A formalized shared decision-making process with individualized decision aids for older patients referred for cardiac surgery.

BACKGROUND: Comprehension of risks, benefits and alternative treatment options is poor among patients referred for cardiac surgery interventions. We sought to explore the impact of a formalized shared decision-making (SDM) process on patient comprehension and decisional quality among older patients referred for cardiac surgery. METHODS: We developed and evaluated a paper-based decision aid for cardiac surgery within the context of a prospective SDM design. Surgeons were trained in SDM through a Web-based program. We acted as decisional coaches, going through the decision aids with the patients and their families, and remaining available for consultation. Patients (aged ≥ 65 yr) undergoing isolated valve, coronary artery bypass graft (CABG) or CABG and valve surgery were eligible. Participants in the non-SDM phase followed standard care. Participants in the SDM group received a decision aid following cardiac catheterization, populated with individualized risk assessment, personal profile and comorbidity status. Both groups were assessed before surgery on comprehension, decisional conflict, decisional quality, anxiety and depression. RESULTS: We included 98 patients in the SDM group and 97 in the non-SDM group. Patients who received decision aids through a formalized SDM approach scored higher in comprehension (median 15.0, interquartile range [IQR] 12.0-18.0) than those who did not (median 9.0, IQR 7.0-12.0, p < 0.001). Decisional quality was greater in the SDM group (median 82.0, IQR 73.0-91.0) than in the non-SDM group (median 76.0, IQR 62.0-82.0, p < 0.05). Decisional conflict scores were lower in the SDM group (mean 1.76, standard deviation [SD] 1.14) than in the non-SDM group (mean 5.26, SD 1.02, p < 0.05). Anxiety and depression scores showed no significant difference between groups. CONCLUSION: Institution of a formalized SDM process including individualized decision aids improved comprehension of risks, benefits and alternatives to cardiac surgery, as well as decisional quality, and did not result in increased levels of anxiety.

Endocarditis is not an Independent Predictor of Blood Transfusion in Aortic Valve Replacement Patients With Severe Aortic Regurgitation.

OBJECTIVE: This study sought to evaluate if the presence of endocarditis was independently associated with increased perioperative blood transfusion in patients undergoing aortic valve replacements (AVR) with aortic regurgitation. DESIGN: This was a retrospective study. SETTING: Large Canadian tertiary care hospital. PARTICIPANTS: Six hundred sixty-two consecutive patients with aortic regurgitation score of 3 or higher undergoing AVR from 1995 to 2012. INTERVENTIONS: No interventions were performed in this retrospective study. MEASUREMENTS AND MAIN RESULTS: After REB approval, data were obtained from a center-specific database. Univariate analysis was performed to identify variables that may be associated with transfusion of any allogeneic blood product perioperatively. A multivariate logistic regression was generated to identify independent predictors of perioperative transfusion. Unadjusted transfusion rates in patients with no endocarditis and with endocarditis were 32% and 70% (p<0.001), respectively. Independent predictors of any transfusion were moderate-to-severe preoperative anemia, preoperative renal failure, non-isolated AVR, age>70, urgent/emergent surgery, BMI<25, and female sex. Endocarditis was not an independent predictor of transfusion (OR = 0.748; 95% CI = 0.35-1.601). CONCLUSIONS: In patients undergoing AVR, unadjusted perioperative transfusion rates were higher when endocarditis was present. However, after adjustment, aortic valve endocarditis was not independently associated with blood transfusion. The authors' observation could be explained by the higher prevalence of many independent predictors of transfusion, such as comorbidities or more complex surgery, within the endocarditis group. Thus, AV endocarditis, in the absence of other risk factors, was not associated with increased perioperative transfusion risk.

Does more than a single chest tube for mediastinal drainage affect outcomes after cardiac surgery?

BACKGROUND: The use of 1 or more mediastinal chest tubes has traditionally been routine for all cardiac surgery procedures to deal with bleeding. However, it remains unproven whether multiple chest tubes offer a benefit over a single chest tube. METHODS: All consecutive patients undergoing cardiac surgery (2005-2010) received at least 1 chest tube at the time of surgery based on surgeon preference. Patients were grouped into those receiving a single chest tube (SCT) and those receiving multiple chest tubes (MCT). The primary outcome was return to the operating room for bleeding or tamponade. RESULTS: A total of 5698 consecutive patients were assigned to 2 groups: 3045 to the SCT and 2653 to the MCT group. Patients in the SCT group were older, more often female and less likely to undergo isolated coronary artery bypass graft than those in the MCT group. Unadjusted outcomes for SCT and MCT, respectively, were return to the operating room for bleeding or tamponade (4.7% v. 5.0%; p = 0.50), intensive care unit stay longer than 48 hours (25.5% v. 27.9%; p = 0.041, postoperative stay > 9 days (31.5% v. 33.1%; p = 0.20) and mortality (3.8% v. 4.6%; p = 0.16). Logistic regression analysis, adjusted for clinical differences between groups, showed that the number of chest tubes was not associated with return to the operating room for bleeding or tamponade. CONCLUSION: The use of multiple mediastinal chest tubes after cardiac surgery confers no advantage over a single chest tube in preventing return to the operating room for bleeding or tamponade.

The risks associated with aprotinin use: a retrospective study of cardiac cases in Nova Scotia.

PURPOSE: In light of the concerns about the safety of aprotinin, we wanted to determine if aprotinin use during cardiac surgery was associated with an increased risk of mortality and morbidity compared with the use of tranexamic acid (TXA). We hypothesized that use of aprotinin is associated with a higher risk of adverse outcomes than use of TXA in our patient population. METHODS: In this retrospective study at a single surgical centre, we examined primary in-hospital outcomes of postoperative mortality, new acute renal failure, and perioperative blood transfusion, and we also investigated secondary outcomes of stroke, infection, and prolonged stay in the intensive care unit (ICU). The effect of the type of antifibrinolytic on outcome was evaluated for aprotinin cases matched 1:1 with TXA cases using propensity score. RESULTS: This study included 3,340 patients who received antifibrinolytics during cardiac surgery (376 patients received aprotinin and 2,964 patients received TXA). Patients who received aprotinin were more often elderly and female; they were more commonly presented with congestive heart failure, atrial fibrillation, renal failure, and lower hemoglobin, and they underwent complex and/or urgent surgery. In the matched sample, in-hospital mortality was significantly higher in the aprotinin group (10.9%) compared with the TXA group (5.9%), and ICU stay >72 hr was significantly increased in the aprotinin group (30.0%) compared with the TXA group (21.7%). There was no significant difference in blood product administration between the two groups. CONCLUSIONS: Aprotinin was associated with an increased risk of in-hospital mortality and morbidity following cardiac surgery, and aprotinin was not associated with a decrease in blood product requirements. Continued use of aprotinin in cardiac surgery should follow careful consideration, weighing the demonstrated risks and potential advantages compared with other TXA.

New onset postoperative atrial fibrillation is associated with a long-term risk for stroke and death following cardiac surgery.

BACKGROUND AND AIM: We sought to evaluate the long-term impact of post-cardiac surgery atrial fibrillation on the risk of stroke and survival. METHODS: Patients undergoing isolated CABG surgery from April 1, 1995 to March 31, 2007 were identified (n = 8058). Long-term stroke data were compiled using Cox modeling adjusted for clinical characteristics comparing patients with new-onset atrial fibrillation (NwAfib) and those without. RESULTS: NwAfib developed in 2214 patients (27.5%). Overall in-hospital mortality was 2.4% and was not different between groups. Unadjusted in-hospital outcomes suggest patients with NwAfib were more likely to suffer a permanent stroke (1% vs 2.5%; p < 0.001) require prolonged mechanical ventilation (p < 0.001) and prolonged stay in hospital (p < 0.001). After discharge patients were followed for a mean of 5.7 years. Stroke was reported in 268 (12.1%) patients in the NwAfib group compared to others (8.4%). After adjustment NwAfib was independently associated with a higher risk for stroke with a hazard ratio of 1.26 (1.08-1.47; p = 0.0034) and a higher risk of death with a hazard ratio of 1.2 (1.08-1.32; p = 0.0007). CONCLUSIONS: Patients with NwAfib perioperatively have increased risk of stroke and early death after discharge independent of other clinical risk factors.

Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery.

BACKGROUND: Frailty is an emerging concept in medicine yet to be explored as a risk factor in cardiac surgery. Where elderly patients are increasingly referred for cardiac surgery, the prevalence of a frail group among these is also on the rise. We assessed frailty as a risk factor for adverse outcomes after cardiac surgery. METHODS AND RESULTS: Functional measures of frailty and clinical data were collected prospectively for all cardiac surgery patients at a single center. Frailty was defined as any impairment in activities of daily living (Katz index), ambulation, or a documented history of dementia. Of 3826 patients, 157 (4.1%) were frail. Frail patients were older, were more likely to be female, and had risk factors for adverse surgical outcomes. By logistic regression, frailty was an independent predictor of in-hospital mortality (odds ratio 1.8, 95% CI 1.1 to 3.0), as well as institutional discharge (odds ratio 6.3, 95% CI 4.2 to 9.4). Frailty was an independent predictor of reduced midterm survival (hazard ratio 1.5, 95% CI 1.1 to 2.2). CONCLUSIONS: Frailty is a risk for postoperative complications and an independent predictor of in-hospital mortality, institutional discharge, and reduced midterm survival. Frailty screening improves risk assessment in cardiac surgery patients and may identify a subgroup of patients who may benefit from innovative processes of care.

Should all patients be treated with an angiotensin-converting enzyme inhibitor after coronary artery bypass graft surgery? The impact of angiotensin-converting enzyme inhibitors, statins, and ß-blockers after coronary artery bypass graft surgery.

BACKGROUND: We sought to evaluate the association between angiotensin-converting enzyme (ACE) inhibitors and outcomes after coronary artery bypass graft surgery (CABG). METHODS: Postoperative outpatient utilization of ACE inhibitors, statins, and ß-blockers was assessed in a cohort of 3,718 patients after CABG 65 years and older. The primary outcome was freedom from a composite of all-cause mortality or hospital readmission for cardiac events or procedures. RESULTS: Use of all 3 medication classes increased significantly over the study period. Female patients and patients with a history of myocardial infarction, diabetes, and poor left ventricular function were independently associated with ACE inhibitor use on multivariate analysis (all P < .05). At a median follow-up of 3 years, postoperative therapy with an ACE inhibitor had no effect on death or rehospitalization for cardiovascular events (adjusted hazard ratio [HR] 1.12, 95% CI 0.96-1.30, P = .16). However, statins (HR 0.65, 95% CI 0.57-0.74, P < .0001) and ß-blockers (HR 0.83, 95% CI 0.74-0.93, P = .001) were associated with a significantly improved event-free survival. CONCLUSIONS: Among patients after CABG 65 years or older, ACE inhibitors had no independent effect on mortality or recurrent ischemic events in the midterm after CABG, although a benefit was observed for statins and ß-blockers.

Delirium as a predictor of sepsis in post-coronary artery bypass grafting patients: a retrospective cohort study.

INTRODUCTION: Delirium is the most common neurological complication following cardiac surgery. Much research has focused on potential causes of delirium; however, the sequelae of delirium have not been well investigated. The objective of this study was to investigate the relationship between delirium and sepsis post coronary artery bypass grafting (CABG) and to determine if delirium is a predictor of sepsis. METHODS: Peri-operative data were collected prospectively on all patients. Subjects were identified as having agitated delirium if they experienced a short-term mental disturbance marked by confusion, illusions and cerebral excitement. Patient characteristics were compared between those who became delirious and those who did not. The primary outcome of interest was post-operative sepsis. The association of delirium with sepsis was assessed by logistic regression, adjusting for differences in age, acuity, and co-morbidities. RESULTS: Among 14,301 patients, 981 became delirious and 227 developed sepsis post-operatively. Rates of delirium increased over the years of the study from 4.8 to 8.0% (P = 0.0003). A total of 70 patients of the 227 with sepsis, were delirious. In 30.8% of patients delirium preceded the development of overt sepsis by at least 48 hours. Multivariate analysis identified several factors associated with sepsis, (receiver operating characteristic (ROC) 79.3%): delirium (odds ratio (OR) 2.3, 95% confidence interval (CI) 1.6 to 3.4), emergent surgery (OR 3.3, CI 2.2 to 5.1), age (OR 1.2, CI 1.0 to 1.3), pre-operative length of stay (LOS) more than seven days (OR 1.6, CI 1.1 to 2.3), pre-operative renal insufficiency (OR 1.9, CI 1.2 to 2.9) and complex coronary disease (OR 3.1, CI 1.8 to 5.3). CONCLUSIONS: These data demonstrate an association between delirium and post-operative sepsis in the CABG population. Delirium emerged as an independent predictor of sepsis, along with traditional risk factors including age, pre-operative renal failure and peripheral vascular disease. Given the advancing age and increasing rates of delirium in the CABG population, the prevention and management of delirium need to be addressed.

Long-term results of heart operations performed by surgeons-in-training.

BACKGROUND: We investigated the association between trainees performing supervised operations and late outcomes of patients undergoing cardiac surgery. METHODS AND RESULTS: Data were prospectively collected on patients who underwent coronary artery bypass graft surgery, aortic valve replacement, or a combination of these between 1998 and 2005 at the Maritime Heart Center, Halifax, Canada. In-hospital mortality and a composite outcome of in-hospital mortality, stroke, bleeding, intra-aortic balloon pump insertion, renal failure, and sternal infection was compared between teaching (n=1054) and nonteaching cases (n=5877). Late survival and cardiovascular hospital readmissions were also examined. To adjust for baseline risk disparities, we used logistic regression for dichotomous in-hospital outcomes and Cox proportional hazards regression for survival data. Resident cases were significantly more likely to have high-risk features such as depressed ventricular function, redo operation, and urgent or emergent procedure. Resident as primary operator was not independently associated with in-hospital mortality (OR, 1.09; 95% CI, 0.75 to 1.58; P=0.66) or with the composite outcome (OR, 1.01; 95%, CI 0.82 to 1.26; P=0.90). The Kaplan-Meier event-free survival of the 2 groups was equivalent at 1, 3, and 5 years (log-rank P=0.06). By Cox regression, resident cases were not associated with late death or cardiovascular rehospitalization (hazard ratio, 1.05; 95% CI, 0.94 to 1.17; P=0.42). CONCLUSIONS: Cases performed by senior-level cardiac surgery residents were more likely to have greater acuity and complexity than staff surgeon-performed cases. However, clinical outcomes were similar in the short- and long-term. Allowing residents to perform cardiac surgery is not associated with adverse patient outcomes.

Versatility of hemisternotomy for cardiac surgery.

BACKGROUND: Hemisternotomy has been suggested as a way to reduce morbidity by limiting the invasiveness of surgical interventions but it is often limited to aortic valve disease. This study reviews the experience of one center employing hemisternotomy and compares patient outcomes, both in-hospital and post-discharge, with a matched group of full sternotomy patients. METHODS: Propensity scores were used to match all hemisternotomy valve cases (Hemi) to full sternotomy valve cases (Full) (1:2). An in-hospital composite outcome (COMP) was defined as mortality, stroke, deep sternal wound infection, sepsis, or return to operating room (OR) for bleeding or valve dysfunction. Provincial administrative health databases were used to determine freedom from mortality and hospital readmission for cardiac cause. RESULTS: During the study period, 70 patients received hemisternotomy for various cardiac surgical interventions with only 38 patients undergoing isolated aortic valve replacement. Examining valve surgery exclusively, 65 Hemi were matched to 130 Full. In-hospital complications were low in both groups, with 1.0% mortality and a non-significant trend toward COMP in the Full group (Hemi=4.6%; Full=8.5%; p=0.39). Ventilation time was significantly decreased in Hemi (median four vs. six hours; p=0.002). At two years follow-up, survival was excellent for both (Hemi=95.0%; Full=93.6%) and freedom from cardiac morbidity (Hemi=76.8%, Full=73.2%) was comparable. CONCLUSION: Hemisternotomy appears to be a safe, effective, and versatile alternative for many cardiac surgical interventions. With a median follow-up of four years, this study represents the longest cardiac morbidity follow-up for hemisternotomy patients. However, we were unable to conclusively show a morbidity benefit with this incision.

Recovery free of heart failure after acute coronary syndrome and coronary revascularization.

AIMS: Previous studies have examined risk factors for the development of heart failure (HF) subsequent to acute coronary syndrome (ACS). Our study seeks to clarify the clinical variables that best characterize patients who remain free from HF after coronary artery bypass grafting (CABG) surgery for ACS to determine novel biological factors favouring freedom from HF in prospective translational studies. METHODS AND RESULTS: Nova Scotia residents (1995-2012) undergoing CABG within 3 weeks of ACS were included. The primary outcome was freedom from readmission to hospital due to HF. Descriptive statistics were generated, and a Cox proportional hazards model assessed outcome with adjustment for clinical characteristics. Of 11 936 Nova Scotians who underwent isolated CABG, 3264 (27%) had a recent ACS and were included. Deaths occurred in 210 (6%) of subjects prior to discharge. A total of 3054 patients were included in the long-term analysis. During follow-up, HF necessitating readmission occurred in 688 (21%) subjects with a hazard ratio of 12% at 2 years. The adjusted Cox model demonstrated significantly better freedom from HF for younger, male subjects without metabolic syndrome and no history of chronic obstructive pulmonary disease, renal insufficiency, atrial fibrillation, or HF. CONCLUSIONS: Our findings have outlined important clinical variables that predict freedom from HF. Furthermore, we have shown that 12% of patients undergoing CABG after ACS develop HF (2 years). Our findings support our next phase in which we plan to prospectively collect blood and tissue specimens from ACS patients undergoing CABG in order to determine novel biological mechanism(s) that favour resolution of post-ACS inflammation.

Medium-term outcomes of coronary artery bypass graft surgery on pump versus off pump: results from a randomized controlled trial.

BACKGROUND: Despite the proposed advantages of off-pump coronary artery bypass graft (CABG) surgery, some controversy remains as to its advantages compared with on-pump CABG. The present study evaluates medium-term outcomes from patients that have been randomized to CABG surgery performed on pump versus off pump. METHODS: All consecutive patients enrolled into a previously completed randomized trial comparing CABG surgery performed on (n = 150) versus off (n = 150) pump were included. The analysis was performed on an intention-to-treat basis. The outcomes of interest were all-cause mortality and readmission to hospital for cardiac reason. RESULTS: The in-hospital outcomes were excellent in both groups with a mortality rate of 0.7% in the on-pump versus 1.3% in the off-pump group (P = .56). Median follow-up was 3.8 years (interquartile range, 3.4-4.4 years) with 1 patient lost to follow-up (99% complete). There were 12 late deaths, 8 in the off-pump group and 4 in the on-pump group, which were not statistically different between groups (P = .23) and resulted in a greater than 90% survival at 4 years. Freedom from readmission to hospital for cardiac cause was not statistical different between the 2 groups with 70% event-free survival at 4 years. Multivariate analysis failed to identify the type of procedure (on vs off pump) as an independent predictor of adverse cardiovascular event (mortality + readmission to hospital). CONCLUSIONS: We have shown that in patients randomized to CABG surgery performed on pump versus off pump, excellent medium-term results can be obtained with either technique. We have been unable to demonstrate that one technique is superior to the other.

The impact of new-onset atrial fibrillation on in-hospital mortality following cardiac surgery.

BACKGROUND: The impact of new-onset postoperative atrial fibrillation (NAF) on in-hospital mortality (IHM) following cardiac surgery is unknown. METHODS: All patients without preoperative atrial fibrillation undergoing isolated coronary artery bypass graft surgery (CABG) and concomitant CABG and valve surgery were identified (n = 7,347). The association between NAF and IHM was determined using logistic regression modeling. Also, propensity score analysis was used to create two matched subgroups of patients with and without NAF (n = 2,015 in each group). The secondary outcomes examined were stroke, myocardial infarction (MI), intra-aortic balloon pump use, GI complications, deep sternal wound infection (DSWI), septicemia, renal failure, and length of stay. RESULTS: NAF developed in 2,047 patients (27.9%). NAF was not an independent predictor of IHM (odds ratio, 0.8; 95% confidence interval, 0.6 to 1.2; p = 0.3). In multivariate analysis, NAF was associated with age >/= 60 years, combined procedures, preoperative MI within 7 days of surgery, COPD, cerebrovascular disease, and male gender. Propensity-adjusted results revealed no difference in IHM between NAF vs no-NAF patients (2.9% vs 3.5%, respectively; Bonferroni-corrected p = 0.99). However, GI complications (4.2% vs 2.1%), DSWI (1.3% vs 0.4%), septicemia (4.0% vs 1.1%), renal failure (7.6% vs 4.3%), and length of stay (8 days vs 6 days) were significantly increased in patients with NAF. CONCLUSION: NAF following cardiac surgery is not associated with increased IHM.

Long-term outcomes in patients requiring stay of more than 48 hours in the intensive care unit following coronary bypass surgery.

BACKGROUND: The primary objective of this study was to determine the long-term outcomes of all patients requiring prolonged intensive care unit (ICU) stay following coronary bypass surgery (CABG) surgery. METHODS: All patients undergoing CABG surgery between 1998 and 2002 were reviewed. Prolonged ICU stay was defined as more than 48 hours. Short-term (in-hospital) and long-term (postdischarge) outcomes were evaluated using available databases. RESULTS: Of 3139 patients who underwent CABG surgery, 598 required an ICU stay of more than 48 hours (19%). The in-hospital mortality for patients requiring prolonged ICU stay was 10.0% as compared with 1.2% for the remainder of patients (P < .0001). The median length of hospitalization for patients requiring prolonged stay was 11 days (IQR 7-18) as compared to 6 days (IQR 5-7). The median follow-up of patients who survived to discharge was 31 months with a 100% follow-up. Using Cox proportional hazard ratio, patients who required a prolonged ICU stay were found to have a significant lower survival and freedom from cardiac readmission to the hospital. Prolonged ICU stay was an independent predictor of composite outcome (death + readmission) with a hazard ratio of 1.8 (1.5-2.1). CONCLUSIONS: Prolonged ICU stay following CABG resulted in increased early and late mortality and lower freedom from readmission to hospital for cardiac reasons.

The impact of diffuseness of coronary artery disease on the outcomes of patients undergoing primary and reoperative coronary artery bypass grafting.

OBJECTIVE: Diffuse coronary artery disease jeopardizes myocardium, increasing surgical mortality in primary coronary artery bypass grafting (CABG). We sought to determine the impact of diffuseness on pre- and post-discharge outcomes for both primary and reoperative CABG (REOP). METHODS: Using a validated system for measuring diffuseness of coronary disease, preoperative angiograms were scored for primary CABG (n=792) and REOP cases (n=268) performed 1997-2004. A diffuseness score (DS)>18 was defined as elevated. In-hospital mortality, intermediate-term survival, and in-hospital composite outcome (COMP) (one or more of: mortality, stroke, MI, deep sternal infection, sepsis, IABP insertion, or return to OR) were examined. RESULTS: In-hospital mortality and COMP for patients with DS>18 were significantly higher (7.9% vs 2.4%, p<0.0001), (17.8% vs 9.2%, p<0.0001). DS (mean+/-SD) was higher in REOP cases than primary CABG (18.9+/-7.1 vs 14.4+/-6.0, p<0.0001). By multivariate analysis, DS>18 (OR 2.00, 95%CI, 1.20-3.32, p=0.008) and REOP (OR 2.40, 95%CI, 1.53-3.77, p<0.0001) were independently associated with COMP. Using propensity scores 82% of cases with DS>18 (n=289) were matched 1:1 to cases with DS18 (6.9% vs 2.8%, p=0.02), (16.6% vs 10.4%, p=0.03). Comparing cases with DS18 and primary CABG versus REOP, survival at 2 years was 92.1% versus 84.5% (p=0.001) and 92.7% versus 82.7% (p<0.0001), respectively. CONCLUSIONS: Diffuse coronary artery disease is an important predictor of morbidity and mortality in primary and REOP CABG patients, and should be considered in both individual patient assessment and risk adjustment.

Cardiac troponin T is an important predictor of mortality after cardiac surgery.

PURPOSE: Serum troponin (cTnT) levels, a commonly measured biomarker of myocardial injury, has rarely been considered in risk models after cardiac surgery. MATERIALS AND METHODS: Retrospective study of patients undergoing any cardiac surgery between 2004 and 2012. Patients with a history of recent myocardial injury (<21 days) were excluded. The minimum P value approach was used to determine categories of peak cTnT associated with in-hospital death. A multivariable analysis was performed to identify independent predictors of mortality. RESULTS: A total of 5318 patients without evidence of preoperative ischemia underwent a number of cardiac surgical interventions ranging from isolated coronary revascularization to combined valve coronary artery bypass grafting. The unadjusted in-hospital mortality rate was 3.3% (n = 175 patients). Four categories of peak cTnT were identified using the minimum P value approach: less than or equal to 0.6 ng/mL, 0.7 to 1.9 ng/mL, 2.0 to 3.1 ng/mL, and greater than 3.1 ng/mL with unadjusted mortality rates of 1.0%, 3.6%, 10.1%, and 33.1%, respectively. Multivariate logistic regression demonstrated that all peak cTnT levels greater than 0.6 ng/mL were independent predictors of in-hospital mortality in a dose-dependent manner. CONCLUSIONS: We demonstrate that in patients without preoperative myocardial ischemia, the demonstration of myocardial injury (>0.6 ng/mL) in the postoperative period is highly predictive of in-hospital death.

Toward Optimal Decision Making among Vulnerable Patients Referred for Cardiac Surgery: A Qualitative Analysis of Patient and Provider Perspectives.

OBJECTIVES: Comprehension of risks, benefits, and alternative treatment options has been shown to be poor among patients referred for cardiac interventions. Patients' values and preferences are rarely explicitly sought. An increasing proportion of frail and older patients are undergoing complex cardiac surgical procedures with increased risk of both mortality and prolonged institutional care. We sought input from patients and caregivers to determine the optimal approach to decision making in this vulnerable patient population. METHODS: Focus groups were held with both providers and former patients. Three focus groups were convened for Coronary Artery Bypass Graft (CABG), Valve, or CABG +Valve patients ≥ 70 y old (2-y post-op, ≤ 8-wk post-op, complicated post-op course) (n = 15). Three focus groups were convened for Intermediate Medical Care Unit (IMCU) nurses, Intensive Care Unit (ICU) nurses, surgeons, anesthesiologists and cardiac intensivists (n = 20). We used a semi-structured interview format to ask questions surrounding the informed consent process. Transcribed audio data was analyzed to develop consistent and comprehensive themes. RESULTS: We identified 5 main themes that influence the decision making process: educational barriers, educational facilitators, patient autonomy and perceived autonomy, patient and family expectations of care, and decision making advocates. All themes were influenced by time constraints experienced in the current consent process. Patient groups expressed a desire to receive information earlier in their care to allow time to identify personal values and preferences in developing plans for treatment. Both groups strongly supported a formal approach for shared decision making with a decisional coach to provide information and facilitate communication with the care team. CONCLUSIONS: Identifying the barriers and facilitators to patient and caretaker engagement in decision making is a key step in the development of a structured, patient-centered SDM approach. Intervention early in the decision process, the use of individualized decision aids that employ graphic risk presentations, and a dedicated decisional coach were identified by patients and providers as approaches with a high potential for success. The impact of such a formalized shared decision making process in cardiac surgery on decisional quality will need to be formally assessed. Given the trend toward older and frail patients referred for complex cardiac procedures, the need for an effective shared decision making process is compelling.

Surgical management of infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: Although retrospective reviews evaluating the surgical management of infective endocarditis (IE) have been conducted in Europe and in the USA, few data exist regarding management of the condition in Canada. The study aim was to evaluate the surgical management of individuals with culture-positive active IE at a Canadian tertiary care university hospital. METHODS: A retrospective analysis was performed of 74 patients (53 males, 21 females; mean age 56 +/- 14 years) with a preoperative diagnosis of acute IE between 1995 and 2003 at the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia. Preoperative clinical variables evaluated included the Duke criteria for endocarditis, correlation between preoperative echocardiographic imaging and intraoperative findings, and postoperative morbidity and mortality. RESULTS: Native valve endocarditis (NVE) was present in 60 patients, and prosthetic valve endocarditis (PVE) in 14. All patients met the Duke criteria for endocarditis. Correlation between preoperative transesophageal echocardiography (TEE) and surgical findings (vegetations 63%, abscesses 96%, leaflet perforation 100%) was superior when compared with preoperative transthoracic echocardiography (vegetations 43%, abscesses 75%, leaflet perforation 89%). There were low rates of postoperative morbidity (reoperation 8%, stroke 5%). Overall in-hospital mortality was 14% (seven NVE, 12%; three PVE, 21%). CONCLUSION: Herein is presented the largest and most current case series of patients treated surgically for active IE. The results demonstrate excellent agreement between preoperative TEE and intraoperative surgical findings in the current era of surgical management of this condition.

Unequal access to interventional cardiac care in Nova Scotia in patients with acute myocardial infarction complicated by cardiogenic shock.

BACKGROUND: The optimal treatment of cardiogenic shock (CS) complicating acute myocardial infarction (AMI) remains controversial and continues to be associated with a high mortality rate. The present study evaluated the outcomes of all patients having AMI complicated by CS in a single Canadian province. METHODS: All consecutive patients diagnosed with AMI and CS from October 1997 to December 2002 in Nova Scotia were included in the present study. The Improving Cardiac Outcomes in Nova Scotia (ICONS) registry was used as the principal source of data. The outcome of interest was in-hospital mortality. RESULTS: During the study period, a total of 11,300 patients with AMI were identified, with 707 complicated by CS, for an incidence of AMI+CS of 6.3%. The overall mortality rate for patients with AMI+CS was 60.1%. Multivariate regression analysis identified age older than 65 years (OR 2.0; 95% CI 1.4 to 2.9) and renal insufficiency (OR 2.1; 95% CI 1.4 to 3.2) as independent predictors of mortality, while access to invasive cardiac care (defined as admission or transfer to the only cardiac catheterization-capable centre in Halifax, Nova Scotia) was found to be an independent predictor of survival (OR 0.4; 95% CI 0.3 to 0.5). Access to invasive cardiac care was limited to 414 (59%) patients, 250 (35%) of whom actually underwent cardiac catheterization. CONCLUSIONS: Admissions to a tertiary care centre that can provide invasive care was independently associated with improved survival, and older age and renal insufficiency were associated with death among patients with AMI and CS.

Creation of a Scorecard to Predict In-Hospital Death in Patients Undergoing Operations for Acute Type A Aortic Dissection.

BACKGROUND: This study evaluated preoperative predictors of in-hospital death for the surgical treatment of patients with acute type A aortic dissection (Type A) and created an easy-to-use scorecard to predict in-hospital death. METHODS: We reviewed retrospectively all consecutive patients who underwent operations for acute Type A between 1996 and 2011 at 2 tertiary care institutions. A logistic regression model was created to identify independent preoperative predictors of in-hospital death. The results were used to create a scorecard predicting operative risk. RESULTS: Emergency operations were performed in 534 consecutive patients for acute Type A. Mean age was 61 ± 14 years and 36.3% were women. Critical preoperative state was present in 31% of patients and malperfusion of one or more end organs in 36%. Unadjusted in-hospital mortality was 18.7% and not significantly different between institutions. Independent predictors of in-hospital death were age 50 to 70 years (odds ratio [OR], 3.8; p = 0.001), age older than 70 years (OR, 2.8; p = 0.03), critical preoperative state (OR, 3.2; p < 0.001), visceral malperfusion (OR, 3.0; p = 0.003), and coronary artery disease (OR, 2.2; p = 0.006). Age younger than 50 years (OR, 0.3; p = 0.01) was protective for early survival. Using this information, we created an easily usable mortality risk score based on these variables. The patients were stratified into four risk categories predicting in-hospital death: less than 10%, 10% to 25%, 25% to 50%, and more than 50%. CONCLUSIONS: This represents one of the largest series of patients with Type A in which a risk model was created. Using our approach, we have shown that age, critical preoperative state, and malperfusion syndrome were strong independent risk factors for early death and could be used for the preoperative risk assessment.