Establishing and using a local/regional cardiac surgery database.

BACKGROUND: In 1993, the Minnesota Society of Thoracic Surgeons and the Minnesota Cardiac Surgery Database were organized in response to a third-party payer demand for data about practice protocols and patient outcomes. It has matured to an active organization of 46 cardiothoracic surgeons, 14 institutions, and more than 7,000 patients who have undergone coronary artery bypass grafting. METHODS: Data are validated for completeness and accuracy through a statewide auditing process. They are coded by hospital, analyzed using the standard Society of Thoracic Surgeons National Cardiac Surgery Database format and definitions, and reviewed quarterly in a continuous quality improvement process. RESULTS: Through data review and exchange site visits, variations in practice protocols and outcomes have been identified. For example, our statewide data review and continuous quality improvement process identified prolonged ventilation (more than 24 hours) as one variation. Multidisciplinary teams were defined, and statewide exchange site visits led by cardiovascular surgeons were implemented. An example of the improvement in the accuracy and completeness of the data used to study procedure outcomes is represented by the improved reporting of ejection fraction values that has resulted from this process. CONCLUSIONS: Using the standardized Society of Thoracic Surgeons National Cardiac Surgery Database and the Minnesota Society of Thoracic Surgeons organizational structure to establish a high-quality database will allow for statewide peer review, exchange of practice guidelines, and promotion of standardization, which eventually can improve outcomes and reduce costs. This organization or model can be replicated at any local, state, or regional level. Thoracic surgeons faced with similar challenges for public disclosure of surgical results can learn much from the successful development of the Minnesota Cardiac Surgery Database.

Repair of aortoesophageal fistula after aortic grafting.

This report describes repair of an aortoesophageal fistula caused by a previously placed thoracic aortic graft. The diagnosis was made by esophagoscopy. The repair consisted of femoral-to-femoral cardiopulmonary bypass, excision of the old graft, placement of a new graft, esophagectomy, cervical esophagostomy, gastrostomy, and later reconstruction by cervical esophagogastrostomy.

Results of composite graft replacement for aortic root aneurysms.

From 1972 to 1980, 41 patients (aged 19 to 79) with aortic root problems have been managed surgically with a composite graft. Forty patients (97.5%) are long-term survivors who to date have had no complications related to the aortic root. This series of patients included 10 with acute dissection of the aortic root and ascending aorta. Thirty-one patients undergoing elective operations for aortic root aneurysms included three with chronic ascending aortic dissection with aortic regurgitation, three with previous operations on the aortic root, and six patients who had associated coronary artery bypass or mitral valve replacement. Follow-up to 8 years shows that patients with composite graft replacement have exhibited no early or late complications of this procedure. Two late deaths at 1 1/2 and 5 1/2 years were unrelated to the aortic root procedure. Experience seems to indicate that composite graft management of aortic root aneurysms is a most reliable and durable operation for the majority of patients with this disease.

Cardiac operation and end-stage renal disease.

From 1972-1979, 22 patients with end-stage renal disease underwent 23 cardiac operations involving the pump oxygenator. Fourteen patients had coronary artery bypasss, 2 had aortic valve replacement, 2 had mitral valve replacement (MVR), 2 had MVR with coronary artery bypass, and 2 had ascending aortic root replacement with a composite graft. One patient underwent successful reoperation for a false aneurysm of the left ventricle after MVR. There were 2 postoperative deaths, for a mortality of 9.1%. The patients undergoing coronary artery bypass had an average of 2.7 grafts and an average Functional Class improvement from New York Heart Association Class III or IV to Class I to II. Eighteen patients required preoperative and postoperative dialysis to control blood volume, potassium, and uremia. Four patients had functioning renal transplants, and 4 patients underwent subsequent successful renal transplantation. We conclude that: (1) patients who have transplants and require dialysis can be successfully managed for cardiac operation in spite of their complex associated medical problems; (2) functional and symptomatic improvement simplifies continued management of the patient needing dialysis; and (3) improvement of a cardiac disability can allow favorable renal transplantation in selected patients.