The Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database Program - Two Decades of Quality Assurance Data.

Over two decades, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) cardiac surgery database program has evolved from a single state-based database to a national clinical quality registry program and is now the most comprehensive cardiac surgical registry in Australia. We report the current structure and governance of the program and its key activities.

Structured Feedback: Acceptability and Feasibility of a Strategy to Enhance the Role of a Clinical Quality Registry to Drive Change in Cardiac Surgical Practice.

BACKGROUND: The Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) Database collects and monitors preoperative, operative, and 30-day outcome data on patients undergoing cardiac surgery, and delivers regular performance feedback reports to key personnel with intent to drive quality improvement. The current feedback approach appears to be ineffective in driving change to minimise Unit performance variation. We sought to determine the acceptability and feasibility of providing structured feedback in addition. METHODS: Cardiac surgeons were surveyed to assess their evaluation of the current feedback reports and assist in developing the content of structured feedback. We then assessed acceptability and performance outcomes of control Units receiving current feedback reports via email, versus intervention Units that in addition received structured feedback. RESULTS: Survey respondents assessing the current feedback report agreed that the content is relevant (95%), key performance indicators (KPIs) are useful (85%), and that it would be beneficial to compare surgeons' KPIs (75%). Survey respondents rating method of feedback, requested structured feedback sessions one to two times annually (67%; control Units), and future structured feedback (83%; intervention Units). With combined report and structured feedback, improved performance was noted for an under-performing Unit. Limitations of feedback in driving quality improvement was high performance of Units at baseline, low surgeon participation, and scheduling challenges for structured feedback. CONCLUSIONS: In this pilot study, compared to the control method, structured feedback did not significantly improve communication. To maximise quality improvement efforts, a collaborative feedback approach that fosters a climate of continuous performance improvement, is recommended.

Preoperative atrial fibrillation is an independent predictor of worse early and late outcomes after isolated coronary artery bypass graft surgery.

OBJECTIVES: To evaluate the impact of preoperative atrial fibrillation (pre-op AF) on early and late mortality after isolated coronary artery bypass graft (CABG) surgery. METHODS: Data obtained prospectively between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analyzed. Patients who underwent concomitant atrial arrhythmia surgery/ablation were excluded. Demographic and operative data were compared between patients with and without pre-op AF. The independent association of pre-op AF on early mortality, perioperative complications, and late mortality was determined. RESULTS: Isolated CABG surgery was performed in 21,534 patients; 1312 (6.1%) presented with pre-op AF. Pre-op AF patients were older (mean age, 71 years vs. 65 years, p<0.001) and had more comorbidities reflected in a higher additive EuroSCORE (8.4±3.5 vs. 6.5±3.2, p=0.001). Even after accounting for confounding factors, however, pre-op AF was associated with a 63% increase in 30-day mortality [4.2% vs. 1.4%; hazard ratio (HR), 1.63; 95% confidence interval (CI), 1.17-2.29; p=0.004] and 39% increase in late mortality (5-year survival, 78% vs. 90%; HR, 1.39; 95% CI, 1.20-1.61; p<0.001). CONCLUSION: Pre-op AF is an independent predictor of poor early and late outcomes. Pre-op AF should be considered, therefore, in the development or update of risk stratification models for CABG surgery.

AusSCORE II in predicting 30-day mortality after isolated coronary artery bypass grafting in Australia and New Zealand.

OBJECTIVES: To update the Australian System for Cardiac Operative Risk Evaluation (AusSCORE) model for operative estimation of 30-day mortality risk after isolated coronary artery bypass grafting in the Australian population. METHODS: Data were collected by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons registry from 2001 to 2011 in 25 hospitals. A total of 31,250 patients underwent isolated coronary artery bypass grafting and the outcome was 30-day mortality. A total of 2154 (6.9%) patients had 1 or multiple missing values. Missing values were estimated assuming missing completely at random and logistic regression with a generalized estimating equation was used to address within-hospital variance. Bootstrapping methods were used to construct and validate the updated model (AusSCORE II). Also the model was validated on an out-of-creation sample of 4700 patients who underwent bypass surgery in 2012. RESULTS: The average age of the patients was 65.6±12.9 years and 78.6% were male. Thirteen variables were selected in the updated model. The bootstrap discrimination and calibration of the AusSCORE II was very good (receiver operating characteristics [ROC], 82.0%; slope calibration, 0.987). The overall observed/AusSCORE II predicted mortality was 1.63% compared with the original AusSCORE predicted mortality of 1.01%. The validation of the AusSCORE II on the out-of-sample data also showed a high performance of the model (ROC, 84.5%; Hosmer-Lemoshow P value, .7654). CONCLUSIONS: The AusSCORE II model provides improved prediction of 30-day mortality and successfully stratifies patient risk. The model will be useful to improve the preoperative consultation regarding risk stratification in terms of 30-day mortality.

A propensity-score matched analysis on the impact of postoperative atrial fibrillation on the early and late outcomes after concomitant aortic valve replacement and coronary artery bypass graft surgery.

BACKGROUND: Postoperative atrial fibrillation (POAF) is a known complication of cardiac surgery. There is a paucity of data on the effects of POAF on short-term and long-term outcomes after concomitant aortic valve replacement and coronary artery bypass grafting (AVR-CABG ). METHODS: We retrospectively reviewed data on patients without preexisting arrhythmia who underwent isolated first-time AVR-CABG between June 2001 and December 2009 using the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program. Preoperative characteristics, early postoperative outcomes and late survival were compared between patients who developed POAF and those who did not. Propensity score matching was performed to account for the differences between the two groups. RESULTS: Isolated AVR-CABG surgery was performed in 2028 patients without preexisting arrhythmias at 18 Australian institutions, of whom 894 (44.1%) developed POAF. POAF patients were generally older (mean age, 75 vs. 73 years, P < 0.001). From the initial study population, 715 propensity-matched patient-pairs were derived; the overall matching rate was 80.0%. In the matched groups, 30-day mortality was similar in both groups (3.5 vs. 2.1%, P = 0.16). Patients with POAF, however, were more likely to develop perioperative complications, including new renal failure, prolonged ventilation (>24 h), multisystem failure and readmission within 30 days of surgery (all P < 0.05). Patients with POAF also had a significantly greater length of hospital stay (P < 0.001). Seven-year survival was not significantly different between the two groups (72 vs. 75%, P = 0.11). CONCLUSION: POAF was not associated with an increased risk of early or late mortality. It is, however, associated with poorer perioperative outcomes. It is important to evaluate potential treatment strategies for POAF.

Training surgeon status is not associated with an increased risk of early or late mortality after isolated aortic valve replacement surgery.

BACKGROUND: Few studies have addressed the effect of "trainee surgeon" status on outcomes after isolated aortic valve replacement (AVR). METHODS AND RESULTS: A retrospective analysis of data, collected by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program between June 2001 and December 2009 was performed. Patient demographics, intra-operative characteristics and early morbidity were compared between trainee and staff cases. Multivariate analyses were used to determine the independent association of training status with 30-day and late mortality. Isolated AVR was performed in 2747 patients; of these, 369 (13.4%) were by trainees. Compared to staff cases, trainee cases were less likely to present with renal failure (1.1% vs. 3.7%, p = 0.010) or in a critical preoperative state (1.4% vs. 3.7%, p = 0.020). The mean EuroSCORE was lower in trainee patients, compared to staff patients (8.11 ± 2.80 vs. 8.81 ± 3.09, p < 0.001). Trainee cases had longer mean perfusion (117.9 min vs. 98.9 min, p < 0.001) and cross-clamp (88.8 min vs. 73.2 min, p < 0.001) times. The incidence of early complications was similar between the two groups, except for post-operative myocardial infarction (1.1% vs. 0.3%, p = 0.008) and red blood cell transfusion (43.9 vs. 40.0%, p = 0.006). On multivariate analysis, trainee status was not associated with an increased risk of 30-day mortality (2.2% vs. 2.4%, p = 0.823). Moreover, there was no significant difference in long-term outcomes and 5-year survival was comparable in both groups (89.9% vs. 84.8%, p = 0.274). CONCLUSIONS: Isolated AVR can be safely and effectively performed by trainee surgeons who are strictly supervised in the operating theatre especially during the technically complex parts of the procedure.

Impact of smoking status on outcomes after concomitant aortic valve replacement and coronary artery bypass graft surgery.

BACKGROUND: There is a paucity of data on the impact of smoking status on outcomes after concomitant aortic valve replacement and coronary artery bypass graft (AVR-CABG) surgery. METHODS: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who were nonsmokers, previous smokers, and current smokers using chi-square test and t-test. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively. RESULTS: Concomitant AVR-CABG surgery was performed in 2,563 patients; smoking status was recorded in 2,558 (99.8%) patients. Of these, 1,052 (41.1%) patients had no previous smoking history, 1,345 (52.6%) patients were previous smokers, and 161 (6.3%) patients were current smokers. The 30-day mortality rate was 3.5% in nonsmokers, 4.1% in previous smokers, and 3.1% in current smokers (p = nonsignificant). The incidence of perioperative complications was similar in the three groups. The mean follow-up period for this study was 36 months (range, 0-105 months). After adjusting for differences in patient variables, the incidence of late mortality was higher in previous smokers (hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.14-1.81; p = 0.002) compared with nonsmokers. A trend toward increased late mortality in current smokers was noted (HR, 1.34; 95% CI, 0.86-2.08; p = 0.201). CONCLUSION: Smoking is not associated with adverse outcomes after concomitant AVR-CABG surgery. Smoking status should not, therefore, preclude these patients from undergoing this procedure. Given the adverse effect of smoking on overall cardiovascular morbidity and mortality and late postoperative mortality, patients should be encouraged to quit smoking.

Impact of left ventricular dysfunction on early and late outcomes in patients undergoing concomitant aortic valve replacement and coronary artery bypass graft surgery.

BACKGROUND: An increasing proportion of patients present for concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) with left ventricular (LV) dysfunction. The aim of this study was to evaluate the early outcomes and late survival of patients with different degrees of LV function undergoing concomitant AVR and CABG. METHODS: Between June 2001 and December 2009, patients undergoing concomitant AVR-CABG were identified from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program. Demographic, operative data and post-operative outcomes were compared between patients with normal (> 60%), moderately impaired (30- -60%), and severely impaired (< 30%) estimated LV ejection fraction (LVEF). Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively. RESULTS: AVR-CABG was performed in 2,563 patients with a mean follow up of 36 months (range 0-106). 144 (5.6%) had severely impaired LVEF, 983 (38.3%) had moderately impaired LVEF while the remaining 1377 (53.7%) had normal LVEF. The 30-day mortality in patients with severely impaired, moderately impaired and normal LVEF was 9.0%, 4.3% and 2.9%, respectively. This was significant on univariate (p < 0.001) but not multivariate analysis (p = NS). Severely impaired, moderately impaired and normal LVEF patients experienced 5-year survivals of 63.7%, 77.1% and 82.5%, respectively. Severely impaired LVEF was an independent multivariable predictor of late mortality (HR 1.71; 95% CI 1.22-2.40; p = 0.002). CONCLUSIONS: Patients with severely impaired LVEF experience worse outcomes. However, in the era of modern surgery, this alone should not predicate exclusion, given the established benefits of surgery in this high-risk group.

Impact of smoking status on early and late outcomes after isolated aortic valve replacement surgery.

BACKGROUND AND AIM OF THE STUDY: Currently, insufficient data exist relating to the impact of smoking status on outcomes after isolated aortic valve replacement (AVR) surgery. METHODS: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (SCTS) Cardiac Surgery Database Program was analyzed retrospectively. Demographic and operative data were compared between patients who were non-smokers, previous smokers and current smokers, using chi-square and t-tests. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively. RESULTS: Isolated AVR surgery was performed in 2,790 patients; smoking status was recorded in 2,784 cases (99.8%). Of these patients 1,346 (48.3%) had no previous smoking history, 1,232 (44.3%) were previous smokers, and 206 (7.4%) were current smokers. The 30-day mortality rate was 2.3% in nonsmokers, 2.7% in previous smokers, and 0.5% in current smokers (p = NS). The incidence of perioperative complications was generally similar in the three groups, but current smokers were at an increased risk of pneumonia (p = 0.030) and postoperative myocardila infarction (p = 0.007). The mean follow up period for the study was 37 months (range: 0-105 months). After adjusting for differences in patient variables, the incidence of late mortality was not higher in previous smokers (HR 1.13; 95% CI 0.87-1.46; p = 0.372) or current smokers (HR 1.25; 95% CI 0.66-2.36; p = 0.494) compared to non-smokers. CONCLUSION: Smoking status does not necessarily portend a poorer perioperative outcome in patients undergoing isolated AVR.

Does the addition of a radial artery graft improve survival after higher risk coronary artery bypass grafting? A propensity-score analysis of a multicentre database.

OBJECTIVES: The use of the radial artery as a second arterial graft during coronary surgery has grown in popularity due to high patency and low harvest site complication rates. We sought to assess whether higher risk patients derive prognostic benefit. METHODS: From 2001 to 2009, 11,388 patients underwent isolated primary multivessel coronary surgery. We identified a higher risk subgroup (n = 2581) according to emergent status, coronary instability, low ejection fraction and/or aortic counterpulsation. Among these, 1832 (71%) received at least one radial artery graft in addition to a left internal thoracic artery (LITA). The remaining 749 (29%) received LITA and veins only. RESULTS: Patients not receiving a radial artery were more likely to be elderly, female, have poor left ventricular function or be of emergent status. These patients experienced higher unadjusted 30-day mortality (radial: 2% vs vein: 8%, P < 0.0001) with lower unadjusted 7-year survival (80 ± 1.3 vs 67 ± 2.4%, P < 0.0001). Subsequently, 515 patients in the radial group were propensity-matched to 515 receiving LITA + veins (mean logistic EuroSCORE, radial: 11.6 ± 9.7% vs vein: 11.6 ± 10.3%, P = 0.99). At 30 days, there were comparable rates of mortality (radial: 4% vs vein: 3%, P > 0.99), stroke (1 vs 1%, P > 0.99), myocardial infarction (1 vs 2%, P = 0.79), and any morbidity/mortality (34 vs 35%, P = 0.95). At 7 years, survival rates between the radial and vein groups were similar (radial: 75 ± 2.6% vs vein: 74 ± 2.9%, P = 0.65). CONCLUSIONS: Patients with the greatest coronary instability, urgency of surgery or impairment of ventricular function are not disadvantaged in early outcomes or mid-term survival by the use of only a single arterial graft.

Impact of smoking status on early and late outcomes after isolated coronary artery bypass graft surgery.

BACKGROUND: There are limited data on the impact of smoking status on outcomes after isolated coronary artery bypass graft (CABG) surgery. METHODS: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who were non-smokers, previous smokers, and current smokers. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively. RESULTS: Isolated CABG surgery was performed in 21 534 patients; smoking status was recorded in 21486 (99.8%). Of these, 7023 (32.6%) had no previous smoking history, 11183 (59.1%) were previous smokers, and 3290 (15.2%) were current smokers. The 30-day mortality rate was 1.8% in non-smokers, 1.5% in previous smokers, and 1.5% in current smokers (p=NS). The incidence of peri-operative complications was generally similar in the three groups, but current smokers were at an increased risk of pneumonia (p<0.001), and multisystem failure (p=0.003). The mean follow-up period for this study was 37 months (range, 0-106 months). After adjusting for differences in patient variables, the incidence of late mortality was higher in previous smokers [hazard ratio (HR), 1.73; 95% confidence interval (CI), 1.47-2.05; p<0.001] or current smokers (HR, 1.41; 95% CI, 1.26-1.59; p<0.001) compared to non-smokers. CONCLUSION: Smoking status is not associated with early mortality after isolated CABG. It is, however, associated with an increased risk of pulmonary complications and reduced long-term survival.

Preoperative atrial fibrillation is an independent risk factor for mid-term mortality after concomitant aortic valve replacement and coronary artery bypass graft surgery.

OBJECTIVES: Preoperative atrial fibrillation (PAF) has been associated with poorer early and mid-term outcomes after isolated valvular or coronary artery bypass graft surgery. Few studies, however, have evaluated the impact of PAF on early and mid-term outcomes after concomitant aortic valve replacement and coronary aortic bypass graft (AVR-CABG) surgery. METHODS: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program was retrospectively analysed. Patients who underwent concomitant atrial arrhythmia surgery/ablation were excluded. Demographic and operative data were compared between patients undergoing concomitant AVR-CABG who presented with PAF and those who did not using chi-square and t-tests. The independent impact of PAF on 12 short-term complications and mid-term mortality was determined using binary logistic and Cox regression, respectively. RESULTS: Concomitant AVR-CABG surgery was performed in 2563 patients; 322 (12.6%) presented with PAF. PAF patients were generally older (mean age 76 vs 74 years; P < 0.001) and presented more often with comorbidities including congestive heart failure, chronic pulmonary disease and cerebrovascular disease (all P < 0.05). PAF was associated with 30-day mortality on univariate analysis (P = 0.019) but not multivariate analysis (P = 0.53). The incidence of early complications was not significantly higher in the PAF group. PAF was independently associated with reduced mid-term survival (HR, 1.58; 95% CI, 1.14-2.19; P = 0.006). CONCLUSIONS: PAF is associated with reduced mid-term survival after concomitant AVR-CABG surgery. Patients with PAF undergoing AVR-CABG should be considered for a concomitant surgical ablation procedure.

Postoperative atrial fibrillation after isolated aortic valve replacement: a cause for concern?

BACKGROUND: Several studies have shown that postoperative atrial fibrillation (POAF) is associated with poorer short-term and long-term outcomes after general cardiac operations. There is, however, a paucity of data on the impact of POAF on outcomes after isolated aortic valve replacement (AVR). METHODS: Data for all patients undergoing isolated first-time AVR between June 2001 and December 2009 was obtained from the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) National Cardiac Surgery Database Program and a retrospective analysis was conducted. Preoperative characteristics, early postoperative outcome, and late survival were compared between patients in whom POAF developed and those in whom it did not. Propensity score matching was performed to correct for differences between the 2 groups. RESULTS: Excluding patients with preoperative arrhythmia, isolated first-time AVR was performed in 2,065 patients. POAF developed in 725 (35.1%) of them. Patients with POAF were significantly older (mean age, 72 versus 65 years; p < 0.001) and presented more often with comorbidities, including hypertension, respiratory disease, and hypercholesterolemia (all p < 0.05). From the initial study population, 592 propensity-matched patient pairs were derived; the overall matching rate was 81.7%. In the matched groups, 30-day mortality was not significantly different between the POAF and non-POAF groups (1.5% versus 1%; p = 0.48). Patients with POAF were, however, at an independently increased risk of perioperative complications, including new renal failure, gastrointestinal complications, and 30-day readmission (p < 0.05). Seven-year mortality was not significantly different between POAF and non-POAF groups (78% versus 83%; p = 0.63). CONCLUSIONS: POAF is a risk factor for short-term morbidity but is not associated with a higher rate of early or late mortality after isolated AVR.

Excellent short- and long-term outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training.

OBJECTIVE: No previous studies have specifically addressed the effect of training on outcomes after concomitant aortic valve replacement and coronary artery bypass grafting. This study evaluated the early and late outcomes after concomitant aortic valve replacement and coronary artery bypass grafting performed by surgeons in training. METHODS: A retrospective analysis of data collected prospectively by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database between June 2001 and December 2009 was performed. Concomitant aortic valve replacement and coronary artery bypass grafting was performed in 2540 patients; of these procedures, 290 (11.4%) were by trainees. Patient demographics, intraoperative characteristics, and early morbidity were compared between trainee and staff cases using chi-square analysis and t tests. Multivariate analyses were used to determine the independent association of training status with 30-day and late mortality. RESULTS: Compared with staff cases, trainee cases were younger (mean age, 73.0 vs 74.2 years; P = .025) and less likely to present with triple vessel disease (27.9% vs 38.3%, P = .001) or previous cardiac surgery (6.3% vs 2.8%, P = .016). Trainee cases had longer mean perfusion (160.4 vs 144.6 minutes, P < .001) and crossclamp (125.2 vs 114.6 minutes, P < .001) times. The incidence of early complications was similar between the 2 groups. On multivariate analysis, trainee status was not associated with an increased risk of 30-day mortality (2.4% vs 4.0%, P = .348). Moreover, there was no significant difference in long-term outcomes, and 5-year survival was comparable in both groups (79.6% vs 77.4%, P = .200). CONCLUSIONS: Concomitant aortic valve replacement and coronary artery bypass grafting can be safely and effectively performed by properly supervised trainees in the contemporary era. It is imperative to offer training opportunities to junior surgeons in this complex procedure to ensure quality patient outcomes in the future.

Does preoperative atrial fibrillation portend a poorer prognosis in patients undergoing isolated aortic valve replacement? A multicentre Australian study.

BACKGROUND: Preoperative atrial fibrillation (preop-AF) has been associated with poorer early and late outcomes after cardiac surgery. Few studies, however, have evaluated the impact of preop-AF on early and late outcomes after isolated aortic valve replacement (AVR). METHODS: Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program was retrospectively analyzed. Patients who underwent concomitant atrial arrhythmia surgery/ablation were excluded. Demographic and operative data were compared between patients undergoing isolated AVR who presented with preop-AF and those in sinus rhythm. The independent effect of preop-AF on 12 short-term complications and long-term survival was determined using binary logistic and cox regression, respectively. RESULTS: Isolated AVR surgery was performed in 2789 patients; 380 (13.6%) presented with preop-AF. Preop-AF patients were generally older (mean age, 73 vs 68 years; P < 0.001) and presented more often with comorbidities including congestive heart failure, diabetes, and cerebrovascular disease (all P < 0.05). There was a trend toward increased 30-day mortality in patients with preop-AF on multivariate analysis (P = 0.051). The incidence of early complications was similar in both groups on multivariate analysis (P > 0.05). Preop-AF was independently associated with reduced long-term survival (hazard ratio, 1.36; 95% confidence interval, 1.01-1.83; P = 0.041). CONCLUSIONS: Preop-AF is associated with an increased risk of late mortality after isolated AVR. As such, concomitant atrial ablation with AVR should be prospectively studied.

Sex differences in outcomes following isolated coronary artery bypass graft surgery in Australian patients: analysis of the Australasian Society of Cardiac and Thoracic Surgeons cardiac surgery database.

OBJECTIVES: Women undergoing isolated coronary artery bypass graft (CABG) surgery have been previously shown to be at an independently increased risk for post-operative morbidity and mortality. The current study evaluates the impact of sex as an independent risk factor for early and late morbidity and mortality following isolated CABG surgery. METHODS: Data obtained between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program was retrospectively analysed. Demographic, operative data and post-operative complications were compared between male and female patients using chi-square and t-tests. Long-term survival analysis was performed using Kaplan-Meier survival curves and the log-rank test. Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively. RESULTS: CABG surgery was undertaken in 21 534 patients at 18 Australian institutions; 22.2% were female. Female patients were generally older (mean age, 68 vs. 65 years, P < 0.001) and presented more often with congestive heart failure (P < 0.001), hypertension (P < 0.001), diabetes mellitus (P < 0.001) and cerebrovascular disease (P < 0.001). Women demonstrated a greater 30-day mortality (2.2% vs. 1.5%, P < 0.001) on univariate analysis but not on multivariate analysis (P = 0.638). Similarly, women demonstrated a greater late mortality than men on univariate analysis (P = 0.006) but not on multivariate analysis (P = 0.093). Women had a decreased risk of early complications including new renal failure (P = 0.001) and deep sternal wound infection (P = 0.017) but were more likely to require red blood cell transfusion (P < 0.001). CONCLUSIONS: Female patients undergoing isolated CABG surgery have a greater 30-day mortality which may be accounted for by a poorer pre-operative risk factor profile. Further investigation is required into the reasons for differential outcome after CABG based on sex.

Early and late outcomes after isolated aortic valve replacement in octogenarians: an Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Study.

OBJECTIVE: The advent of percutaneous aortic valve implantation has increased interest in the outcomes of conventional aortic valve replacement in elderly patients. The current study critically evaluates the short-term and long-term outcomes of elderly (≥80 years) Australian patients undergoing isolated aortic valve replacement. METHODS: Data obtained prospectively between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analysed. Isolated aortic valve replacement was performed in 2791 patients; of these, 531 (19%) were at least 80 years old (group 1). The patient characteristics, morbidity and short-term mortality of these patients were compared with those of patients who were <80 years old (group 2). The long-term outcomes in elderly patients were compared with the age-adjusted Australian population. RESULTS: Group 1 patients were more likely to be female (58.6% vs 38.0%, p<0.001) and presented more often with co-morbidities including hypertension, cerebrovascular disease and peripheral vascular disease (all p<0.05). The 30-day mortality rate was not independently higher in group 1 patients (4.0% vs 2.0%, p=0.144). Group 1 patients had an independently increased risk of complications including new renal failure (11.7% vs 4.2%, p<0.001), prolonged (≥24 h) ventilation (12.4% vs 7.2%, p=0.003), gastrointestinal complications (3.0% vs 1.3%, p=0.012) and had a longer mean length of intensive care unit stay (64 h vs 47 h, p<0.001). The 5-year survival post-aortic valve replacement was 72%, which is comparable to that of the age-matched Australian population. CONCLUSION: Conventional aortic valve replacement in elderly patients achieves excellent outcomes with long-term survival comparable to that of an age-adjusted Australian population. In an era of percutaneous aortic valve implantation, it should still be regarded as the gold standard in the management of aortic stenosis.

Usefulness of postoperative atrial fibrillation as an independent predictor for worse early and late outcomes after isolated coronary artery bypass grafting (multicenter Australian study of 19,497 patients).

Several studies have shown that postoperative atrial fibrillation (POAF) is associated with poorer short- and long-term outcomes after isolated coronary artery bypass grafting surgery. Nevertheless, there is considerable debate as to whether this reflects an independent association of POAF with poorer outcomes or confounding by other factors. We sought to investigate this issue. Data obtained from June 2001 through December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analyzed. Demographic and operative data were compared between patients who developed POAF and those who did not using chi-square and t tests. The independent impact of POAF on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively. Excluding patients with preoperative arrhythmia, isolated coronary artery bypass grafting surgery was performed in 19,497 patients. Of these, 5,547 (28.5%) developed POAF. Patients with POAF were generally older (mean age 69 vs 65 years, p <0.001) and presented more often with co-morbidities including congestive heart failure (p <0.001), hypertension (p <0.001), cerebrovascular disease (p <0.001), and renal failure (p = 0.046). Patients with POAF demonstrated a greater 30-day mortality on univariate analysis but not on multivariate analysis (p = 0.376). Patients with POAF were, however, at an independently increased risk of perioperative complications including permanent stroke (p <0.001), new renal failure (p <0.001), infective complications (p <0.001), gastrointestinal complications (p <0.001), and return to the theater (p <0.001). POAF was also independently associated with shorter long-term survival (p = 0.002). In conclusion, POAF is a risk factor for short-term morbidity and decreased long-term survival. Rigorous evaluation of various therapies that prevent or decrease the impact of POAF is imperative. Moreover, patients who develop POAF should undergo strict surveillance and be routinely screened for complications after discharge.