Graft Failure After Coronary Artery Bypass Grafting and Its Association With Patient Characteristics and Clinical Events: A Pooled Individual Patient Data Analysis of Clinical Trials With Imaging Follow-Up.

BACKGROUND: Graft patency is the postulated mechanism for the benefits of coronary artery bypass grafting (CABG). However, systematic graft imaging assessment after CABG is rare, and there is a lack of contemporary data on the factors associated with graft failure and on the association between graft failure and clinical events after CABG. METHODS: We pooled individual patient data from randomized clinical trials with systematic CABG graft imaging to assess the incidence of graft failure and its association with clinical risk factors. The primary outcome was the composite of myocardial infarction or repeat revascularization occurring after CABG and before imaging. A 2-stage meta-analytic approach was used to evaluate the association between graft failure and the primary outcome. We also assessed the association between graft failure and myocardial infarction, repeat revascularization, or all-cause death occurring after imaging. RESULTS: Seven trials were included comprising 4413 patients (mean age, 64.4±9.1 years; 777 [17.6%] women; 3636 [82.4%] men) and 13 163 grafts (8740 saphenous vein grafts and 4423 arterial grafts). The median time to imaging was 1.02 years (interquartile range [IQR], 1.00-1.03). Graft failure occurred in 1487 (33.7%) patients and in 2190 (16.6%) grafts. Age (adjusted odds ratio [aOR], 1.08 [per 10-year increment] [95% CI, 1.01-1.15]; P=0.03), female sex (aOR, 1.27 [95% CI, 1.08-1.50]; P=0.004), and smoking (aOR, 1.20 [95% CI, 1.04-1.38]; P=0.01) were independently associated with graft failure, whereas statins were associated with a protective effect (aOR, 0.74 [95% CI, 0.63-0.88]; P<0.001). Graft failure was associated with an increased risk of myocardial infarction or repeat revascularization occurring between CABG and imaging assessment (8.0% in patients with graft failure versus 1.7% in patients without graft failure; aOR, 3.98 [95% CI, 3.54-4.47]; P<0.001). Graft failure was also associated with an increased risk of myocardial infarction or repeat revascularization occurring after imaging (7.8% versus 2.0%; aOR, 2.59 [95% CI, 1.86-3.62]; P<0.001). All-cause death after imaging occurred more frequently in patients with graft failure compared with patients without graft failure (11.0% versus 2.1%; aOR, 2.79 [95% CI, 2.01-3.89]; P<0.001). CONCLUSIONS: In contemporary practice, graft failure remains common among patients undergoing CABG and is strongly associated with adverse cardiac events.

Does prehabilitation before esophagectomy improve postoperative outcomes? A systematic review and meta-analysis.

Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and mental functioning prior to surgery, improves postoperative outcomes. A systematic review and meta-analysis was conducted to evaluate the effect of prehabilitation on post-operative outcomes after esophagectomy. Data sources included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PEDro, with information from 1 January 2000 to 5 August 2023. The analysis included randomized controlled trials and observational studies that compared prehabilitation interventions to standard care prior to esophagectomy. A random effects model was used to generate a pooled estimate for pairwise meta-analysis, meta-analysis of proportions, and meta-analysis of means. A total of 1803 patients were included with 584 in randomized controlled trials (RCTs) and 1219 in observational studies. In the randomized evidence, there were no significant differences between prehabilitation and control in the odds of postoperative pneumonia (15.0 vs. 18.9%, odds ratio (OR) 1.06 [95% confidence interval (CI): 0.66;1.72]) or pulmonary complications (14 vs. 25.6%, OR 0.68 [95% CI: 0.32;1.45]). In the observational data, there was a reduction in both postoperative pneumonia (22.5 vs. 32.9%, OR 0.48 [95% CI: 0.28;0.83]) and pulmonary complications (26.1 vs. 52.3%, OR 0.35 [95% CI: 0.17;0.75]) with prehabilitation. Hospital and intensive care unit length of stay (days), operative mortality, and severe complications (Clavien-Dindo ≥ 3) did not differ between groups in both the randomized data and observational data. Prehabilitation demonstrated reductions in postoperative pneumonia and pulmonary complications in observational studies, but not RCTs. The overall certainty of these findings is limited by the low quality of the available evidence.

Postoperative pericardial effusion, pericardiotomy, and atrial fibrillation: An explanatory analysis of the PALACS trial.

BACKGROUND: In the Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery (PALACS) trial, posterior pericardiotomy was associated with a significant reduction in postoperative atrial fibrillation (POAF) after cardiac surgery. We aimed to investigate the mechanisms underlying this effect. METHODS: We included PALACS patients with available echocardiographic data (n = 387/420, 92%). We tested the hypotheses that the reduction in POAF with the intervention was associated with 1) a reduction in postoperative pericardial effusion and/or 2) an effect on left atrial size and function. Spline and multivariable logistic regression analyses were used. RESULTS: Most patients (n = 307, 79%) had postoperative pericardial effusions (anterior 68%, postero-lateral 51.9%). The incidence of postero-lateral effusion was significantly lower in patients undergoing pericardiotomy (37% vs 67%; P < .001). The median size of anterior effusion was comparable between patients with and without POAF (5.0 [IQR 3.0-7.0] vs 5.0 [IQR 3.0-7.5] mm; P = .42), but there was a nonsignificant trend towards larger postero-lateral effusion in the POAF group (5.0 [IQR 3.0-9.0] vs 4.0 [IQR 3.0-6.4] mm; P = .06). There was a non-linear association between postero-lateral effusion and POAF at a cut-off at 10 mm (OR 2.70; 95% CI 1.13, 6.47; P = .03) that was confirmed in multivariable analysis (OR 3.5, 95% CI 1.17, 10.58; P = 0.02). Left atrial dimension and function did not change significantly after posterior pericardiotomy. CONCLUSIONS: Reduction in postero-lateral pericardial effusion is a plausible mechanism for the effect of posterior pericardiotomy in reducing POAF. Measures to reduce postoperative pericardial effusion are a promising approach to prevent POAF.

Baseline Intraoperative Left Ventricular Diastolic Function Is Associated with Postoperative Atrial Fibrillation after Cardiac Surgery.

BACKGROUND: Detailed understanding of the association between intraoperative left atrial and left ventricular diastolic function and postoperative atrial fibrillation is lacking. In this post hoc analysis of the Posterior Left Pericardiotomy for the Prevention of Atrial Fibrillation after Cardiac Surgery (PALACS) trial, we aimed to evaluate the association of intraoperative left atrial and left ventricular diastolic function as assessed by transesophageal echocardiography (TEE) with postoperative atrial fibrillation. METHODS: PALACS patients with available intraoperative TEE data (n = 402 of 420; 95.7%) were included in this cohort study. We tested the hypotheses that preoperative left atrial size and function, left ventricular diastolic function, and their intraoperative changes were associated with postoperative atrial fibrillation. Normal left ventricular diastolic function was graded as 0 and with lateral e' velocity 10 cm/s or greater. Diastolic dysfunction was defined as lateral e' less than 10 cm/s using E/e' cutoffs of grade 1, E/e' 8 or less; grade, 2 E/e' 9 to 12; and grade 3, E/e' 13 or greater, along with two criteria based on mitral inflow and pulmonary wave flow velocities. RESULTS: A total of 230 of 402 patients (57.2%) had intraoperative diastolic dysfunction. Posterior pericardiotomy intervention was not significantly different between the two groups. A total of 99 of 402 patients (24.6%) developed postoperative atrial fibrillation. Patients who developed postoperative atrial fibrillation more frequently had abnormal left ventricular diastolic function compared to patients who did not develop postoperative atrial fibrillation (75.0% [n = 161 of 303] vs. 57.5% [n = 69 of 99]; P = 0.004). Of the left atrial size and function parameters, only delta left atrial area, defined as presternotomy minus post-chest closure measurement, was significantly different in the no postoperative atrial fibrillation versus postoperative atrial fibrillation groups on univariate analysis (-2.1 cm2 [interquartile range, -5.1 to 1.0] vs. 0.1 [interquartile range, -4.0 to 4.8]; P = 0.028). At multivariable analysis, baseline abnormal left ventricular diastolic function (odds ratio, 2.02; 95% CI, 1.15 to 3.63; P = 0.016) and pericardiotomy intervention (odds ratio, 0.46; 95% CI, 0.27 to 0.78, P = 0.004) were the only covariates independently associated with postoperative atrial fibrillation. CONCLUSIONS: Baseline preoperative left ventricular diastolic dysfunction on TEE, not left atrial size or function, is independently associated with postoperative atrial fibrillation. Further studies are needed to test if interventions aimed at optimizing intraoperative left ventricular diastolic function during cardiac surgery may reduce the risk of postoperative atrial fibrillation.

Does previous asbestos exposure increase the risk of a post coronary artery bypass graft (CABG) pleural effusion - a routine data study?

BACKGROUND: Development of pleural effusion (PE) following CABG is common. Post-CABG PE are divided into early- (within 30 days of surgery) and delayed-onset (30 days-1 year) which are likely due to distinct pathological processes. Some experts suggest asbestos exposure may confer an independent risk for late-onset post-CABG PE, however no large studies have explored this potential association. RESEARCH QUESTION: To explore possible association between asbestos exposure and post-CABG PE using routine data. METHODS: All patients who underwent CABG 01/04/2013-31/03/2018 were identified from the Hospital Episode Statistics (HES) Database. This England-wide population was evaluated for evidence of asbestos exposure, pleural plaques or asbestosis and a diagnosis of PE or PE-related procedure from 30 days to 1 year post-CABG. Patients with evidence of PE three months prior to CABG were excluded, as were patients with a new mesothelioma diagnosis. RESULTS: 68,150 patients were identified, of whom 1,003 (1%) were asbestos exposed and 2,377 (3%) developed late-onset PE. After adjusting for demographic data, Index of Multiple Deprivation and Charlson Co-morbidity Index, asbestos exposed patients had increased odds of PE diagnosis or related procedure such as thoracentesis or drainage (OR 1.35, 95% CI 1.03-1.76, p = 0.04). In those with evidence of PE requiring procedure alone, the adjusted OR was 1.66 (95% CI 1.14-2.40, p = 0.01). Additional subgroup analysis of the 518 patients coded for pleural plaques and asbestosis alone revealed an adjusted OR of post-CABG PE requiring a procedure of 2.16 (95% CI 1.38-3.37, p = 0.002). INTERPRETATION: This large-scale study demonstrates prior asbestos exposure is associated with modestly increased risk of post-CABG PE development. The risk association appears higher in patients with assigned clinical codes indicative of radiological evidence of asbestos exposure (pleural plaques or asbestosis). This association may fit with a possible inflammatory co-pathogenesis, with asbestos exposure 'priming' the pleura resulting in greater propensity for PE evolution following the physiological insult of CABG surgery. Further work, including prospective studies and clinicopathological correlation are suggested to explore this further.

Using Patient Decision Aids for Cardiology Care in Diverse Populations.

PURPOSE OF REVIEW: Patient decision aids (PDAs) are tools that help guide treatment decisions and support shared decision-making when there is equipoise between treatment options. This review focuses on decision aids that are available to support cardiac treatment options for underrepresented groups. RECENT FINDINGS: PDAs have been developed to support multiple treatment decisions in cardiology related to coronary artery disease, valvular heart disease, cardiac arrhythmias, heart failure, and cholesterol management. By considering the unique needs and preferences of diverse populations, PDAs can enhance patient engagement and promote equitable healthcare delivery in cardiology. In this review, we examine the benefits, challenges, and current trends in implementing PDAs, with a focus on improving decision-making processes and outcomes for patients from underrepresented racial and ethnic groups. In addition, the article highlights key considerations when implementing PDAs and potential future directions in the field.

Coronary Artery Bypass Surgery to Treat Anomalous Origin of Coronary Arteries in Adults: A Systematic Review.

OBJECTIVE: To review the available literature on the use of coronary artery bypass grafting (CABG) as a treatment option for anomalous origin of coronary artery in adults. METHODS: A systematic literature search was performed in March 2023 (including Ovid MEDLINE, Ovid Embase, and the Cochrane Library databases) to identify studies reporting the use of CABG in adult patients with anomalous origin of coronary artery. RESULTS: A total of 31 studies and 62 patients were included, 32 patients (52%) were women, and the mean age was 45.1±16.1 years. The most common coronary anomaly was the right coronary artery arising from the left coronary sinus in 26 patients (42%), followed by an anomalous left coronary artery from the pulmonary artery in 23 patients (37%). A total of 65 conduits were used in 61 patients, and 1 case report did not report conduit type. Reported grafts included saphenous vein (23 of 65 [35.4%]), left internal thoracic artery (15 of 65 [23.1%]), right internal thoracic artery (23 of 65 [35.4%]), and radial artery (2 of 65 [3.1%]); right gastroepiploic artery and basilic vein were used once (1.5%) each. Ligation of the native coronary artery was performed in 42 (67.7%) patients. Patient follow-up was available in 19 studies with a mean of 31.2 months. Only 1 operative mortality was reported. CONCLUSIONS: Based on the limited available data, CABG can be performed with good early results. Use of arterial conduits and ligation of the native coronary artery may improve long-term graft patency.

Evaluation of the quality of COVID-19 guidance documents in anaesthesia using the Appraisal of Guidelines for Research and Evaluation II instrument.

BACKGROUND: Guidance documents are a valuable resource to clinicians to guide evidenced-based decision making. The quality of guidelines in anaesthesia and across other specialties has been demonstrated to be poor. COVID-19 presented an urgent need for immediate guidance for anaesthetists as frontline clinicians. The aim of this study was to evaluate the quality of COVID-19 guidance documents using the internationally validated Appraisal of Guidelines for Research & Evaluation (AGREE) II tool. METHODS: A search was conducted in Ovid EMBASE and Ovid MEDLINE to identify all COVID-19 anaesthesia guidance documents from 2020-2021. Thirty-eight guidance documents were selected for analysis by 4 independent appraisers using the AGREE II instrument, across its 6 domains and 23 items. A scoring threshold for high quality was agreed by the working group via consensus. RESULTS: Overall, the body of COVID-19 guidance documents achieved poor scores using AGREE II. Only 5% of documents met the high-quality criteria. Markers of quality included international and multi-institutional collaboration. Document title ('guideline' vs 'consensus statement'/ 'recommendations') did not yield any differences in domain scores and overall quality ratings. Compared with recent general anaesthesia guidelines, COVID-19 guidelines performed significantly worse. CONCLUSIONS: COVID-19 guidance documents published during the first two years of the pandemic lacked rigour and appropriate quality. This raises concern about their trustworthiness for use in clinical practice. Enhanced systems are required to ensure the integrity of rapidly formulated guidance.

"Time is aorta?": Timeliness of surgical repair in type A aortic dissection.

Acute type A aortic dissection is a life-threatening event that requires prompt management, a complex interaction among the timing of aortic surgical repair, presence or absence of organ malperfusion, and surgical outcomes exists. Whether resection of intimal entry tear should be deferred after reversal of malperfusion and end-organ ischemia is a matter of controversy. In fact, the timing of aortic repair should be considered within the clinical presentation and baseline characteristics of each patient. Moreover, every effort should be made to minimize times between symptom onset, diagnosis, and surgery.

On the left or on the right side of the table. Where do you stand?

Being able to perform surgery first-hand represents the backbone of every training program and the key to successful development of the new generation of skilful surgeons. In this issue of the Journal, Comanici et al. presented a thorough systematic summary of the current evidence on the outcomes of cardiothoracic operations performed by trainees. Taking for granted the importance of training young surgeons, it is paramount to identify and tackle any potential obstacles hindering the surgical growth of a trainee.

Octogenarians needing reoperative aortic valve surgery-Does one size fit all?

Early and midterm outcomes, rather than long-term outcomes, are perhaps more relevant in octogenarians undergoing transcatheter aortic valve replacement (TAVR) or redo-surgical aortic valve replacement. Considering that early and midterm outcomes are similar with both the interventions, TAVR appears to be an attractive option in these patients. However, decision-making should consider other factors like presence of porcelain aorta, or severe primary mitral regurgitation among others that may influence the strategy to be adopted. The philosophy of shared decision making, and heart team consultation is, therefore, ever most relevant in these high-risk and vulnerable groups of patients. The recommendations rather than being universal must be individualized based on the type of previous surgery carried out, need for isolated AVR or concomitant surgery, co-morbid conditions, available expertise, and patient choice.

On- versus off-pump CABG in octogenarians: A propensity-matched analysis from the UK National Database.

INTRODUCTION: Coronary artery bypass grafting (CABG) remains a good revascularization strategy in octogenarians with excellent clinical outcomes and quality of life postoperatively. However, the benefits of off-pump over on-pump CABG in the elderly population are still controversial. We investigated this issue in the UK National Audit database. METHOD: We retrospectively analyzed all octogenarians undergoing nonemergency, isolated CABG from 1996 to 2019. Propensity score matching (PSM) was conducted to adjust for imbalance in the baseline characteristics between the off-pump and on-pump groups. Primary outcome was in-hospital mortality and postoperative cerebrovascular accidents. Secondary outcomes were bleeding requiring reoperation, deep sternal wound infection, and postoperative dialysis. RESULT: A total of 6436 patients were included for analysis. No differences were observed between off- and on-pump group in-hospital mortality (4% vs. 3.8%, p = .89), return to theater rate (5.4% vs. 6.2%, p = .16) and incidence of deep sternal wound infection (1.1% vs. 1.6%, p = .34). However, octogenarian undergoing off-pump CABG were less likely to experience postoperative transient ischemic attack (TIA)/stroke (1.4% vs. 2.3%, p = .004) but more likely to require renal dialysis (4.8% vs. 3.5%, p = .03). CONCLUSION: The data show similar in-hospital mortality in octogenarians regardless of the revascularization technique used. Off-pump when compared with on-pump CABG is associated with a lower incidence in postoperative neurological events but a higher need for renal dialysis.

Surgical outcomes of post-infarct ventricular septal defect repair: Insights from the UK national adult cardiac surgery audit database.

OBJECTIVES: Ventricular septal defect (VSD) is becoming a progressively less frequent mechanical complication of myocardial infarction (MI). However, this event is still associated with high operative mortality. We aimed to describe the trends and the risk factors associated with surgical VSD repair outcomes and to provide a clinical benchmark for percutaneous VSD closure strategies. METHODS: Using the UK National Adult Cardiac Surgery Audit database, we identified 1010 patients undergoing surgical VSD repair from 1996 to 2018. The primary outcome was operative mortality. Mixed-model, multivariable logistic regression was used to identify the risk factors associated with operative mortality taking into account the variation related to the centre, the surgeon and the year of the operation. RESULTS: Both the number of surgical VSD repair and the mortality rate did not change significantly over the 23-year timeframe. Operative mortality was 38.9% overall and was higher when patients were operated within the first 6 h (75%) or the first 24 h (61.3%) from the index MI. Risk factors associated with higher odds of mortality were early surgery, older age, cardiogenic shock, renal failure, previous percutaneous coronary intervention and urgent/emergent operations. Moreover, the mortality rate was similar among patients undergoing isolated VSD repair and VSD repaired combined with surgical coronary revascularization alone or with concomitant mitral valve procedures. CONCLUSIONS: Post MI VSD remains a dreaded mechanical complication characterized by high surgical operative mortality. A delayed operation, whenever possible, appears to be the most beneficial strategy to reduce mortality.

Treatment of severe acute mitral regurgitation following thoracoabdominal aortic aneurysm repair.

An asymptomatic 63-year-old male with chronic type B aortic dissection underwent repair of an expanding 6.1 cm extent I thoracoabdominal aortic aneurysm. His postoperative course was complicated by respiratory failure from severe acute mitral regurgitation likely due to papillary muscle rupture, which was corrected with transcatheter MitraClip edge-to-edge repair.

Sex differences in saphenous vein graft patency: A systematic review and meta-analysis.

BACKGROUND: Saphenous vein grafts (SVG) are the most commonly used conduits in coronary artery bypass grafting (CABG). Graft failure is observed in up to 50% of SVG at 10 years after surgery. Whether a difference in SVG patency rates exists between men and women remains unclear. METHODS: We performed a study-level meta-analysis to evaluate sex-related differences in follow-up patency rates of SVG after CABG. A systematic literature search was conducted to identify studies on CABG that reported follow-up SVG patency rates in men and women. The primary outcome was SVG patency rates by sex at follow-up. RESULTS: Seventeen studies totaling 8235 patients and 14,781 SVG grafts were included. There was no significant difference in follow-up SVG patency rates between men and women (incidence rate ratio 0.96, 95% confidence interval 0.90-1.03, p = .24), with mean angiographic follow-up of 33.5 months (standard deviation 29.2). Leave-one-out and cumulative analysis were consistent with the main analysis. We concluded that follow-up SVG patency rate is similar between men and women undergoing CABG.

Mortality after sternal reconstruction with pectoralis major flap vs omental flap for postsurgical mediastinitis: A systematic review and meta-analysis.

BACKGROUND: Deep sternal wound infections are rare but severe complications after median sternotomy and can be managed with sternal reconstruction. The use of pectoralis major flap (PMF) has traditionally been the first-line approach for flap reconstruction but the advantage in patients' survival when compared to the omental flap (OF) transposition is still not clear. We performed a study-level meta-analysis evaluating the association of the type of flap on postoperative outcomes. METHODS: A systematic search of the literature was performed to identify all studies comparing the postoperative outcomes of PMF versus OF for sternal reconstruction. The primary outcome was postoperative mortality. Secondary outcomes were the occurrence of sepsis, pneumonia, operative time, and length of stay. Binary outcomes were pooled using an inverse variance method and reported as odds ratio (OR) with corresponding 95% confidence interval (CI). Continuous outcomes were pooled using an inverse variance method and reported as standardized mean difference (SMD) with corresponding 95% CI. RESULTS: Four studies with a total of 528 patients were included in the analysis. Overall, 443 patients had PMF reconstruction, and 85 patients had OF reconstruction. Baseline characteristics were similar in both groups. There were no statistically significant differences between PMF patients and OF patients in mortality (OR 0.6 [0.16; 2.17]; p = .09), sepsis (OR 1.1 [0.49; 2.47]; p = .43), pneumonia (OR 0.72 [0.18; 2.8]; p = .11), length of stay (SMD -0.59 [-2.03; 0.85]; p < .01), and operative time (SMD 0.08 [-1.21; 1.57]; p < .01). CONCLUSION: Our analysis found no association between the type of flap and postoperative mortality, the incidence of pneumonia, sepsis, operation time, and length of stay.

Females have an increased risk of short-term mortality after cardiac surgery compared to males: Insights from a national database.

OBJECTIVES: Female sex is considered a risk factor for mortality and morbidity following cardiac surgery. This study is the first to review the UK adult cardiac surgery national database to compare outcomes following surgical coronary revascularisation and valvular procedures between females and males. METHODS: Using data from National Adult Cardiac Surgery Audit, we identified all elective and urgent, isolated coronary artery by-pass grafting (CABG), aortic valve replacement (AVR) and mitral valve replacement/repair (MVR) procedures from 2010 to 2018. We compared baseline data, operative data and outcomes of mortality, stroke, renal failure, deep sternal wound infection, return to theater for bleeding, and length of hospital stay. Multivariable mixed-effect logistical/linear regression models were used to assess relationships between sex and outcomes, adjusting for baseline characteristics. RESULTS: Females, compared to males, had greater odds of experiencing 30-day mortality (CABG odd ratio [OR] 1.76, confidence interval [CI] 1.47-2.09, p < .001; AVR OR 1.59, CI 1.27-1.99, p < .001; MVR OR 1.37, CI 1.09-1.71, p = .006). After CABG, females also had higher rates of postoperative dialysis (OR 1.31, CI 1.12-1.52, p < .001), deep sternal wound infections (OR 1.43, CI 1.11-1.83, p = .005) and longer length of hospital stay (ß 1.2, CI 1.0-1.4, p < .001) compared to males. Female sex was protective against returning to theater for postoperative bleeding following CABG (OR 0.76, CI 0.65-0.87, p < .001) and AVR (OR 0.72, CI 0.61-0.84, p < .001). CONCLUSION: Females in the United Kingdom have an increased risk of short-term mortality after cardiac surgery compared to males. This highlights the need to focus on the understanding of the causes behind these disparities and implementation of strategies to improve outcomes in females.

Determinants of outcomes following surgery for type A acute aortic dissection: the UK National Adult Cardiac Surgical Audit.

AIMS: Operability of type A acute aortic dissections (TAAAD) is currently based on non-standardized decision-making process, and it lacks a disease-specific risk evaluation model that can predict mortality. We investigated patient, intraoperative data, surgeon, and centre-related variables for patients who underwent TAAAD in the UK. METHODS AND RESULTS: We identified 4203 patients undergoing TAAAD surgery in the UK (2009-18), who were enrolled into the UK National Adult Cardiac Surgical Audit dataset. The primary outcome was operative mortality. A multivariable logistic regression analysis was performed with fast backward elimination of variables and the bootstrap-based optimism-correction was adopted to assess model performance. Variation related to hospital or surgeon effects were quantified by a generalized mixed linear model and risk-adjusted funnel plots by displaying the individual standardized mortality ratio against expected deaths. Final variables retained in the model were: age [odds ratio (OR) 1.02, 95% confidence interval (CI) 1.02-1.03; P < 0.001]; malperfusion (OR 1.79, 95% CI 1.51-2.12; P < 0.001); left ventricular ejection fraction (moderate: OR 1.40, 95% CI 1.14-1.71; P = 0.001; poor: OR 2.83, 95% CI 1.90-4.21; P < 0.001); previous cardiac surgery (OR 2.29, 95% CI 1.71-3.07; P < 0.001); preoperative mechanical ventilation (OR 2.76, 95% CI 2.00-3.80; P < 0.001); preoperative resuscitation (OR 3.36, 95% CI 1.14-9.87; P = 0.028); and concomitant coronary artery bypass grafting (OR 2.29, 95% CI 1.86-2.83; P < 0.001). We found a significant inverse relationship between surgeons but not centre annual volume with outcomes. CONCLUSIONS: Patient characteristics, intraoperative factors, cardiac centre, and high-volume surgeons are strong determinants of outcomes following TAAAD surgery. These findings may help refining clinical decision-making, supporting patient counselling and be used by policy makers for quality assurance and service provision improvement.

Sex differences in outcomes after coronary artery bypass grafting: a pooled analysis of individual patient data.

AIMS: Data suggest that women have worse outcomes than men after coronary artery bypass grafting (CABG), but results have been inconsistent across studies. Due to the large differences in baseline characteristics between sexes, suboptimal risk adjustment due to low-quality data may be the reason for the observed differences. To overcome this limitation, we undertook a systematic review and pooled analysis of high-quality individual patient data from large CABG trials to compare the adjusted outcomes of women and men. METHODS AND RESULTS: The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), stroke, and repeat revascularization (major adverse cardiac and cerebrovascular events, MACCE). The secondary outcome was all-cause mortality. Multivariable mixed-effect Cox regression was used. Four trials involving 13 193 patients (10 479 males; 2714 females) were included. Over 5 years of follow-up, women had a significantly higher risk of MACCE [adjusted hazard ratio (HR) 1.12, 95% confidence interval (CI) 1.04-1.21; P = 0.004] but similar mortality (adjusted HR 1.03, 95% CI 0.94-1.14; P = 0.51) compared to men. Women had higher incidence of MI (adjusted HR 1.30, 95% CI 1.11-1.52) and repeat revascularization (adjusted HR 1.22, 95% CI 1.04-1.43) but not stroke (adjusted HR 1.17, 95% CI 0.90-1.52). The difference in MACCE between sexes was not significant in patients 75 years and older. The use of off-pump surgery and multiple arterial grafting did not modify the difference between sexes. CONCLUSIONS: Women have worse outcomes than men in the first 5 years after CABG. This difference is not significant in patients aged over 75 years and is not affected by the surgical technique.

Postoperative Atrial Fibrillation and Long-Term Risk of Stroke After Isolated Coronary Artery Bypass Graft Surgery.

BACKGROUND: Postoperative atrial fibrillation (pAF) after coronary artery bypass grafting is a common complication. Whether pAF is associated with an increased risk of cerebrovascular accident (CVA) remains uncertain. We investigated the association between pAF and long-term risk of CVA by performing a post hoc analysis of 10-year outcomes of the ART (Arterial Revascularization Trial). METHODS: For the present analysis, among patients enrolled in the ART (n=3102), we excluded those who did not undergo surgery (n=25), had a history of atrial fibrillation (n=45), or had no information on the incidence of pAF (n=9). The final population consisted of 3023 patients, of whom 734 (24.3%) developed pAF with the remaining 2289 maintaining sinus rhythm. Competing risk and Cox regression analyses were used to investigate the association between pAF and the risk of CVA. RESULTS: At 10 years, the cumulative incidence of CVA was 6.3% (4.6%-8.1%) versus 3.7% (2.9%-4.5%) in patients with pAF and sinus rhythm, respectively. pAF was an independent predictor of CVA at 10 years (hazard ratio, 1.53 [95% CI, 1.06-2.23]; P=0.025) even when CVAs that occurred during the index admission were excluded from the analysis (hazard ratio, 1.47 [95% 1.02-2.11]; P=0.04). CONCLUSIONS: Patients with pAF after coronary artery bypass grafting are at higher risk of CVA. These findings challenge the notion that pAF is a benign complication.