Carboxyhemoglobin in Cardiac Surgery Patients and Its Association with Risk Factors and Biomarkers of Hemolysis.

BACKGROUND: Cardiac surgery with cardiopulmonary bypass (CPB) is associated with hemolysis. Yet, there is no easily available and frequently measured marker to monitor this hemolysis. However, carboxyhemoglobin (CO-Hb), formed by the binding of carbon monoxide (a product of heme breakdown) to hemoglobin, may reflect such hemolysis. We hypothesized that CO-Hb might increase after cardiac surgery and show associations with operative risk factors and indirect markers for hemolysis. METHODS: We conducted a retrospective descriptive cohort study of data from on-pump cardiac surgery patients. We analyzed temporal changes in CO-Hb levels and applied a generalized linear model to assess patient characteristics associated with peak CO-Hb levels. Additionally, we examined their relationship with red blood cell (RBC) transfusion and bilirubin levels. RESULTS: We studied 38,487 CO-Hb measurements in 1735 patients. CO-Hb levels increased significantly after cardiac surgery, reaching a peak CO-Hb level 2.1 times higher than baseline (P < .001) at a median of 17 hours after the initiation of surgery. Several factors were independently associated with higher peak CO-Hb, including age (P < .001), preoperative respiratory disease (P = .001), New York Heart Association Class IV (P = .019), the number of packed RBC transfused (P < .001), and the duration of CPB (P = .002). Peak CO-Hb levels also significantly correlated with postoperative total bilirubin levels (Rho = 0.27, P < .001). CONCLUSIONS: CO-Hb may represent a readily obtainable and frequently measured biomarker that has a moderate association with known biomarkers of and risk factors for hemolysis in on-pump cardiac surgery patients. These findings have potential clinical implications and warrant further investigation.

Alexis retractor efficacy in transthoracic thoracoscopically assisted discectomy for thoracic disc herniations.

PURPOSE: A transthoracic anterior or lateral approach for giant thoracic disc herniations is a complex operation which requires optimal exposure and maximal visualisation. Traditional metal rigid retractors may inflict significant skin trauma especially with prolonged operative use and limit the working angles of endoscopic instrumentation at depth. We pioneer the use of the Alexis retractor in transthoracic thoracoscopically assisted discectomy for the first time. METHODS: The authors describe and demonstrate the technical use of the Alexis retractor during operative cases. Patient positioning, clinical rationale and operative nuances are elucidated for readers to gain an appreciation of the transthoracic approach to thoracic disc herniations. RESULTS: The advantages of the Alexis retractor include minimally invasive circumferential flexible retraction, facilitation of bimanual instrument use, diminished risk of surgical site infections and reduced rib retraction leading to less postoperative pain. CONCLUSION: Use of the flexible and intuitive Alexis retractor maximises operative exposure and is an effective adjunct when performing complex transthoracic approaches for thoracic disc herniations.

A novel two-stage approach to the treatment of renal cell carcinoma with intra-cardiac tumour extension and Budd-Chiari syndrome.

OBJECTIVE: To present the early results of a new technique for the treatment of renal cell carcinoma with intra-cardiac tumour extension and Budd-Chiari syndrome. PATIENTS AND METHODS: The first stage involves transdiaphragmatic debulking of the right heart, inferior vena cava (IVC) and hepatic veins via median sternotomy, followed by a purse-string suture placed in the IVC below the hepatic veins. The second stage is performed separately and involves en bloc resection of the affected kidney, and IVC and vascular reconstruction via an abdominal incision. RESULTS: Three of five patients presented with clinical Budd-Chiari syndrome; two had radiological features only. The median time between surgical procedures was 12 days (IQR 13 days). Four of the five patients had a R0 resection. While all five patients successfully completed both operative stages, one patient died 22 days after the second stage. Of the remaining four, all survive with no disease recurrence. CONCLUSION: While we continue to compile longer-term data for a larger follow-up series, these preliminary findings show the feasibility of this technique and support the development of this programme of surgery.

Intracranial Atherosclerosis Increases the Risk of Postoperative Stroke After Cardiac Surgery: A Review and Meta-Analysis.

BACKGROUND: Postoperative stroke is a devastating complication of cardiac surgery with high morbidity, mortality, and health care cost. Extracranial carotid atherosclerosis (ECAS) is a known risk factor for stroke; however, the impact of intracranial atherosclerosis (ICAS) remains unclear. To our knowledge, this is the first literature review of ICAS in cardiac surgery. We aimed to assess the prevalence, association with postoperative stroke, and perioperative management of ICAS in cardiac surgery. METHOD: A search was performed to identify studies reporting rates of ICAS and stroke after cardiac surgery. Data extraction and primary outcomes for meta-analysis included the prevalence of preoperative ICAS and the association between ICAS and stroke. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled by random-effects modelling. RESULTS: Seventeen studies were reviewed and seven were included in the meta-analysis, comprising 4,936 patients. Prevalence of intracranial atherosclerosis (ICAS) among cardiac surgery patients was 21% (95% CI 13%-32%). Patients with ICAS were more likely to develop postoperative stroke (RR 3.61; 95% CI 2.30-5.67; p<0.001). ICAS was more closely associated with stroke than ECAS. Preoperative brain perfusion single-photon emission computed tomography with acetazolamide challenge, staged intracerebral revascularisation, or conversion to off-pump coronary artery bypass grafting are described management options for ICAS. CONCLUSION: Patients with ICAS are 3.61 times more likely to develop stroke after cardiac surgery. Known predictors for ICAS can be used to develop risk stratification screening tools. Further research with diverse cohorts is required to develop evidence-based guidelines for screening and management of ICAS in cardiac surgery.

Left brachiocephalic venous thrombus initially presenting as acute aortic syndrome.

Upper extremity deep venous thrombosis (UEDVT) is rare but carries significant morbidity. Primary UEDVT presents non-specifically and there are no clear diagnostic or management guidelines, which are essential for early treatment to prevent potentially devastating complications such as pulmonary embolus or post-thrombotic pain syndrome. A patient with left brachiocephalic vein UEDVT initially diagnosed radiographically as an acute aortic syndrome and referred to a cardiothoracic unit is presented. Computed tomography venogram confirmed the diagnosis of UEDVT and therapeutic anticoagulation was started. This case highlights the need for validated diagnostic and management algorithms for UEDVT. Furthermore, this relatively rare condition should be considered for patients with acute chest pain and abnormal imaging referred to surgical units.

Branch-first Continuous Perfusion Aortic Arch Replacement: Midterm Results.

BACKGROUND: Aortic arch surgery necessitates interruption of perfusion, thus conferring higher morbidity and mortality compared with other aortic surgery. This report describes a branch-first continuous perfusion aortic arch replacement (BF-CPAR) technique that overcomes these shortcomings and describes midterm results with this technique. METHODS: This report represents the corresponding author's 15-year experience with BF-CPAR, which involves preliminary mobilization and branch reconstruction before circulatory arrest by using a modified trifurcation graft. Demographic, procedural, and outcome (mortality, reintervention, morbidity, and stroke) were analyzed with Kaplan-Meier and Cox regression. RESULTS: Over 15 years (July 2005-February 2021), 155 patients underwent BF-CPAR, at a median age of 66.8 years, 106 (68.3%) on an elective basis and 49 (31.6%) on an emergency basis. There were no aortic deaths after the first postoperative year, thereby resulting in a 1- and 10-year freedom from aortic death constant at 95.6% in patients undergoing elective BF-CPAR and 93.3% in patients undergoing emergency BF-CPAR patients, respectively. Freedom from reintervention on the operated segment at 5 and 9 years was 93.2% and 93.2% in patients undergoing elective cases and 97.1% and 91.4% in emergency cases, respectively. The 10-year freedom from any aortic reintervention was 72.8% in elective patients and 29.2% in emergency patients; there were 38 reinterventions, 76.3% (n = 29/38) done for progression of aneurysmal or dissection disease, of which 79.3% (n = 23/29) were completed endovascularly. Freedom from cerebrovascular-related events at 5 and 10 years was 90.3% and 82.6% in patients undergoing elective BF-CPAR and 75.4% for both time points in patients undergoing emergency BF-CPAR, respectively. CONCLUSIONS: BF-CPAR has excellent 10-year results for elective and emergency cases of arch replacement.

Silver nitrate therapy for persistent tracheocutaneous fistula following prolonged tracheostomy and invasive ventilation: A case report.

We report the case of a man with severe Guillain-Barré syndrome who developed a persistent tracheocutaneous fistula (TCF) following prolonged tracheostomy and mechanical ventilation. Following tracheostomy decannulation, the TCF had a deleterious effect on non-invasive positive pressure ventilation efficacy and ability to effectively clear airway secretions due to air leaking from the patent stoma. This case highlights a non-surgical approach to TCF management that is not well-described in the literature and presents an alternative management option for cohorts of patients in which the risk associated with surgical interventions may be undesirable.

Modern Cardiac Surgical Outcomes in Nonagenarians: A Multicentre Retrospective Observational Study.

Background: There have been multiple recent advancements in the selection, optimisation and management of patients undergoing cardiac surgery. However, there is limited data regarding the outcomes in nonagenarians, despite this cohort being increasingly referred for these interventions. The objective of this study was to describe the patient characteristics, management and outcomes of a cohort of nonagenarians undergoing cardiac surgery receiving contemporary peri-operative care. Methods: After receiving ethics approval, we conducted a retrospective observational study of nonagenarians who had undergone cardiac surgery requiring a classic median sternotomy. All operative indications were included. We excluded patients who underwent transcatheter aortic valve implantation (TAVI), and surgery on the thoracic aorta via an endovascular approach (TEVAR). Patients undergoing TEVAR often have the procedure done under sedation and regional blocks with local anesthetic solution. There is no open incision and these patients do not require cardiopulmonary bypass. We also excluded patients undergoing minimally invasive mitral valve surgery via a videoscope assisted approach. These patients do not have a median sternotomy, have the procedure done via erector spinae block, and often are extubated on table. Data were collected from four hospitals in Victoria, Australia, over an 8-year period (January 2012-December 2019). The primary objective was to assess 6-month mortality in nonagenarian patients undergoing cardiac surgery and to provide a detailed overview of postoperative complications. We hypothesized that cardiac surgery in nonagenarian patients would be associated with a 6-month postoperative mortality <10%. As a secondary outcome, we hypothesized that significant postoperative complications (i.e., Clavien Dindo Grade IIIb or greater) would occur in > 30% of patients. Results: A total of 12,358 adult cardiac surgery patients underwent surgery during the study period, of whom 18 nonagenarians (0.15%) fulfilled inclusion criteria. The median (IQR) [min-max] age was 91.0 years (90.0:91.8) [90-94] and the median body mass index was 25.0 (kg/m2) (22.3:27.0). Comorbidities, polypharmacy, and frailty were common. The median predicted mortality as per EuroSCORE-II was 6.1% (4.1:14.5). There were no cases of intra-operative, in-hospital, or 6-month mortality. One (5.6%) patient experienced two Grade IIIa complications. Three (16.7%) patients experienced Grade IIIb complications. Three (16.7%) patients had an unplanned hospital readmission within 30 days of discharge. The median value for postoperative length of stay was 11.6 days (9.8:17.6). One patient was discharged home and all others were discharged to an inpatient rehabilitation facility. Conclusion: In this selected, contemporary cohort of nonagenarian patients undergoing cardiac surgery, postoperative 6-month mortality was zero. These findings support carefully selected nonagenarian patients being offered cardiac surgery (Trials Registry: https://www.anzctr.org.au/ACTRN12622000058774.aspx).

STABILISE; treatment of aortic dissection, a single Centre experience.

PURPOSE: To outline the process of the STABILISE technique and its use; reporting patient outcomes and midterm follow up for complicated aortic dissection. MATERIALS AND METHODS: Single centre retrospective analysis from January 2011 to January 2021 using the STABILISE technique which utilises balloon assistance to facilitate intimal disruption and promote aortic relamination. RESULTS: Sixteen patients underwent endovascular aortic repair with the STABILISE technique for aortic dissection over the study period. Fourteen patients (14/16; 88%) had acute dissection. Two of 16 (12%) were chronic. The median age of the patient cohort was 61 years (range 32-80 years) and consisted of a male majority (n = 11; 69%). The median time from diagnosis to intervention was 5 days (1-115 days; IQR 1-17.3). More than half (56%) had surgical repair of a acute type A aortic dissection prior to radiological intervention. The procedure was technically successful with no procedural mortality. Two patients were lost to follow up and two died in the post-operative period. Twelve patients had ongoing follow up with an average number of 2.9 ± 1.6 scans performed. Follow up was available in thirteen patients (81%) with a median follow up period of 1097 days (IQR 707-1657). The rate of re-intervention (n = 2/16; 13%) requiring additional stenting was in line with published re-intervention data (15%). Follow up showed a reduction in false lumen size following treatment with total luminal dimensions remaining stable over the follow-up period. CONCLUSION: The STABILISE technique as a procedure for complicated aortic dissection, either acute or chronic, appears safe with stable mid-term aortic remodelling and patient outcomes. LEVEL OF EVIDENCE: Level 3, Retrospective cohort study.

Opioid Prescription After Cardiac Surgery.

OBJECTIVES: To characterise short-term and long-term opioid prescription patterns after cardiac surgery. DESIGN, SETTING AND PARTICIPANTS: We obtained data from a single Australian tertiary hospital from November 2012 to July 2019 and included 2,205 patients who underwent a primary cardiac surgical procedure. MAIN OUTCOME AND MEASURES: The primary outcome was the dose of opioids at hospital discharge. Secondary outcomes included factors associated with high dose opioid prescriptions and persistent opioids use after cardiac surgery. RESULTS: Overall, 76.4% of study patients were prescribed opioids at hospital discharge, with a median discharge prescription of 150 mg oral morphine equivalents. Moreover, 52.8% of discharge opioid prescriptions were as slow-release formulations and 60.0% of all discharge prescriptions were for patients who had received no opioids the day before discharge. In the subset of our patients with long-term data, 14.0% were still receiving opioids at 3-12 months after cardiac surgery. CONCLUSIONS: In cardiac surgical patients, opioid prescriptions at discharge were common, most were at higher than recommended doses and more than half were slow-release formulations. Such prescription was associated with one in seven patients continuing to receive opioids 3-12 months after surgery.

Fast-track recovery program after cardiac surgery in a teaching hospital: a quality improvement initiative.

OBJECTIVE: Fast-track cardiac anesthesia (FTCA) is a technique that may improve patient access to surgery and maximize workforce utilization. However, feasibility and factors impacting FTCA implementation remain poorly explored both locally and internationally. We describe the specific intraoperative and postoperative protocols for our FTCA program, assess protocol compliance and identify reasons for FTCA failure. RESULTS: We tested the program in 16 patients undergoing elective cardiac surgery requiring cardiopulmonary bypass. There was 100% compliance with the FTCA protocols. Four (25%) patients successfully completed the FTCA protocol (extubated < 4 h postoperatively and discharged from the intensive care unit on the same operative day).

Pulmonary carcinoid tumours: A multi-centre analysis of survival and predictors of outcome following sublobar, lobar, and extended pulmonary resections.

BACKGROUND: Pulmonary carcinoids are rare neoplasms, accounting for approximately 1%-2% of all lung malignancies. A retrospective analysis was undertaken of all patients who underwent surgical resection of pulmonary carcinoid tumours across multiple institutions in Melbourne, Australia. METHODS: From May 2000 through April 2020, 241 patients who underwent surgical resection of pulmonary carcinoid tumours were retrospectively reviewed. Patient demographics, pathologic data, and long-term outcomes were recorded. RESULTS: Median age was 57.7 years and the majority of patients were female (58.9% vs. 41.1%). Typical carcinoid was present in 77.1%. Histological subtype was associated with several factors. Atypical carcinoid was more likely to have larger tumour size and nodal involvement. Overall survival for typical carcinoid at 5, 10, and 15 years was 98%, 95%, and 84%, and for atypical carcinoid was 88%, 82%, and 62%, respectively. Histological subtype and age were found to be independent predictors of overall survival, with worse outcomes for atypical and those above 60 years of age. Disease-free survival was related to sublobar resection (p < 0.001, sub-hazard ratio (SHR): 6.89), lymph node involvement (p = 0.022, SHR: 3.18), and atypical histology (p < 0.001, SHR: 9.89). CONCLUSION: Excellent long-term outcomes can be achieved following surgical resection of pulmonary carcinoids. Atypical histology and lymph node involvement are significant prognostic factors, and sublobar resection should not be considered in patients with either of the above features. Typical carcinoid tumour without nodal involvement may be appropriate for sublobar resection. Typical and atypical carcinoid tumours should be considered distinct disease entities, and as such treated accordingly.

Predicting Acute Kidney Injury After Cardiac Surgery Using a Simpler Model.

OBJECTIVE: To develop a simple model for the prediction of acute kidney injury (AKI) and renal replacement therapy (RRT) that could be used in clinical or research risk stratification. DESIGN: Retrospective analysis. SETTING: Multi-institutional. PARTICIPANTS: All cardiac surgery patients from September 2016 to December 2018. INTERVENTIONS: Observational. MEASUREMENTS AND MAIN RESULTS: The study cohort was divided into a development set (75%) and validation set (25%). The following 2 data epochs were used: preoperative data and immediate postoperative data (within 4 h of intensive care unit admission). Univariate statistics were used to identify variables associated with AKI or RRT. Stepwise logistic regression was used to develop a parsimonious model. Model discrimination and calibration were evaluated in the test set. Models were compared with previously published models and with a more comprehensive model developed using the least absolute shrinkage and selection operator. The study included 22,731 patients at 33 hospitals. The incidences of AKI (any stage) and RRT for the present analysis were 5,829 patients (25.6%) and 488 patients (2.1%), respectively. Models were developed for AKI, with an area under the receiver operating curve (AU-ROC) of 0.67 and 0.69 preoperatively and postoperatively, respectively. Models for RRT had an AU-ROC of 0.77 and 0.80 preoperatively and postoperatively, respectively. These models contained between 3 and 5 variables. Comparatively, comprehensive least absolute shrinkage and selection operator models contained between 21 and 26 variables, with an AU-ROC of 0.71 and 0.72 for AKI and 0.84 and 0.87 for RRT respectively. CONCLUSION: In the present study, simple, clinically applicable models for predicting AKI and RRT preoperatively and immediate postoperatively were developed. Even though AKI prediction remained poor, RRT prediction was good with a parsimonious model.

Long-Term Results of the RAPCO Trials.

BACKGROUND: An internal thoracic artery graft to the left anterior descending artery is standard in coronary bypass surgery, but controversy exists on the best second conduit. The RAPCO trials (Radial Artery Patency and Clinical Outcomes) were designed to compare the long-term patency of the radial artery (RA) with that of the right internal thoracic artery (RITA) and the saphenous vein (SV). METHODS: In RAPCO-RITA (the RITA versus RA arm of the RAPCO trial), 394 patients <70 years of age (or <60 years of age if they had diabetes mellitus) were randomized to receive RA or free RITA graft on the second most important coronary target. In RAPCO-SV (the SV versus RA arm of the RAPCO trial), 225 patients ≥70 years of age (or ≥60 years of age if they had diabetes mellitus) were randomized to receive RA or SV graft. The primary outcome was 10-year graft failure. Long-term mortality was a nonpowered coprimary end point. The main analysis was by intention to treat. RESULTS: In the RA versus RITA comparison, the estimated 10-year patency was 89% for RA versus 80% for free RITA (hazard ratio for graft failure, 0.45 [95% CI, 0.23-0.88]). Ten-year patient survival estimate was 90.9% in the RA arm versus 83.7% in the RITA arm (hazard ratio for mortality, 0.53 [95% CI, 0.30-0.95]). In the RA versus SV comparison, the estimated 10-year patency was 85% for the RA versus 71% for the SV (hazard ratio for graft failure, 0.40 [95% CI, 0.15-1.00]), and 10-year patient survival estimate was 72.6% for the RA group versus 65.2% for the SV group (hazard ratio for mortality, 0.76 [95% CI, 0.47-1.22]). CONCLUSIONS: The 10-year patency rate of the RA is significantly higher than that of the free RITA and better than that of the SV. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00475488.

Continuous Magnesium Infusion to Prevent Atrial Fibrillation After Cardiac Surgery: A Sequential Matched Case-Controlled Pilot Study.

OBJECTIVE: The authors aimed to test whether a bolus of magnesium followed by continuous intravenous infusion might prevent the development of atrial fibrillation (AF) after cardiac surgery. DESIGN: Sequential, matched, case-controlled pilot study. SETTING: Tertiary university hospital. PARTICIPANTS: Matched cohort of 99 patients before and intervention cohort of 99 consecutive patients after the introduction of a continuous magnesium infusion protocol. INTERVENTIONS: The magnesium infusion protocol consisted of a 10 mmol loading dose of magnesium sulphate followed by a continuous infusion of 3 mmol/h over a maximum duration of 96 hours or until intensive care unit discharge. MEASUREMENTS AND MAIN RESULTS: The study groups were balanced except for a lower cardiac index in the intervention cohort. The mean duration of magnesium infusion was 27.93 hours (95% confidence interval [CI]: 24.10-31.76 hours). The intervention group had greater serum peak magnesium levels: 1.72 mmol/L ± 0.34 on day 1, 1.32 ± 0.36 on day 2 versus 1.01 ± 1.14 and 0.97 ± 0.13, respectively, in the control group (p < 0.01). Atrial fibrillation occurred in 25 patients (25.3%) in the intervention group and 40 patients (40.4%) in the control group (odds ratio 0.49, 95% CI, 0.27-0.92; p = 0.023). On a multivariate Cox proportional hazards model, the hazard ratio for the development of AF was significantly less in the intervention group (hazard ratio 0.45, 95% CI, 0.26-0.77; p = 0.004). CONCLUSION: The magnesium delivery strategy was associated with a decreased incidence of postoperative AF in cardiac surgery patients. These findings provide a rationale and preliminary data for the design of future randomized controlled trials.

Left atrial cavernous haemangioma presenting with cardiac tamponade in a patient with Cowden syndrome.

Cowden syndrome (CS) is a rare disorder characterised by multiple non-cancerous, tumour-like growths called hamartomas. The syndrome is associated with the development of cancer of the breast, endometrium, kidneys, skin and rarely the brain. We report a rare case of symptomatic cardiac haemangioma in a patient with CS. A 54-year-old woman with CS presented with dyspnoea and orthopnoea in the setting of cardiac tamponade. Echocardiography revealed a large haemopericardium and tamponade physiology, secondary to a pericardial mass. The patient underwent urgent cardiopulmonary bypass with removal of the mass. Histopathology confirmed a benign cavernous haemangioma. We postulate that tumours involving the heart/pericardium may be an additional manifestation of CS. This case further highlights the necessity to consider pericardial/cardiac manifestations in patients with hamartomatous syndromes who present with cardiorespiratory symptoms, so that opportunistic investigation and treatment may be instituted.

Development and Validation of a Score to Identify Cardiac Surgery Patients at High Risk of Prolonged Mechanical Ventilation.

OBJECTIVE: To develop and validate a score for the early identification of cardiac surgery patients at high risk of prolonged mechanical ventilation (MV) who may be suitable targets for interventional trials. DESIGN: Retrospective analysis. SETTING: Tertiary intensive care unit. PARTICIPANTS: Cardiac surgery patients. INTERVENTIONS: Observational study. MEASUREMENTS AND MAIN RESULTS: The study comprised 1,994 patients. Median age was 67 years, and 1,457 patients (74%) were male. Median duration of MV was 9.4 hours. A total of 229 (11%), 182 (9%), and 127 (6%) patients received MV for ≥24, ≥36, and ≥48 hours, respectively. In-hospital mortality was 13%, 15%, and 17%, respectively. For the study model, all preoperative, intraoperative, and early (first 4 hours) postoperative variables were considered. A multivariable logistic regression model was developed, and a predictive scoring system was derived. Using MV ≥24 hours as the primary outcome, the model performance in the development set was good with a c-index of 0.876 (95% confidence interval 0.846-0.905) and a Brier's score of 0.062. In the validation set, the c-index was 0.907 (0.867-0.948), Brier's score was 0.059, and the model remained well calibrated. CONCLUSIONS: The authors developed a simple score to predict prolonged MV after cardiac surgery. This score, if externally validated, is potentially suitable for identifying a high-risk target population for future randomized controlled trials of postoperative care after cardiac surgery.

Bilateral versus Single Internal-Thoracic-Artery Grafts at 10 Years.

BACKGROUND: Multiple arterial grafts may result in longer survival than single arterial grafts after coronary-artery bypass grafting (CABG) surgery. We evaluated the use of bilateral internal-thoracic-artery grafts for CABG. METHODS: We randomly assigned patients scheduled for CABG to undergo bilateral or single internal-thoracic-artery grafting. Additional arterial or vein grafts were used as indicated. The primary outcome was death from any cause at 10 years. The composite of death from any cause, myocardial infarction, or stroke was a secondary outcome. RESULTS: A total of 1548 patients were randomly assigned to undergo bilateral internal-thoracic-artery grafting (the bilateral-graft group) and 1554 to undergo single internal-thoracic-artery grafting (the single-graft group). In the bilateral-graft group, 13.9% of the patients received only a single internal-thoracic-artery graft, and in the single-graft group, 21.8% of the patients also received a radial-artery graft. Vital status was not known for 2.3% of the patients at 10 years. In the intention-to-treat analysis at 10 years, there were 315 deaths (20.3% of the patients) in the bilateral-graft group and 329 deaths (21.2%) in the single-graft group (hazard ratio, 0.96; 95% confidence interval [CI], 0.82 to 1.12; P=0.62). Regarding the composite outcome of death, myocardial infarction, or stroke, there were 385 patients (24.9%) with an event in the bilateral-graft group and 425 patients (27.3%) with an event in the single-graft group (hazard ratio, 0.90; 95% CI, 0.79 to 1.03). CONCLUSIONS: Among patients who were scheduled for CABG and had been randomly assigned to undergo bilateral or single internal-thoracic-artery grafting, there was no significant between-group difference in the rate of death from any cause at 10 years in the intention-to-treat analysis. Further studies are needed to determine whether multiple arterial grafts provide better outcomes than a single internal-thoracic-artery graft. (Funded by the British Heath Foundation and others; Current Controlled Trials number, ISRCTN46552265 .).

Predictors and Outcomes of Cardiac Surgery-Associated Delirium. A Single Centre Retrospective Cohort Study.

BACKGROUND: The predictors and independent outcome association of delirium after cardiac surgery are important and yet poorly characterised. METHODS: We performed a retrospective observational study of cardiac surgery patients between January 2009 and March 2016. We defined delirium using ICD-10 diagnostic codes. Multivariable analysis was conducted to find independent associations between baseline variables, delirium, and key clinical outcomes. RESULTS: We studied 2,447 study patients (28.7% female, median age was 66 [IQR 57-74] years). Delirium was coded for in 12.9% of patients overall, and in 22.9% of those aged >75years. Increasing age, Charlson co-morbidity index, admission not from home, peripheral vascular disease, respiratory disease, preoperative atrial fibrillation, duration of cardiopulmonary bypass and nature of surgery were all independent predictors of delirium. Delirium was independently and strongly associated with increased risk of reintubation (OR 8.18 [95% CI 5.24-12.78]), tracheostomy (OR 10.44 [95% CI 5.91-18.45]), and increased length of stay by 113.7 [95% CI 99.7-127.7] ICU hours and 6.95 [95% CI 5.94-7.95] hospital days, but not 30-day mortality (OR 0.78 [95% CI 0.38-1.59]; p=0.5). CONCLUSIONS: Delirium is common in cardiac surgery patients and increases with age. Delirium was the strongest predictor of reintubation, need for tracheostomy, and prolongation of intensive care unit (ICU) and hospital length of stay. Delirium prevention and attenuation are a priority in cardiac surgery patients.