriately reflected in the G-DRG system, and (3) a DRG system's inability to adapt timely to innovative procedures may adversely affect anesthesia departments and medical progress.

Economic evaluation of coronary artery bypass grafting surgery with and without cardiopulmonary bypass: cost-effectiveness and quality-adjusted life years in a randomized controlled trial.

The objective of this study is to evaluate the costs and health benefits of coronary artery bypass grafting (CABG) surgery with and without cardiopulmonary bypass (CPB). Randomized controlled clinical trial is used as the design. The setting is in a single tertiary cardiothoracic center in Middlesex, UK. Participants were 168 patients (27 females) requiring primary isolated CABG surgery. Patients were randomized to have the procedure performed by a single surgeon either with CPB (n = 84) or by an off-pump coronary artery bypass (OPCAB) surgery (n = 84). Health-related quality of life was assessed at baseline, 6 weeks, and 6 months using the World Health Organization Quality-of-Life (WHOQOL-100) questionnaire. Mean total costs of patient management by either technique were calculated using different available key sources. A utility measure, derived from WHOQOL-100, was used to calculate quality-adjusted life year (QALY) gained in each group, on basis of which a cost-effectiveness analysis was performed. The mean total costs of an OPCAB patient was 5859 pounds , whereas for a CPB patient it was 7431 pounds with a mean difference of 1572 pounds (standard error [SE] 674 pounds ; P = 0.02). Three patients died in the CPB group and two in the OPCAB group during the 6-month follow-up period. Mean QALYs over 6 months was 0.379 in the OPCAB group and 0.362 in the CPB group, but the difference was not significant (mean difference 0.017; SE 0.016; P = 0.305). OPCAB surgery offered patients in this randomized trial similar health benefits to CPB over a 6-month period, but at a significantly less cost.