Postoperative Acute Kidney Injury and Blood Product Transfusion After Synthetic Colloid Use During Cardiac Surgery.

OBJECTIVES: This study assessed the effect of 2 types of hydroxyethyl starches (HES) on renal integrity and blood transfusion in cardiac surgery patients. DESIGN: Retrospective investigation. SETTING: Patients from a single tertiary medical center. PARTICIPANTS: Inclusion criteria included coronary artery bypass graft (CABG) and/or valve surgery that included cardiopulmonary bypass with aortic cross-clamping. INTERVENTIONS: Intraoperative HES and blood product administration. MEASUREMENTS AND MAIN RESULTS: The study comprised 1,265 patients who met inclusion criteria. Of these patients, 70% received HES, and of these, 47% received<1,000 mL and 53% received≥1,000 mL. There was no difference in the development of acute kidney injury between the 2 groups. A parsimonious propensity model for colloids showed that combined CABG and valve surgery were less likely to be associated with HES administration than was CABG alone (OR 0.68, confidence interval [CI] 0.46-0.97; p = 0.04). Intra-aortic balloon pump use was less likely to be associated with HES administration (OR 0.57, CI 0.38-0.86; p = 0.007). Patients with chronic kidney disease, stages 3 to 5, were less likely to receive HES, with an OR of 0.56 (CI 0.38-0.84; p = 0.004); 0.51 (CI 0.20-1.33; p = 0.170); and 0.23 (CI 0.12-0.44; p<0.0001), respectively, for each stage. No difference was noted in red blood cell transfusion. However, fresh frozen plasma, cryoprecipitate, and platelet transfusions were significantly higher with larger volumes of HES, with an OR of 2.03 (CI 1.64-2.52; p<0.001); 1.60 (CI 1.30-1.97; p<0.000); and 1.62 (CI 1.21-2.15; p = 0.006), respectively. No differences in surgical mortality were found between the colloid and noncolloid groups. CONCLUSIONS: This study showed no association of postoperative acute kidney injury and red blood cell transfusion between the colloid and noncolloid groups. Although the complication rate was higher with HES administration, there was no difference in surgery mortality between the 2 groups.

Rigid Sternal Fixation Versus Modified Wire Technique for Poststernotomy Closures: A Retrospective Cost Analysis.

BACKGROUND: Rigid sternal fixation (RSF) has been shown to reduce sternal wound complications in high-risk patients. However, the higher initial cost continues to deter its use. This study evaluates the cost of caring for high-risk sternotomy patients who underwent RSF compared with those who underwent sternal closure with a modified wire technique (MWT). METHODS: A retrospective single institution review of high-risk patients who underwent MWT (n = 45) and RSF (n = 30) for primary sternal closure from 2006 to 2009 was conducted. Total hospital cost, revenue, and net cost associated with surgery and subsequent care were analyzed. RESULTS: Overall rates of wound dehiscence and wound infections (superficial and deep) were higher in MWT patients (n = 14, 13, and 7, respectively) than RSF patients (n = 3, 2, and 0, respectively; P < 0.05). Modified wire technique patients also required more operations (mean ± SEM: 0.4 ± 0.1 vs 0.1 ± 0.1; P = 0.045), and had longer follow-up time (55.0 ± 9.1 vs 13.4 ± 10.5 days; P = 0.004). Overall, the hospital suffered a greater loss caring for MWT patients (US $18,903 ± 2,160) than RSF patients (US $8,935 ± 2,647). Modified wire technique patients who developed a complication had higher costs associated with their operative hospitalization, outpatient care, and home health than RSF patients (total net loss: US $41,436 ± 7327 vs US $10,612 ± 4,258; P = 0.034). CONCLUSIONS: In high-risk patients, RSF is associated with lower rates of infections, including the "never event" mediastinitis, compared with MWT. Moreover, despite the initial higher cost, RSF affords an overall lower cost of care compared with MWT in patients at high-risk for developing sternal complications.

Treatment of sternal wound infection with vacuum-assisted closure.

INTRODUCTION: Previous work has demonstrated the efficacy of vacuum-assisted closure (VAC) in the treatment of poststernotomy local wound infections, compared to historical treatment protocol. The negative pressure has been found to protect wounds against contamination, prevent wound fluid retention, increase blood flow, and increase rates of granulation tissue formation. For this study, a retrospective analysis compared patients receiving VAC as definitive treatment versus bridging to delayed flap closure. METHODS: Sixteen patients developed sternal wound infections after cardiac surgeries at the authors' institution from 2006 to 2008. Data was gathered regarding patient comorbidities, treatment method, and outcome. Study objectives included assessment of risk factors that warranted secondary surgicalclosure and examination of long-term followup where VAC was thedefinitive treatment modality. RESULTS: Group A (n = 12) had VAC as the final treatment modality. Group B (n = 4) required myocutaneous flap closure. One patient in Group B passed away prior to flap surgery. Both groups had similar risk factors, except Group B had a higher risk of body mass index (BMI) > 35 that was near statistically significant (P = 0.085; odds ratio = 0.0, 95% CI = [0.0 - 1.21]). Group A required a shorter hospital stay on average. Long-term follow-up showed the majority of Group A had completely healed sternal wounds 2-3 years from initial cardiac surgery. CONCLUSIONS: Vacuum-assisted closure as definitive treatment modality is a successful, first line therapy for local superficial sternal wound infections. When deep infections occur, however, VAC as bridge-to-flap coverage is recommended over attempted secondary healing with VAC. .

MicroRNA profiling predicts a variance in the proliferative potential of cardiac progenitor cells derived from neonatal and adult murine hearts.

Cardiac progenitor cells (CPCs) are multipotent cells that may offer tremendous potentials for the regeneration of injured myocardium. To expand the limited number of CPCs for effective clinical regeneration of myocardium, it is important to understand their proliferative potentials. Single-cell based assays were utilized to purify c-kit(pos) CPCs from human and mouse hearts. MicroRNA profiling identified eight differentially expressed microRNAs in CPCs from neonatal and adult hearts. Notably, the predicted protein targets were predominantly involved in cellular proliferation-related pathways. To directly test this phenotypic prediction, the developmental variance in the proliferation of CPCs was tested. Ki67 protein expression and DNA kinetics were tested in human and mouse in vivo CPCs, and doubling times were tested in primary culture of mouse CPCs. The human embryonic and mouse neonatal CPCs showed a six-fold increase in Ki67 expressing cells, a two-fold increase in the number of cells in S/G2-M phases of cell cycle, and a seven-fold increase in the doubling time in culture when compared to the corresponding adult CPCs. The over-expression of miR-17-92 increased the proliferation in adult CPCs in vivo by two-fold. In addition, the level of retinoblastoma-like 2 (Rbl2/p130) protein was two-fold higher in adult compared to neonatal-mouse CPCs. In conclusion, we demonstrate a differentially regulated cohort of microRNAs that predicts differences in cellular proliferation in CPCs during postnatal development and target microRNAs that are involved in this transition. Our study provides new insights that may enhance the utilization of adult CPCs for regenerative therapy of the injured myocardium.

Cardiac small conductance Ca2+-activated K+ channel subunits form heteromultimers via the coiled-coil domains in the C termini of the channels.

RATIONALE: Ca(2+)-activated K(+) channels are present in a wide variety of cells. We have previously reported the presence of small conductance Ca(2+)-activated K(+) (SK or K(Ca)) channels in human and mouse cardiac myocytes that contribute functionally toward the shape and duration of cardiac action potentials. Three isoforms of SK channel subunits (SK1, SK2, and SK3) are found to be expressed. Moreover, there is differential expression with more abundant SK channels in the atria and pacemaking tissues compared with the ventricles. SK channels are proposed to be assembled as tetramers similar to other K(+) channels, but the molecular determinants driving their subunit interaction and assembly are not defined in cardiac tissues. OBJECTIVE: To investigate the heteromultimeric formation and the domain necessary for the assembly of 3 SK channel subunits (SK1, SK2, and SK3) into complexes in human and mouse hearts. METHODS AND RESULTS: Here, we provide evidence to support the formation of heteromultimeric complexes among different SK channel subunits in native cardiac tissues. SK1, SK2, and SK3 subunits contain coiled-coil domains (CCDs) in the C termini. In vitro interaction assay supports the direct interaction between CCDs of the channel subunits. Moreover, specific inhibitory peptides derived from CCDs block the Ca(2+)-activated K(+) current in atrial myocytes, which is important for cardiac repolarization. CONCLUSIONS: The data provide evidence for the formation of heteromultimeric complexes among different SK channel subunits in atrial myocytes. Because SK channels are predominantly expressed in atrial myocytes, specific ligands of the different isoforms of SK channel subunits may offer a unique therapeutic opportunity to directly modify atrial cells without interfering with ventricular myocytes.

Complex aortic valve repair following excision of a papillary fibroelastoma.

Complex aortic valve repair after mass lesion resection, in an otherwise normal, thin leafleted valve, is rarely described in the literature. We present a 68-year-old woman who underwent resection of an asymptomatic aortic valve papillary fibroelastoma. Due to extensive involvement of her left coronary cusp, the resection resulted in a significant defect in the leaflet, requiring a complex repair to preserve her otherwise normal aortic valve. We describe the operative findings, repair technique, and associated literature.

Molecular coupling of a Ca2+-activated K+ channel to L-type Ca2+ channels via alpha-actinin2.

Cytoskeletal proteins are known to sculpt the structural architecture of cells. However, their role as bridges linking the functional crosstalk of different ion channels is unknown. Here, we demonstrate that a small conductance Ca(2+)-activated K(+) channels (SK2 channel), present in a variety of cells, where they integrate changes in intracellular Ca(2+) concentration [Ca(2+)(i)] with changes in K(+) conductance and membrane potential, associate with L-type Ca(2+) channels; Ca(v)1.3 and Ca(v)1.2 through a physical bridge, alpha-actinin2 in cardiac myocytes. SK2 channels do not physically interact with L-type Ca(2+) channels, instead, the 2 channels colocalize via their interaction with alpha-actinin2 cytoskeletal protein. The association of SK2 channel with alpha-actinin2 localizes the channel to the entry of external Ca(2+) source, which regulate the channel function. Furthermore, we demonstrated that the functions of SK2 channels in atrial myocytes are critically dependent on the normal expression of Ca(v)1.3 Ca(2+) channels. Null deletion of Ca(v)1.3 channel results in abnormal function of SK2 channel and prolongation of repolarization and atrial arrhythmias. Our study provides insight into the molecular mechanisms of the coupling of SK2 channel with voltage-gated Ca(2+) channel, and represents the first report linking the coupling of 2 different types of ion channels via cytoskeletal proteins.

Late surgical mitral valve repair after percutaneous repair with the MitraClip system.

Percutaneous approaches for treating mitral regurgitation are under investigation, including repair with the MitraClip percutaneous mitral repair system (Evalve, Inc., Menlo Park, CA, USA), which has undergone extensive preclinical and clinical evaluation in the EVEREST I and II trials. The procedure involves the transcatheter placement of one or two MitraClip devices under echocardiographic and fluoroscopic guidance to restore leaflet coaptation. A desirable feature of any percutaneous mitral valve (MV) repair system is that the device should not impede subsequent surgical repair if needed. To date, the majority of reported MV surgeries after MitraClip device implantation have occurred earlier, within one year of treatment. We herein describe four previously unreported cases of successful surgical MV repair up to five years after MitraClip device implantation, demonstrating that late MV repair remains possible, including after implantation of two clips.

Off-pump coronary artery bypass graft surgery in California, 2003 to 2005.

BACKGROUND: The impact of off-pump coronary artery bypass graft surgery (OPCAB) on operative mortality compared to conventional coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CCB) has not been clarified. METHOD: Patient clinical characteristics were compared between OPCAB and CCB for isolated CABG surgeries in 2003 to 2005 using data from the California CABG outcomes reporting program. A propensity score method and logistic regression models were used to compute propensity-adjusted operative mortality for patients undergoing OPCAB or CCB. RESULTS: Of 57,284 isolated CABGs, 13,515 (22.9%) were OPCAB. Compared to CCB, OPCAB patients were older, more females/nonwhite, and had a higher prevalence of certain noncardiac risk factors but were fewer with diabetes, acute myocardial infarction, New York Heart Association class IV heart failure or angina, cardiogenic shock, prior cardiac surgery, left main coronary disease, or > or =3-vessel coronary disease (all P < .01). Overall, the propensity-adjusted operative mortalities (PAOMRs) were significantly lower in OPCAB patients compared to CCB patients (OPCAB 2.59% [95% CI 2.52%-2.67%] vs CCB 3.22% [95% CI 3.17%-3.27%]). Off-pump CABG had a protective advantage for all quintile subgroups (all P < .05). However, within the OPCAB cohort, those who converted to CCB intraoperately had higher PAOMR (converters 3.47% [95% CI 3.16%-3.77%] vs nonconverters 2.53% [95% CI 2.46%-2.61%]). Age, female sex, nonwhite race, diabetes, congestive heart failure, prior cadiac surgery, left main disease, and with > or =3 diseased coronary arteries were associated with a higher risk of intraoperative conversion from OPCAB to CCB (all <0.05). CONCLUSION: OPCAB and CCB patients had significantly different preoperative risk profiles, and OPCAB was associated with lower operative mortality compared to CCB.

Implantable cardioverter-defibrillators: a new preventive medical option.

Implantable cardioverter-defibrillator (ICD or defibrillator) therapy has revolutionized the fields of cardiology and electrophysiology. Hundreds of thousands of patients at risk for sudden cardiac death receive them each year. The devices are not much larger than a pacemaker, and they have full pacemaker capabilities in addition to being able to shock patients out of life-threatening ventricular arrhythmias. The Multicenter Automatic Defibrillator Implantation Trial (MADIT) in 1996 was a landmark trial that showed for the first time a mortality benefit of ICD therapy over medications in patients at high risk for sudden death. Multicenter Automatic Defibrillator Implantation Trial II, published in 2002, extended these results to all patients with ischemic heart failure with depressed heart function. Candidates for ICD implantation include most patients with an ejection fraction of <30%, especially those with coronary artery disease. More work needs to be done to define those patients with nonischemic cardiomyopathies who will benefit from ICDs and biventricular pacing for heart failure.

Molecular Mechanisms and New Treatment Paradigm for Atrial Fibrillation.

BACKGROUND: Atrial fibrillation represents the most common arrhythmia leading to increased morbidity and mortality, yet, current treatment strategies have proven inadequate. Conventional treatment with antiarrhythmic drugs carries a high risk for proarrhythmias. The soluble epoxide hydrolase enzyme catalyzes the hydrolysis of anti-inflammatory epoxy fatty acids, including epoxyeicosatrienoic acids from arachidonic acid to the corresponding proinflammatory diols. Therefore, the goal of the study is to directly test the hypotheses that inhibition of the soluble epoxide hydrolase enzyme can result in an increase in the levels of epoxyeicosatrienoic acids, leading to the attenuation of atrial structural and electric remodeling and the prevention of atrial fibrillation. METHODS AND RESULTS: For the first time, we report findings that inhibition of soluble epoxide hydrolase reduces inflammation, oxidative stress, atrial structural, and electric remodeling. Treatment with soluble epoxide hydrolase inhibitor significantly reduces the activation of key inflammatory signaling molecules, including the transcription factor nuclear factor κ-light-chain-enhancer, mitogen-activated protein kinase, and transforming growth factor-ß. CONCLUSIONS: This study provides insights into the underlying molecular mechanisms leading to atrial fibrillation by inflammation and represents a paradigm shift from conventional antiarrhythmic drugs, which block downstream events to a novel upstream therapeutic target by counteracting the inflammatory processes in atrial fibrillation.

Contemporary Outcomes of Coronary Artery Bypass Grafting Among Patients With Insulin-Treated and Non-Insulin-Treated Diabetes.

BACKGROUND: More than 40% of patients undergoing coronary artery bypass grafting (CABG) have diabetes. However, it is unknown how insulin treatment status influences cardiac surgical outcomes among patients with diabetes. METHODS: All isolated CABG, CABG plus aortic valve replacement or plus mitral valve repair/replacement procedures performed in 2012 were extracted from the California CABG Outcomes Reporting Program database. Patients were grouped into three categories: (1) no diabetes, (2) non-insulin-treated diabetes (NITDM), and (3) insulin-treated diabetes (ITDM). Demographic and clinical baseline characteristics and observed postoperative major adverse events, including 30-day mortality, stroke, deep sternal wound infection, prolonged ventilation, new dialysis requirement, renal failure, and 30-day readmission were compared. Multivariable logistic regression models were developed for predicting the impact of NITDM and ITDM on postoperative major adverse events. RESULTS: A total of 14,051 patients underwent isolated CABG or CABG plus aortic/mitral valve procedures in California during 2012; 6700 (47.7%) had no diabetes, 5165 (36.8%) had NITDM, and 2183 (15.6%) had ITDM. Compared with the nondiabetic and NITDM groups, the ITDM group was younger, more frequently women and nonwhite, and had a higher prevalence of preoperative comorbidities (all p < 0.05). After adjusting for baseline risk factors and surgery type compared with patients without diabetes, both NITDM and ITDM were associated with significantly increased risk of major adverse events [NITDM: adjusted odds ratio (AOR), 1.15, 95 % confidence interval (CI), 1.04 to 1.26, p = 0.005; ITDM: AOR, 1.49, 95% CI, 1.32 to 1.68, p < 0.0001]. A subgroup comparison indicated a similar gradient of risk for each category of cardiac surgery. CONCLUSIONS: Patients with diabetes undergoing CABG have substantially increased risk of major adverse events. Patients with ITDM represent an especially high-risk group.

Septic thrombophlebitis of the coronary sinus with complete recovery after surgical intervention.

This case represents a unique presentation of septic thrombophlebitis of the coronary sinus in that the infection was localized to the coronary sinus, the etiology was unclear, and the patient recovered uneventfully after surgery.

Intraoperative conversion from off-pump to on-pump coronary artery bypass is associated with increased 30-day hospital readmission.

BACKGROUND: We evaluated the impact of intraoperative conversion from off-pump coronary artery bypass graft surgery (OPCAB) to conventional coronary artery bypass graft surgery (CABG) with cardiopulmonary bypass (CCB) on rates of postoperative 30-day hospital readmissions. METHODS: Using data from the California CABG outcomes reporting program, postoperative 30-day hospital readmissions were compared among CCB, OPCAB, and intraoperative conversions from OPCAB to CCB (IOC) for isolated CABG operations. A multivariable logistic regression model with inverse propensity for OPCAB weighting was used to compute risk-adjusted readmission rates. General linear models were used to test the differences in propensity-weighted and risk-adjusted readmission rates among CCB, OPCAB, and IOC cases. RESULTS: Among 22,389 isolated CABGs, 5,125 (22.9%) were OPCAB; 595 (11.6%) OPCAB patients had intraoperative conversion from OPCAB to CCB (IOC). The patients who underwent IOC had a higher prevalence of preoperative heart failure, left main coronary artery disease, and 3 or greater diseased coronary vessels compared with OPCAB without conversion. The risk-adjusted readmission model (weighted for OPCAB propensity) showed OPCAB without conversion was not associated with any increase in readmission rates when compared with CCB (adjusted odds ratio [AOR]; 1.02, 95% confidence interval [CI], 0.963 to 1.081) but OPCAB with IOC had a significant effect on readmission (AOR, 1.258; 95% CI, 1.122 to 1.411, p<0.0001). The OPCAB with IOC was also associated with a higher proportion of readmissions due to postoperative infection (19.1% vs 11.9% of readmissions for CCB). CONCLUSIONS: Intraoperative conversions from OPCAB to CCB are associated with a higher rate of postoperative hospital readmission and infection.

A stepwise model for delivering medical humanitarian aid requiring complex interventions.

OBJECTIVES: Cardiothoracic surgeons and practitioners of cardiovascular medicine have a long history of humanitarian aid. Although this is worthwhile at multiple levels and occasionally described in some detail, few efforts have a proven algorithm with demonstrable outcomes that suggest effective educational methodology or clinical results approaching accepted standards in developed countries. METHODS: Our report provides a stepwise approach to developing highly successful self-sustainable, replicable, and scalable humanitarian congenital cardiac surgical programs, and provides data to allow insight into the efficacy of our model. RESULTS: This program model has evolved over 25 years, during which it has been replicated several times and scaled throughout a vast and populous country. Since 1989, Russia has undergone considerable social, political, and economic changes. Our program model proved successful throughout this time despite dynamic social, political, and medical landscapes. CONCLUSIONS: The positive results of our program model indicate that these methodologies may be helpful to others attempting to address the worldwide shortage of cardiovascular care and particularly the complex interventions required in the management of congenital cardiovascular disease.

Post-bypass dexmedetomidine use and postoperative acute kidney injury in patients undergoing cardiac surgery with cardiopulmonary bypass.

BACKGROUND: AND OBJECTIVES: The aim of this retrospective investigation was to study the relationships among chronic kidney disease, acute kidney injury (AKI), and potential benefits by post-bypass dexmedetomidine use in patients undergoing cardiac surgery. METHODS: The patient data were reviewed from the institutional Society of Thoracic Surgeons National Adult Cardiac Surgery Database after IRB approval. 1,133 patients were identified and divided into two groups: those who received dexmedetomidine or those who did not during the post-bypass period. The postoperative outcomes include the incidence of AKI, any complication and all cause of mortality. RESULTS: Post-bypass dexmedetomidine use was associated with significantly reduced the incidence of total AKI (26.1% vs. 33.75%; adjusted OR, 0.7033; 95%CI, 0.540 to 0.916; p=0.0089). In addition, post-bypass dexmedetomidine use was more likely to reduce the incidence of AKI in these patients with preoperative normal kidney function (Stage1; 32.8% to 22.8%; p=0.0233) and mild CKD (Stage 2; 32.8% to 24.7; p=0.0003) after cardiac surgery. Post-bypass infusion of dexmedetomidine was associated with significantly reduced incidence of any complication and 30-day mortalities. CONCLUSIONS: Post-bypass dexmedetomidine use is associated with a significant reduction in the incidence of AKI, especially mild AKI in patients with preoperative normal renal function and mild CKD undergoing cardiac surgery.

Effect of coronary artery disease extent on contemporary outcomes of combined aortic valve replacement and coronary artery bypass graft surgery.

BACKGROUND: Concomitant aortic valve replacement (AVR) and coronary artery bypass graft surgery (CABG) is a common procedure. Whether the extent of coronary artery disease (CAD) influences outcomes of AVR plus CABG is unknown. METHODS: All AVR plus CABG cases from 2008 to 2010 were extracted from the California CABG Outcomes Reporting Program database. Patients with left main coronary artery stenosis greater than 50% or at least three diseased vessels were defined as having extensive CAD, and patients with one or two diseased coronary vessels were defined as having less extensive CAD. Multivariable logistic regression models were developed for predicting major postoperative complications and 30-day mortality. A Cox proportional hazards model was developed to predict the risk of 1-year mortality. RESULTS: Between 2008 and 2010, 6,151 AVR plus CABG were performed in California. Compared with patients with one- or two-vessel CAD, patients with extensive CAD undergoing AVR plus CABG were on average older, more often male, had greater prevalence of multiple comorbidities, and underwent more urgent or emergent operations (all p < 0.05). After adjusting for baseline risk factors, AVR plus CABG with extensive CAD was associated with significantly increased risk of major postoperative complications (adjusted odds ratio, 1.24; 95% confidence interval, 1.10 to 1.40; p = 0.001) but not operative mortality (adjusted odds ratio, 1.00; 95% confidence interval, 0.77 to 1.29; p = 0.978). A Cox proportional hazards model showed that age and other medical comorbidities, but not extensive CAD, were significant risk factors for 1-year mortality. CONCLUSIONS: Compared with AVR plus CABG for one- or two-vessel CAD, AVR plus CABG for left main or three or more vessel CAD had higher observed and risk-adjusted rates of postoperative complications but not operative or 1-year mortality.

The Joint Council on Thoracic Surgery Education coronary artery assessment tool has high interrater reliability.

BACKGROUND: Barriers to incorporation of simulation in cardiothoracic surgery training include lack of standardized, validated objective assessment tools. Our aim was to measure interrater reliability and internal consistency reliability of a coronary anastomosis assessment tool created by the Joint Council on Thoracic Surgery Education. METHODS: Ten attending surgeons from different cardiothoracic residency programs evaluated nine video recordings of 5 individuals (1 medical student, 1 resident, 1 fellow, 2 attendings) performing coronary anastomoses on two simulation models, including synthetic graft task station (low fidelity) and porcine explant (high fidelity), as well as in the operative setting. All raters, blinded to operator identity, scored 13 assessment items on a 1 to 5 (low to high) scale. Each performance also received an overall pass/fail determination. Interrater reliability and internal consistency were assessed as intraclass correlation coefficients and Cronbach's α, respectively. RESULTS: Both interrater reliability and internal consistency were high for all three models (intraclass correlation coefficients = 0.98, 0.99, and 0.94, and Cronbach's α = 0.99, 0.98, and 0.97 for low fidelity, high fidelity, and operative setting, respectively). Interrater reliability for overall pass/fail determination using κ were 0.54, 0.86, 0.15 for low fidelity, high fidelity, and operative setting, respectively. CONCLUSIONS: Even without instruction on the assessment tool, experienced surgeons achieved high interrater reliability. Future resident training and evaluation may benefit from utilization of this tool for formative feedback in the simulated and operative environments. However, summative assessment in the operative setting will require further standardization and anchoring.

Unusual effect of an atrial septal aneurysm on venous drainage during cardiopulmonary bypass.

Atrial septal aneurysm is an uncommon cardiac anomaly that is usually asymptomatic or occasionally associated with cardioembolic events. We present the unusual impeding effect of an atrial septal aneurysm on venous drainage during cardiopulmonary bypass in a 70-year-old man who underwent aortic valve replacement and coronary artery bypass graft surgery.