Synchronous Carotid Endarterectomy and Anaortic Off-Pump Coronary Artery Bypass Surgery.

BACKGROUND: There is ongoing debate regarding the optimal strategy and timing for the surgical management of patients with severe concomitant carotid and coronary artery disease. Anaortic off-pump coronary artery bypass (anOPCAB), which avoids aortic manipulation and cardiopulmonary bypass, has been shown to reduce the risk of perioperative stroke. We present the outcomes of a series of synchronous carotid endarterectomy (CEA) and anOPCAB. METHODS: A retrospective review was performed. The primary endpoint was stroke at 30 days post-operation. Secondary endpoints included transient ischaemic attack, myocardial infarction and mortality 30 days post-operation. RESULTS: From 2009 to 2016, 1,041 patients underwent anOPCAB with a 30-day stroke rate of 0.4%. The majority of patients had preoperative carotid-subclavian duplex ultrasound screening and 39 were identified with significant concomitant carotid disease who underwent synchronous CEA-anOPCAB. The mean age was 71±7.5 years. Nine patients (23.1%) had previous neurological events. Thirty (30) patients (76.9%) underwent an urgent operation. For CEA, a conventional longitudinal carotid endarterectomy with patch angioplasty was performed in all patients. For anOPCAB, total arterial revascularisation rate was performed in 84.6% and the mean number of distal anastomoses was 2.9±0.7. In the 30-day postoperative period, there was one stroke (2.63%), two deaths (5.26%), two transient ischaemic attacks (TIAs) (5.26%) and no myocardial infarction. Two patients experienced acute kidney injury (5.26%), one of which required haemodialysis (2.63%). Mean length of stay was 11.37±7.9 days. CONCLUSION: Synchronous CEA and anOPCAB is a safe and effective option for patients' severe concomitant disease. Preoperative carotid-subclavian ultrasound screening allows identification of these patients.

Silent brain infarcts and early cognitive outcomes after transcatheter aortic valve implantation: a systematic review and meta-analysis.

BACKGROUND: Silent brain infarcts (SBIs) are frequently identified after transcatheter aortic valve implantation (TAVI), when patients are screened with diffusion-weighted magnetic resonance imaging (DW-MRI). Outside the cardiac literature, SBIs have been correlated with progressive cognitive dysfunction; however, their prognostic utility after TAVI remains uncertain. This study's main goals were to explore (i) the incidence of and potential risk factors for SBI after TAVI; and (ii) the effect of SBI on early post-procedural cognitive dysfunction (PCD). METHODS AND RESULTS: A systematic literature review was performed to identify all publications reporting SBI incidence, as detected by DW-MRI after TAVI. Silent brain infarct incidence, baseline characteristics, and the incidence of early PCD were evaluated via meta-analysis and meta-regression models. We identified 39 relevant studies encapsulating 2408 patients. Out of 2171 patients who underwent post-procedural DW-MRI, 1601 were found to have at least one new SBI (pooled effect size 0.76, 95% CI: 0.72-0.81). The incidence of reported stroke with focal neurological deficits was 3%. Meta-regression noted that diabetes, chronic renal disease, 3-Tesla MRI, and pre-dilation were associated with increased SBI risk. The prevalence of early PCD increased during follow-up, from 16% at 10.0 ± 6.3 days to 26% at 6.1 ± 1.7 months and meta-regression suggested an association between the mean number of new SBI and incidence of PCD. The use of cerebral embolic protection devices (CEPDs) appeared to decrease the volume of SBI, but not their overall incidence. CONCLUSIONS: Silent brain infarcts are common after TAVI; and diabetes, kidney disease, and pre-dilation increase overall SBI risk. While higher numbers of new SBIs appear to adversely affect early neurocognitive outcomes, long-term follow-up studies remain necessary as TAVI expands to low-risk patient populations. The use of CEPD did not result in a significant decrease in the occurrence of SBI.

Intracardiac Echocardiography for Point-of-Care Guided Left Ventricular Assist Device Implantation: Surgical Implications for COVID-19.

Data from animal models is now available to initiate assessment of human safety and feasibility of wide-angle three-dimensional intracardiac echocardiography (3D ICE) to guide point-of-care implantation of percutaneous left ventricular assist devices in critical care settings. Assessment of these combined new technologies could be best achieved within a surgical institution with pre-existing expertise in separate utilization of ICE and Impella.

Surgical outcomes for people with serious mental illness are poorer than for other patients: a systematic review and meta-analysis.

OBJECTIVE: To assess the association between having a serious mental illness and surgical outcomes for adults, including in-hospital and 30-day mortality, post-operative complications, and hospital length of stay. STUDY DESIGN: Systematic review and meta-analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in-hospital and 30-day mortality, post-operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates. DATA SOURCES: MEDLINE, EMBASE, PsychINFO, and the Cochrane Library. DATA SYNTHESIS: Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post-operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15-1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8-4.4 days) were statistically significant, but not those for in-hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69-2.12) or 30-day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86-3.99). CONCLUSIONS: Having a serious mental illness is associated with higher rates of post-operative complications and longer stays in hospital, but not with higher in-hospital or 30-day mortality. Targeted pre-operative interventions may improve surgical outcomes for these vulnerable patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42018080114 (prospective).

Detailed cost of robotic-assisted surgery in the Australian public health sector: from implementation to a multi-specialty caseload.

BACKGROUND: A barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector. METHODS: A retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs. RESULTS: Of 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (Interquartile range (IQR): $15,445 to $32,199). The RAS specific costs were $8828 (46%) made up of fixed costs including $4691 (24%) implementation and $2290 (12%) maintenance, both of which are volume dependent; and $1848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation. CONCLUSIONS: There is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector.

Five-Year Survival of Transcatheter Aortic Valve Implantation in High-Risk Patients.

BACKGROUND: Although transcatheter aortic valve implantation (TAVI) has become the standard treatment for severe aortic stenosis in high-risk patients in Australia, there is still limited data on long term survival. METHODS: All patients undergoing TAVI at a single tertiary institution between September 2009 and December 2015 were included. The primary outcome was survival, by linkage of patients with the National Death Index of the Australian Institute of Health and Welfare. Post-procedure data and echocardiographic measurements were retrospectively analysed for all patients. RESULTS: A total of 186 patients were included. It was a high-risk patient population (mean EuroSCORE 31.5±20.5, mean age 83.0±8.2 years). Valve prostheses used were Edwards SAPIEN (ES) (Edwards, Irvine, CA, USA) in 16.1%, Edwards SAPIEN XT (ESXT) in 74.2%, and Medtronic CoreValve (MCV) (Medtronic, Minneapolis, MN, USA) in 9.7%. Median survival time for the entire cohort was 68.2 months (95% Confidence Interval [CI]; Lower Limit [LL] 58.0 months, Upper Limit [UL] not defined). The 2- and 5-year estimates of survival were 85% (LL 80%, UL 90%) and 56% (LL 48%, UL 66%), respectively. There was no statistically significant difference in median survival between the ES and ESXT valves, or implantation approach. Survival was greater in patients with creatinine <200 µmol/L compared to >200 µmol/L (68.8 months [LL 61.4, UL n/a] vs 48.0 months [LL 25.5, UL n/a]). Over the study period, there was a statistically significant trend in increasing mean transvalvular gradient (ES: 1.66 mmHg/yr, p=0.0058; ESXT: 2.50 mmHg/yr, p≤0.001) and maximum velocity (ESXT: 0.16 m/s/yr, p=0.004) and decreasing valve area (ESXT: -0.07 cm2/yr, p<0.001). There was substantial attrition of patient echocardiographic follow-up (number of echocardiograms followed up at 5 years=6, number at risk=41). CONCLUSIONS: This study has demonstrated acceptable survival in a high-risk cohort of patients undergoing TAVI, with comparable results to larger international experiences. There was a trend for worsening haemodynamics that needs to be monitored. Future studies need to examine patient quality of life and the performance of newer generation prostheses.

Evaluation of aortic stenosis using cardiovascular magnetic resonance: a systematic review & meta-analysis.

BACKGROUND: As the average age of patients with severe aortic stenosis (AS) who receive procedural intervention continue to age, the need for non-invasive modalities that provide accurate diagnosis and operative planning is increasingly important. Advances in cardiovascular magnetic resonance (CMR) over the past two decades mean it is able to provide haemodynamic data at the aortic valve, along with high fidelity anatomical imaging. METHODS: Electronic databases were searched for studies comparing CMR to transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE) in the diagnosis of AS. Studies were included only if direct comparison was made on matched patients, and if diagnosis was primarily through measurement of aortic valve area (AVA). RESULTS: Twenty-three relevant, prospective articles were included in the meta-analysis, totalling 1040 individual patients. There was no significant difference in AVA measured as by CMR compared to TEE. CMR measurements of AVA size were larger compared to TTE by an average of 10.7% (absolute difference: + 0.14cm2, 95% CI 0.07-0.21, p < 0.001). Reliability was high for both inter- and intra-observer measurements (0.03cm2 +/- 0.04 and 0.02cm2 +/- 0.01, respectively). CONCLUSIONS: Our analysis demonstrates the equivalence of AVA measurements using CMR compared to those obtained using TEE. CMR demonstrated a small but significantly larger AVA than TTE. However, this can be attributed to known errors in derivation of left ventricular outflow tract size as measured by TTE. By offering additional anatomical assessment, CMR is warranted as a primary tool in the assessment and workup of patients with severe AS who are candidates for surgical or transcatheter intervention.

Three-dimensional intracardiac echocardiography and pulmonary embolism.

BACKGROUND: Three-dimensional intracardiac echocardiography (3D ICE) with wide azimuthal elevation is a novel technique performed for assessment of cardiac anatomy and guidance of intracardiac procedures, being able to provide unique views with good spatial and temporal resolution. Complications arising from this invasive procedure and the value of 3D ICE in the detection and diagnosis of acute cardiovascular pathology are not comprehensively described. This case illustrates a previously unreported iatrogenic complication of clot displacement from the intra-vascular sheath upon insertion of a 3D ICE catheter and the value of 3D ICE in immediate diagnosis of clot in transit through the heart with pulmonary embolism. CASE PRESENTATION: We conducted a translational study of 3D ICE with wide azimuthal elevation to guide implantation of a left ventricular assist device (Impella CP®) in eight adult sheep. A large-bore 14 Fr central venous sheath was used to enable right atrial and right ventricular access for the intracardiac catheter. Insertion of the 3D ICE catheter was accompanied by a sudden severe cardiorespiratory deterioration in one animal. 3D ICE revealed a large highly mobile mass within the right heart chambers, determined to be a clot-in-transit. The diagnosis of pulmonary clot embolism resulting from the retrograde blood entry into the large-bore sheath introducer, rapid clot formation and consequent displacement into venous circulation by the ICE catheter was made. The sheep survived this life-threatening event following institution of cardiovascular support allowing completion of the primary research protocol. CONCLUSION: This report serves as a serious warning to the researchers and clinicians utilizing long large-bore sheath introducers for 3D ICE and illustrates the value of 3D ICE in detecting clot-in-transit within right heart chambers.

Novel Oral Anticoagulants Compared to Warfarin for Postoperative Atrial Fibrillation After Isolated Coronary Artery Bypass Grafting.

BACKGROUND: Postoperative atrial fibrillation (POAF) is common after cardiac surgery and contributes to short- and long-term morbidity, particularly thromboembolism. Anticoagulation for sustained or recurrent POAF is suggested to reduce thromboembolism. Novel oral anticoagulants may present a safe alternative to warfarin with further benefits including shorter hospital length of stay and better patient convenience. METHODS: A retrospective analysis was performed on all isolated cases of coronary artery surgery (CABG) at our institution between January 2015 and December 2018, totalling 960 patients. Rates of POAF were examined with particular focus on preoperative factors, postoperative outcomes, and anticoagulation practices. RESULTS: The incidence of POAF was 31.8% (305 patients) and was higher in older patients (67.6±9.4 yrs vs 63.0±10.7 yrs, p<0.001), those with a history of cerebrovascular disease (14.6% vs 8.7%, p=0.02), those with higher CHADS-VASc scores (2.5±1.3 vs 2.8±1.3, p<0.001) those who had a postoperative return to theatre (2.6% vs 0.8%, p=0.002), and those with new renal failure (4.9% vs 1.8%, p=0.02). Off-pump surgery was associated with lower incidence of POAF (29.8% vs 37.1%, p=0.03). Patients who developed POAF had significantly longer admissions than those without (12.6±10.6 days vs 9.3±16.3 days, p<0.001). In total, 106 patients (11.0%) went home anticoagulated; 77 (72.6%) on warfarin and 29 (27.4% on a NOAC). Readmission for bleeding was higher in patients on anticoagulation (1.0% vs 0.0%, p=0.02), but did not drive readmission for pericardial effusion (0.3% vs 0.6%, p=0.55). No bleeding complications occurred in patients who were discharged on a NOAC. Overall mortality at median of 2 years was 1.8% (17 patients) and no mortality occurred in any patient discharged on anticoagulation. CONCLUSION: Postoperative atrial fibrillation is a common adverse event and is linked to higher preoperative and postoperative morbidity. Anticoagulation may be safely started in these patients and use of novel anticoagulation does not appear to increase postoperative complications, although overall numbers are low.

Rural and Remote Cardiology During the COVID-19 Pandemic: Cardiac Society of Australia and New Zealand (CSANZ) Consensus Statement.

THE CHALLENGES: Rural and remote Australians and New Zealanders have a higher rate of adverse outcomes due to acute myocardial infarction, driven by many factors. The prevalence of cardiovascular disease (CVD) is also higher in regional and remote populations, and people with known CVD have increased morbidity and mortality from coronavirus disease 2019 (COVID-19). In addition, COVID-19 is associated with serious cardiac manifestations, potentially placing additional demand on limited regional services at a time of diminished visiting metropolitan support with restricted travel. Inter-hospital transfer is currently challenging as receiving centres enact pandemic protocols, creating potential delays, and cardiovascular resources are diverted to increasing intensive care unit (ICU) and emergency department (ED) capacity. Regional and rural centres have limited staff resources, placing cardiac services at risk in the event of staff infection or quarantine during the pandemic. MAIN RECOMMENDATIONS: Health districts, cardiologists and government agencies need to minimise impacts on the already vulnerable cardiovascular health of regional and remote Australians and New Zealanders throughout the COVID-19 pandemic. Changes in management should include.

COVID-19 and Acute Heart Failure: Screening the Critically Ill - A Position Statement of the Cardiac Society of Australia and New Zealand (CSANZ).

Up to one-third of COVID-19 patients admitted to intensive care develop an acute cardiomyopathy, which may represent myocarditis or stress cardiomyopathy. Further, while mortality in older patients with COVID-19 appears related to multi-organ failure complicating acute respiratory distress syndrome (ARDS), the cause of death in younger patients may be related to acute heart failure. Cardiac involvement needs to be considered early on in critically ill COVID-19 patients, and even after the acute respiratory phase is passing. This Statement presents a screening algorithm to better identify COVID-19 patients at risk for severe heart failure and circulatory collapse, while balancing the need to protect health care workers and preserve personal protective equipment (PPE). The significance of serum troponin levels and the role of telemetry and targeted transthoracic echocardiography (TTE) in patient investigation and management are addressed, as are fundamental considerations in the management of acute heart failure in COVID-19 patients.

ARHGAP18 Protects Against Thoracic Aortic Aneurysm Formation by Mitigating the Synthetic and Proinflammatory Smooth Muscle Cell Phenotype.

RATIONALE: Thoracic aortic aneurysm (TAA) is a potentially lethal condition, which can affect individuals of all ages. TAA may be complicated by the sudden onset of life-threatening dissection or rupture. The underlying mechanisms leading to TAA formation, particularly in the nonsyndromal idiopathic group of patients, are not well understood. Thus, identification of new genes and targets that are involved in TAA pathogenesis are required to help prevent and reverse the disease phenotype. OBJECTIVE: Here we explore the role of ARHGAP18, a novel Rho GAP expressed by smooth muscle cells (SMCs), in the pathogenesis of TAA. METHODS AND RESULTS: Using human and mouse aortic samples, we report that ARHGAP18 levels were significantly reduced in the SMC layer of aortic aneurysms. Arhgap18 global knockout (Arhgap18-/-) mice exhibited a highly synthetic, proteolytic, and proinflammatory smooth muscle phenotype under basal conditions and when challenged with angiotensin II, developed TAA with increased frequency and severity compared with littermate controls. Chromatin immunoprecipitation studies revealed this phenotype is partly associated with strong enrichment of H3K4me3 and depletion of H3K27me3 at the MMP2 and TNF-α promoters in Arhgap18-deficient SMC. We further show that TAA formation in the Arhgap18-/- mice is associated with loss of Akt activation. The abnormal SMC phenotype observed in the Arhgap18-/- mice can be partially rescued by pharmacological treatment with the mTORC1 inhibitor rapamycin, which reduces the synthetic and proinflammatory phenotype of Arhgap18-deficient SMC. CONCLUSION: We have identified ARHGAP18 as a novel protective gene against TAA formation and define an additional target for the future development of treatments to limit TAA pathogenesis.

Bilateral Versus Single Internal Mammary Artery Use in Coronary Artery Bypass Grafting: A Propensity Matched Analysis.

BACKGROUND: Bilateral internal mammary artery (BIMA) grafts have demonstrated superior long-term outcomes compared with single internal mammary artery (SIMA) grafts. Despite this, BIMA remains widely underutilised due to perceived technical challenges and concerns regarding wound healing. We sought to examine the morbidity and mortality associated with BIMA use in a propensity-matched cohort of patients. METHODS: From 2009 to 2016, 3,594 consecutive patients underwent coronary artery bypass surgery at three affiliated institutions. Thirty-day (30) mortality and morbidity data were collected prospectively. Propensity-score matched analyses were performed for BIMA versus SIMA use controlling for a number of preoperative characteristics. RESULTS: Overall, 29% of procedures were performed off pump, with a greater proportion in the BIMA group (43% vs. 21%, p<0.001). In the propensity-score analysis consisting of 820 matched pairs, there were similar rates of 30-day mortality (1.3% BIMA vs. 0.9% SIMA, p=0.48) and deep sternal wound infection (1.1% BIMA vs. 0.9% SIMA, p=0.84). The rate of superficial sternal wound infection trended towards being higher in the BIMA group (2.6% vs. 1.3%, p=0.077). The rates of red blood cell transfusions (27.4% vs. 27%, p=0.217), other blood product transfusions (18% vs. 20%, p=0.217), and reoperation for bleeding (2.9% vs. 2.1%, p=0.349) were similar. CONCLUSIONS: Bilateral internal mammary artery use was associated with similar rates of deep sternal wound infection compared to SIMA use, with a preponderance of superficial sternal wound infections that did not result in increased mortality or transfusion requirements. The use of BIMA should be more widely considered for coronary artery bypass surgery.

Composite Y Grafts From the Left Internal Mammary Artery: Current Considerations.

The use of composite coronary artery bypass grafts from the left internal mammary artery (LIMA) has increased over the last 20 years. Total arterial revascularisation can be achieved with two arterial conduits and is associated with a reduced risk of stroke. However, the traditional coronary bypass graft configurations of the in situ LIMA and aorto-coronary saphenous vein grafts remain as the mainstay of coronary bypass surgery in most centres. Concerns regarding composite Y grafts relate to (1) the adequacy of a single inflow for all coronary bypass grafts; (2) the risk of compromising the LIMA flow to the left anterior descending coronary artery; (3) the effects of competitive flow on graft patency; and (4) the use of sequential coronary anastomoses. The evidence upon which these concerns are based will be discussed along with the evidence relating to the use of the various second conduit options.

Heart Valve Surgery Performed by Trainee Surgeons: Meta-Analysis of Clinical Outcomes.

BACKGROUND: Cardiac surgical units must balance trainee education with the duty to provide optimal patient care. This is particularly challenging with valvular surgery, given the lower volume and increased complexity of these procedures. The present meta-analysis was conducted to assess the impact of trainee operator status on clinical outcomes following valvular surgery. METHODS: Medline, Embase and CENTRAL databases were systematically searched for studies reporting clinical outcomes according to the training status of the primary operator (consultant or trainee). Data were extracted and meta-analysed according to pre-defined endpoints. RESULTS: Eleven observational studies met the inclusion criteria, reporting on five patient cohorts undergoing mitral valve surgery (n=3975), six undergoing aortic valve replacement (AVR) (n=6236) and three undergoing combined AVR and coronary artery bypass grafting (CABG) (n=3495). Perioperative mortality was not significantly different between trainee and consultant cases for mitral valve surgery (odds ratio [OR] 0.92; 95% confidence interval [CI], 0.62-1.37), AVR (OR 0.67; 95% CI, 0.37-1.24), or combined AVR and CABG (OR 1.07; 95% CI, 0.40-2.85). The incidences of perioperative stroke, myocardial infarction, arrhythmias, acute renal failure, reoperation or wound infection were not significantly different between trainee and consultant cases. There was a paucity of mid-term survival data. CONCLUSIONS: Valvular surgery cases performed primarily by trainees were not associated with adverse perioperative outcomes. These findings suggest the rigorous design of cardiac surgical trainee programs can sufficiently mitigate trainee deficiencies. However, studies with longer follow-up duration and echocardiographic data are required to assess long-term durability and safety.

Neurocognitive and Psychiatric Issues Post Cardiac Surgery.

Neurocognitive and psychiatric complications are common following cardiac surgery and impact on patient quality of life, recovery from surgery, participation in rehabilitation and long-term mortality. Postoperative cognitive decline, depressive disorders, post-traumatic stress disorder and neurocognitive impairment related to silent brain infarcts have all been linked to the perioperative period of cardiac surgery, and potentially have serious consequences. The accurate assessment of these conditions, particularly in determining the aetiology, and impact on patients is difficult due to the poorly recognised nature of these complications as well as similarities in presentation with postoperative delirium. This review aims to summarise current understanding surrounding psychiatric disturbances following cardiac surgery including the impact on patient quality of life and long-term outcomes.

Application of Clinical Databases to Contemporary Cardiac Surgery Practice: Where are We now?

Cardiac surgery has embraced and encouraged the use of large, multi-institutional datasets in clinical practice. From a research perspective, database studies have facilitated an increased understanding of cardiac surgery. Among other uses, they have allowed an investigation of disease incidence and mortality, high risk groups, disparities in health care delivery and the impact of new devices and techniques. Databases are also important tools for clinical governance and quality improvement. Despite their obvious utility, clinical databases have limitations; they are subject to treatment bias, contain missing data and cannot establish causality. Moreover, the ongoing maintenance of the database requires significant human and financial resources. In the future, inclusion of more detailed follow-up data and integration with other datasets will improve the utility of clinical databases.

The Benefits and Pitfalls of the Use of Risk Stratification Tools in Cardiac Surgery.

Risk assessment tools are increasingly used in surgery. In cardiac surgery, risk models are used for patient counselling, surgical decision-making, performance benchmarking, clinical research, evaluation of new therapies and quality assurance, among others. However, they have numerous disadvantages which need to be considered. This article evaluates the utility of risk assessment tools in cardiac surgery including a discussion of their advantages and disadvantages.

The Aortic Root Replacement Procedure: 12-year Experience from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database.

BACKGROUND: The aortic root replacement procedure (ARR), is often considered the gold standard in the management of aortic root and ascending aorta aneurysms. Our aim was to review the Australian experience with this procedure to ascertain early and late outcomes of mortality and morbidity. METHODS: We reviewed the Australian and New Zealand Society of Cardiac and Thoracic Surgeons' (ANZSCTS) database for patients undergoing ARR. Preoperative, intraoperative and postoperative variables were analysed. Multiple regression was performed to determine independent predictors of 30-day mortality and permanent stroke, and predictors of late death. Survival estimates were obtained by cross-linking the ANZSCTS database with the Australian Institute of Health and Welfare's National Death Index database. RESULTS: Between January 2001 and December 2011, 954 patients underwent ARR with a mean age of 56±15.2 years. The overall 30-day mortality was 5.9% (n=56) with a permanent stroke rate of 2.3% (n=21). The elective surgery mortality was 3.6%. Long-term survival was estimated as 84.4% and 68.7% at 5 and 10 years, respectively. CONCLUSIONS: Aortic root replacement surgery reveals acceptable early mortality, low postoperative stroke rates, and acceptable long-term survival.

Cardiac Magnetic Resonance Imaging Predictors of Short-Term Outcomes after High Risk Coronary Surgery.

BACKGROUND: The euroSCORE II is a widely used pre-coronary artery bypass graft surgery (CAGS) risk score, but its predictive power lacks the specificity to predict outcomes in high-risk patients (16) and left ventricular (LV) dysfunction (<40%) based on 2D-echocardiography who underwent CAGS and in whom CMRI (1.5T) was performed preoperatively were retrospectively studied. Cardiac magnetic resonance imaging parameters were assessed in patients who either had complications immediately post-surgery (n=35), six weeks post-surgery (n=20) or were uncomplicated. RESULTS: The average age of patients recruited was 69±5 years with high euroSCORE II (22±4) and low 2D-echocardiography LV ejection fraction (38%±2%). Cardiac magnetic resonance imaging results demonstrated that those with immediate complications had higher LV scar/infarct burden as a proportion of LV mass (17±3% vs 10±3%; p=0.04) with lower circumferential relaxation index (2.5±0.46 vs 2.8±0.56; p=0.05) compared to those with no complications. Early mortality from surgery was 17% (n=9) and was associated with lower RV stroke volume (55±12 vs 68±18; p=0.03) and higher LV infarct scar/burden (18±2% vs 10±2%, p=0.04). Cardiac magnetic resonance imaging showed patients with complications at six weeks post-surgery had higher LV scar/infarct burden (14.5±2% vs 6.8±2%, p=0.03) compared to those without complications. CONCLUSION: Cardiac magnetic resonance imaging preoperative LV and RV parameters are valuable in assessing the likelihood of successful outcomes from CAGS in high-risk patients with LV dysfunction.