Gender is Independently Associated With Red Blood Cell and Platelet Transfusion in Patients Undergoing Coronary Artery Bypass Grafting: Data From the Netherlands Heart Registration.

OBJECTIVES: The aim of this study was to evaluate the incidence of transfusions, including red blood cells (RBC), platelets, and fresh frozen plasma (FFP) during and after coronary artery bypass grafting (CABG) in the Netherlands. Furthermore, the authors aimed to identify the impact of sex on blood product transfusion. DESIGN: A retrospective multicenter cohort study. Data were collected from January 2013 to December 2021 from the Netherlands Heart Registration (NHR) database. SETTING: The NHR receives its data from 16 heart centers in the Netherlands. PARTICIPANTS: Patients older than 18 years who underwent CABG in the Netherlands. INTERVENTIONS: Coronary artery bypass grafting with extracorporeal circulation or off-pump coronary artery bypass grafting. MEASUREMENTS AND MAIN RESULTS: The incidence of blood transfusion, defined as transfusions intraoperatively and during the length of the hospital admission after CABG. In addition, a differentiation was made according to the type of transfusion (packed RBC, platelets, and FFP). In the overall cohort (N = 42,388), the number of patients who received a transfusion of any type was 27.0% (n = 11,428). Women received more often RBC transfusions compared with men (45.4% v 15.6%, respectively, p < 0.001). There was a significant difference between the 2 sexes regarding platelet transfusion (women 10.0% v men 11.1%, p = 0.005) but not in FFP transfusion. Female sex was independently associated with RBC transfusion, using the multivariate logistic regression analysis. CONCLUSIONS: The incidence of any blood transfusion was 27.0%, and was higher in women than in men. The female sex was independently associated with receiving RBC during and after CABG.

Long-term Outcome of Reexploration for Bleeding After Coronary Artery Bypass Grafting.

OBJECTIVES: This study aimed to determine the influence of reexploration for bleeding and blood product requirement after coronary artery bypass grafting (CABG) on long-term mortality. DESIGN: A retrospective cohort study. SETTING: A single-center institution. PARTICIPANTS: All patients who underwent CABG between January 1998 and December 2019 were included. INTERVENTIONS: The parameters were analyzed to assess the association between reexploration for bleeding and long-term mortality. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was all-cause mortality up to the end of follow-up (June 1, 2021). The secondary endpoints were 30-day mortality, duration of admission, blood product transfusion, postoperative use of an intra-aortic balloon pump, deep sternal wound infection, myocardial infarction, and neurologic complications. The Cox proportional hazards model was used to assess the association between reexploration and blood product use and all-cause mortality. Median follow-up was 9.7 years (IQR 5.1-14.6). In total, 576 out of 21,346 (2.7%) patients were reexplored for bleeding. Thirty-day mortality was 6.2% v 1.6% for the reexplored versus not reexplored patients. Reexploration for bleeding was not significantly correlated with long-term mortality (hazard ratio [HR] 1.029; p = 0.068). On the other hand, blood product transfusion (HR = 1.135; p < 0.001), and in particular, packed red blood cell (pRBC) transfusion (HR = 1.139; p < 0.001), was significantly associated with higher long-term mortality. After multivariate Cox regression using ≥5 pRBC transfused as a cut-off point, reexploration for bleeding was not significantly associated with long-term mortality (HR 0.982; p = 0.813). Receiving ≥5 pRBCs was significantly associated with higher long-term mortality (HR 1.249; p < 0.001). CONCLUSION: Reexploration for bleeding was significantly associated with higher 30-day mortality but not with long-term mortality. Poorer long-term mortality was attributed to patient characteristics and higher use of postoperative blood products.

Predictors and Outcomes of Stroke After Isolated Coronary Artery Bypass Grafting. A Single-Center Experience in 20,582 Patients.

OBJECTIVE: Stroke remains a devastating complication after cardiac surgical procedures despite perioperative monitoring and management advances. This study aimed to determine the predictors of stroke in a large, contemporary coronary artery surgery population. DESIGN: Patient data were analyzed retrospectively. SETTING: This single-center study was performed in the Catharina Hospital (Eindhoven). PARTICIPANTS: All patients who underwent isolated coronary artery bypass grafting (CABG) between January 1998 and February 2019 were included. INTERVENTIONS: Isolated CABG. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was a postoperative stroke, defined according to the international updated definition for stroke. Logistic regression was performed to retrieve variables associated with postoperative stroke. A total of 20,582 patients underwent CABG during the period of the study. Stroke was observed in 142 patients (0.7%), of which 75 (52.8%) occurred during the first 72 hours. The incidence of postoperative stroke declined over the years. A significantly higher 30-day mortality rate was seen in patients with stroke (20.4%) compared with 1.8% in the rest of the population; p < 0.001. Multivariate logistic regression analysis showed age, peripheral arterial disease, reexploration for bleeding, perioperative myocardial infarction, and year of surgery as independent predictors for stroke. Patients with postoperative stroke had worse long-term survival (log-rank p < 0.001). Cox regression analysis revealed postoperative stroke (odds ratio 2.13 [1.73-2.64)) as an independent predictor of late mortality. CONCLUSIONS: Stroke after CABG is associated with high early and late mortality. Age, peripheral vascular disease, and the year of surgery were associated with postoperative stroke.

Introduction of a New Method to Monitor Patient-Relevant Outcomes and Costs: Using a Quality Improvement Project in Transcatheter Aortic Valve Implantation Care as an Example.

BACKGROUND AND OBJECTIVE: Routine outcome monitoring is becoming standard in care evaluations, but costs are still underrepresented in these efforts. The primary aim of this study was therefore to assess if patient-relevant cost drivers can be used alongside clinical outcomes to evaluate an improvement project and to provide insight into (remaining) areas for improvement. METHODS: Data from patients who underwent transcatheter aortic valve implantation (TAVI) between 2013 and 2018 at a single center in the Netherlands were used. A quality improvement strategy was implemented in October 2015, and pre- (A) and post-quality improvement cohorts (B) were distinguished. For each cohort, clinical outcomes, quality of life (QoL), and cost drivers were collected from the national cardiac registry and hospital registration data. The most appropriate cost drivers in TAVI care were selected from hospital registration data using a novel stepwise approach with an expert panel of physicians, managers, and patient representatives. A radar chart was used to visualize the clinical outcomes, QoL and the selected costs drivers. RESULTS: We included 81 patients in cohort A and 136 patients in cohort B. All-cause mortality at 30 days was borderline significantly lower in cohort B than in cohort A (1.5% vs 7.4%, P = .055). QoL improved after TAVI for both cohorts. The stepwise approach resulted in 21 patient-relevant cost drivers. Costs for pre-procedural outpatient clinic visits (€535, interquartile range [IQR] = 321-675, vs €650, IQR = 512-890, P < .001), costs for the procedure (€1354, IQR = 1236-1686, vs €1474, IQR = 1372-1620, P < .001), and imaging during admission (€318, IQR = 174-441, vs €329, IQR = 267-682, P = .002) were significantly lower in cohort B than in cohort A. Possible improvement potential was seen in 30-day pacemaker implantation and 120-day readmission. CONCLUSION: A selection of patient-relevant cost drivers is a valuable addition to clinical outcomes for use in evaluation of improvement projects and identification of room for further improvement.

Sex Difference in Long-Term Survival After Coronary Artery Bypass Grafting Is Age-Dependent.

OBJECTIVES: Women undergoing coronary artery bypass grafting (CABG) demonstrate higher rates of postoperative morbidity and mortality than men. The aim of this study was to compare the patient profile and long-term outcomes of men and women undergoing isolated CABG. DESIGN: A retrospective patient record study and propensity score-matched analysis. SETTING: This single-center study was performed at Catharina Hospital in Eindhoven, The Netherlands. PARTICIPANTS: The study comprised 17,483 patients, of whom 13,564 (77.6%) were men and 3,919 (22.4%) were women. INTERVENTIONS: Coronary artery bypass grafting was performed between January 1998 and December 2015. MEASUREMENTS AND MAIN RESULTS: The mean follow-up period was 8.8 ± 5.0 years. Women were older than men (67.7 ± 9.4 years v 63.9 ± 9.6 years, p < 0.001) and had lower preoperative hemoglobin levels. Early mortality (30-day) (2.8% v 1.9%; p < 0.001) and one-year mortality (5.2% v 3.8%; p < 0.001) rates were significantly higher in women than in men. Women demonstrated worse long-term survival than men only in the population younger than 70 years. After propensity score matching, female sex was not identified as an independent risk factor for long-term survival. CONCLUSIONS: In the patient population, propensity score-matched analysis showed that female sex was not an independent risk factor for long-term survival after CABG. Poorer survival in women after CABG only was observed in patients <70 years of age.

Impact of preoperative antithrombotic therapy in patients undergoing elective isolated coronary artery bypass grafting.

OBJECTIVES: The objective of this retrospective study was to assess differences in clinical outcomes between patients on acetylsalicylic acid (ASA) monotherapy and patients on other antithrombotic (AT) regimens undergoing elective coronary artery bypass grafting (CABG). METHODS: Patients who underwent elective isolated CABG between 2017 and 2019 at the Catharina Hospital Eindhoven were eligible for this study. The primary end points were re-exploration for bleeding and postoperative blood product transfusion. Secondary end points included 30-day mortality, in-hospital stroke, in-hospital myocardial infarction and duration of hospitalization. Propensity matching was used to compare outcomes of the main study groups (ASA vs other AT therapy) and subgroups of AT therapy (guideline adherence vs non-adherence). RESULTS: A total of 1068 patients were included: 710 patients on ASA monotherapy and 358 patients on other AT regimens. In the 256 matched patients in the main study groups, using AT regimens other than ASA monotherapy was associated with increased risk of re-exploration for bleeding [6.6% vs 2.0%, P = 0.017; odds ratio (OR) 3.57 (1.29-9.83)] and increased use of blood products [37.5% vs 20.3%, P < 0.001; OR 2.35 (1.58-3.49)]. In 122 matched subgroup patients, non-adherence was associated with an increased risk of re-exploration [10.7% vs 3.3%, P = 0.044; OR 3.52 (1.11-11.12)] and increased blood product use [51.6% vs 25.4%, P < 0.001; OR 3.13 (1.83-5.38)]. Secondary end points were not significantly different among the main study groups and subgroups. CONCLUSIONS: Preoperative use of AT therapy other than ASA monotherapy in patients who elected CABG was associated with the increased postoperative use of blood products and risk of re-exploration for bleeding; this finding was even more pronounced in non-guideline-adherent patients.

Recent trends in aortic valve interventions: Data of the Netherlands heart registration.

BACKGROUND AND AIM OF THE STUDY: Transcatheter aortic valve implantation (TAVI) has evolved from bailout for inoperable patients to an alternative to surgical aortic valve replacement (SAVR) in higher-risk groups. The aim of this study is to describe these clinical trends in TAVI and SAVR in patients with aortic valve disease. METHODS: We analyzed data of the Netherlands Heart Registration (NHR) up to 2018 to explore the trends in TAVI and SAVR among 14 cardiac centers in the Netherlands. RESULTS: Between 2013 and 2017, a total of 7432 isolated SAVR and 5929 TAVI procedures have been performed. A 43.9% increase in the total number of procedures was observed, mainly due to the considerable increase in the number of TAVI procedures. In 2017, there was a decrease in the number of SAVR procedures. In the TAVI group, 30- and 120-day mortality decreased significantly from 7.2% and 10.6% in 2013 to 3.4% and 5.7% in 2017, respectively. In the SAVR group, 30- and 120-day mortality decreased from 1.7% and 2.9% in 2013 to 1.2% and 1.7% in 2017, respectively. Outcomes showed a significant decrease in vascular complications after TAVI. The risk profile of TAVI patients has changed over time. CONCLUSIONS: The recent developments in TAVI have contributed to the increasing numbers of aortic valve interventions in the Netherlands. Mortality rates after SAVR and TAVI decreased as did the rate of complications after TAVI. Furthermore, a trend towards decrease of preoperative risk was observed.

Effect of Adding Ticagrelor to Standard Aspirin on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting (POPular CABG): A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Approximately 15% of saphenous vein grafts (SVGs) occlude during the first year after coronary artery bypass graft surgery (CABG) despite aspirin use. The POPular CABG trial (The Effect of Ticagrelor on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting Surgery) investigated whether ticagrelor added to standard aspirin improves SVG patency at 1 year after CABG. METHODS: In this investigator-initiated, randomized, double-blind, placebo-controlled, multicenter trial, patients with ≥1 SVGs were randomly assigned (1:1) after CABG to ticagrelor or placebo added to standard aspirin (80 mg or 100 mg). The primary outcome was SVG occlusion at 1 year, assessed with coronary computed tomography angiography, in all patients that had primary outcome imaging available. A generalized estimating equation model was used to perform the primary analysis per SVG. The secondary outcome was 1-year SVG failure, which was a composite of SVG occlusion, SVG revascularization, myocardial infarction in myocardial territory supplied by a SVG, or sudden death. RESULTS: Among 499 randomly assigned patients, the mean age was 67.9±8.3 years, 87.1% were male, the indication for CABG was acute coronary syndrome in 31.3%, and 95.2% of procedures used cardiopulmonary bypass. Primary outcome imaging was available in 220 patients in the ticagrelor group and 223 patients in the placebo group. The SVG occlusion rate in the ticagrelor group was 10.5% (51 of 484 SVGs) versus 9.1% in the placebo group (43 of 470 SVGs), odds ratio, 1.29 [95% CI, 0.73-2.30]; P=0.38. SVG failure occurred in 35 (14.2%) patients in the ticagrelor group versus 29 (11.6%) patients in the placebo group (odds ratio, 1.22 [95% CI, 0.72-2.05]). CONCLUSIONS: In this randomized, placebo-controlled trial, the addition of ticagrelor to standard aspirin did not reduce SVG occlusion at 1 year after CABG. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02352402.

Preventing spasm of the radial artery conduit during coronary artery bypass grafting: Nicardipine versus verapamil.

BACKGROUND AND AIM OF THE STUDY: In vitro studies have shown a reduction in radial artery spasm with the use of calcium antagonists. The purpose of this study was to evaluate the efficacy of topical treatment of the radial artery conduit using either verapamil or nicardipine before the anastomoses. METHODS: This prospective randomized study included 131 patients, who underwent coronary artery bypass grafting surgery with the use of the radial artery as a conduit. In 65 patients, the harvested radial artery was topically treated with verapamil and in 66 patients with nicardipine. After harvesting the radial artery, the direct flow through the conduit was measured in vitro before 5-minute incubation in nicardipine or verapamil and measured again after incubation. The flow before and after incubation was compared. Postincubation flow was also compared in the two groups. After performing the anastomosis, the flow through the radial artery was measured in vivo. RESULTS: The mean flow after NaCl incubation was 19.93 ± 12.66 mL/min and after incubation in the Ca+ channel blocker 47.16 ± 14.58 mL/min (P < .001). No significant difference in postincubation free flow was found between verapamil (46.29 ± 15.43 mL/min) and nicardipine (48.01 ± 13.77 mL/min; P = .503). CONCLUSION: Topical treatment with Ca+ channel blockers reduces radial artery spasm and significantly increases the free flow through the radial artery conduit. Nicardipine is a safe and effective alternative of verapamil in preventing spasm of radial artery conduit.

A case of right ventricular outflow tract obstruction after minimally invasive aortic valve replacement.

Minimally invasive aortic valve replacement is commonly used to treat aortic valve disease through smaller incisions and upper hemisternotomy. No major differences in postoperative outcomes have been reported compared with full sternotomy aortic valve replacement. In this case report, we present a rare complication of right ventricular outflow tract obstruction after minimally invasive aortic valve replacement.

Benefits of Endoscopic Vein Harvesting in Coronary Artery Bypass Grafting.

BACKGROUND: Earlier reports concerning endoscopic vein harvesting have been controversial regarding the patency of the vein graft after coronary artery bypass grafting (CABG). In addition, data on the quality of life are lacking. In this study, we investigated our experience with endoscopic vein harvesting with regard to these end points. METHODS: The analysis included patients undergoing isolated CABG between 2012 and 2016. Patients were divided in 2 groups stratified by the technique of saphenous vein harvesting: open vs endoscopic. Primary end points were the rate of repeat revascularization and leg wound complications. Secondary end points were the physical and mental quality of life scores of the 36-Item Short Form Health Survey questionnaire. Cox proportional hazard analysis was performed to adjust the end point of repeat revascularization for relevant covariates. RESULTS: The open group included 2123 patients, and the endoscopic group included 883 patients. Overall mortality was not significantly different between the groups (P = .060). Revascularization-free survival was similar between the groups (adjusted hazard ratio, 0.65; 95% confidence interval, 0.42 to 1.02; P = .059). Endoscopic vein harvesting was significantly associated with a decreased hazard for the combined end point of death or repeat revascularization (adjusted hazard ratio, 0.64; 95% confidence interval, 0.46 to 0.90; P = .009). Significantly more leg wound complications were seen in the open group (24 vs 0; P = .002). Postoperative quality of life showed no significant differences between the 2 groups. CONCLUSIONS: Apart from the benefits on leg wound complications, endoscopic vein harvesting was comparable to open vein harvesting in the rate of repeat revascularization and quality of life.

Sex Difference in Coronary Artery Bypass Grafting: Preoperative Profile and Early Outcome.

OBJECTIVE: According to the available risk-stratification systems, women have a higher risk of mortality than men after coronary artery bypass grafting (CABG). In this study, the authors investigated the authors' CABG database to trace factors contributing to this difference in outcome between sexes. DESIGN: A retrospective patient record study. SETTING: This single-center study was performed at the Catharina Hospital in Eindhoven, the Netherlands. PARTICIPANTS: The study comprised 17,919 patients, of whom 4,016 (22.4%) were women and 13,903 (77.6%) were men. INTERVENTIONS: Coronary artery bypass grafting was performed between January 1998 and July 2016. MEASUREMENTS AND MAIN RESULTS: Early mortality was significantly higher in women than in men (2.7% v 1.9%; p = 0.001). Regarding the baseline characteristics, women were older and had a lower hemoglobin level and a lower creatinine level than men. Women more often had hypertension, diabetes, underweight (body mass index [BMI] <20 kg/m2), and obesity (BMI >30 kg/m2). The mean number of grafts per patient was less in women than in men (3.2 ± 1.1 v 3.5 ± 1.1; p < 0.001). However, the mean cross-clamp time per graft was longer in female patients than in male patients (11.6 ± 8.7 min. v 11.2 ± 7.0 min.; p = 0.013). Logistic regression analyses showed that chronic obstructive pulmonary disease, peripheral vascular disease, cross-clamp time, and underweight were independent risk factors for early mortality only in men. CONCLUSION: The preoperative patient profile is significantly different between men and women undergoing CABG. The predictive value of well-known risk factors for early mortality is different between the 2 sexes.

Impact of Sex on the Outcome of Isolated Aortic Valve Replacement and the Role of Different Preoperative Profiles.

OBJECTIVE: The aim of this study was to compare the patient profiles and outcomes of men and women undergoing isolated aortic valve replacement. DESIGN: Patient data were analyzed retrospectively. SETTING: This single-center study was performed at Catharina Hospital in Eindhoven, the Netherlands. PARTICIPANTS: The study comprised 2,362 patients, of whom 1,040 (44%) were women and 1,322 were men (56%). INTERVENTIONS: Isolated aortic valve replacement was performed between January 1998 and December 2016. MEASUREMENTS AND MAIN RESULTS: The mean follow-up was 8.3 ± 5.1 years. Women were relatively older (69.9 years v 64.6 years; p < 0.001); more of them were underweight, obese, and diabetic; and they had lower hemoglobin values and worse renal function than did men. However, fewer women than men experienced chronic obstructive pulmonary disease, aortic regurgitation, left ventricular dysfunction, and endocarditis. Early mortality did not differ significantly between men and women (p = 0.238). Overall survival was worse in women (p < 0.001). After correction for potential risk factors, female sex was not associated with worse survival. During the study period, the mean age of patients undergoing aortic valve replacement increased. In addition, the mean age at the time of death increased, following the trend of national statistics. CONCLUSIONS: Although women undergoing aortic valve replacement have relatively more risk factors than do men, early mortality in women is not significantly higher than in men. Overall survival is worse in women than in men; however, after adjustment for preoperative risk factors, there is no difference in overall survival between women and men.

Conduction disorders and impact on survival after sutureless aortic valve replacement compared to conventional stented bioprostheses.

OBJECTIVES: Sutureless and rapid-deployment aortic valve prostheses are frequently used for the treatment of aortic stenosis. However, postoperative left bundle branch block (LBBB) and permanent pacemaker (PPM) implantation have emerged as frequent complications. The aim of this study was to compare the incidence of new-onset LBBB and PPM implantation after sutureless aortic valve replacement (sAVR) with stented bioprostheses, and the impact on postoperative survival. METHODS: Patients undergoing isolated surgical aortic valve replacement (AVR) or concomitant AVR with coronary artery bypass surgery between January 2010 and July 2017 were included in the study. Two groups were defined: sAVR and conventional AVR (cAVR). The findings of preoperative electrocardiograms were compared with postoperative electrocardiogram findings for both groups. The incidence of new-onset LBBB and the requirement for PPM implantation were recorded. The effect of these conduction disorders on late survival was analysed. RESULTS: A total of 987 patients were analysed, consisting of 132 sAVR and 855 cAVR patients. The sAVR group had an increased incidence of new-onset LBBB compared to the cAVR group (16.7% vs 2.3%, P < 0.001). A significantly higher rate of postoperative PPM implantation was found for sAVR patients compared to cAVR (6.8% vs 1.6%, P = 0.001). The multivariate Cox analysis revealed that neither postoperative new-onset LBBB nor PPM implantation was associated with increased mortality (hazard ratio 1.73, 95% confidence interval 0.74-4.03, P = 0.204). CONCLUSIONS: sAVR is associated with an increased risk of new-onset LBBB and PPM requirement compared to cAVR. In this population, postoperative conduction disorders did not affect the mid-term survival.

Significantly Elevated C-Reactive Protein Levels After Epicardial Clipping of the Left Atrial Appendage.

OBJECTIVE: Besides mechanical and anatomical changes of the left atrium, epicardial closure of the left atrial appendage has also possible homeostatic effects. The aim of this study was to assess whether epicardial clipping of the left atrial appendage has different biochemical effects compared with complete removal of the left atrial appendage. METHODS: Eighty-two patients were included and underwent a totally thoracoscopic AF ablation procedure. As part of the procedure, the left atrial appendage was excluded with an epicardial clip (n = 57) or the left atrial appendage was fully amputated with an endoscopic vascular stapler (n = 25). From all patients' preprocedural and postprocedural blood pressure, electrolytes and inflammatory parameters were collected. RESULTS: The mean age and left atrial volume index were comparable between the epicardial clip and stapler group (64 ± 8 years vs. 60 ± 9 years, P = non-significant; 44 ± 15 mL/m vs. 40 ± 13 mL/m, P = non-significant). Patients receiving left atrial appendage clipping had significantly elevated C-reactive protein levels compared with patients who had left atrial appendage stapling at the second, third, and fourth postoperative day (225 ± 84 mg/L vs. 149 ± 76 mg/L, P = 0.002, 244 ± 78 vs. 167 ± 76, P = 0.004, 190 ± 74 vs. 105 ± 48, P < 0.001, respectively). Patients had a significant decrease in sodium levels, systolic, and diastolic blood pressure at 24 and 72 hours after left atrial appendage closure. However, this was comparable for both the left atrial appendage clipping and stapling group. CONCLUSIONS: Increased activation of the inflammatory response was observed after left atrial appendage clipping compared with left atrial appendage stapling. Furthermore, a significant decrease in blood pressure was observed after surgical removal of the left atrial appendage. Whether the inflammatory response affects the outcome of arrhythmia surgery needs to be further evaluated.

Use of an intraoperative checklist to decrease the incidence of re-exploration for postoperative bleeding after cardiac surgery.

OBJECTIVES: We have implemented an intraoperative checklist aiming to reduce the incidence of re-exploration for bleeding after cardiac surgery. The present report addresses the results of adopting such a checklist regarding the incidence of postoperative bleeding. METHODS: The checklist was implemented by presenting it in several staff meetings of the Catharina Heart Center. Copies of the checklist were presented in every operating room. Data were collected by the Catharina Heart Center, aligned with the 'Meetbaar Beter' data manual and validated by 'Meetbaar Beter' through their data quality system. The incidence of re-exploration for bleeding was analysed in a variable life-adjusted display curve. The patient population operated after the implementation of the checklist was compared with a recent historical population before its implementation. RESULTS: From January 2013 through April 2016, 4817 cardiac surgical procedures were performed in our institution. Before May 2015, 3210 procedures were performed (Group 1), complicated by 112 re-exploration for bleeding (3.5%). The 'reoperation for bleeding checklist' was implemented on 1 May 2015. After this date, the number of re-explorations for bleeding decreased to 29 (1.8%) of the 1607 cardiac surgical procedures (Group 2) (P < 0.05). CONCLUSIONS: An intraoperative checklist is feasible to implement, low cost, quick and simple to measure with a significant reduction in the incidence of re-exploration for bleeding. This report shows an example of the positive effects of transparency in publishing outcomes' data in cardiac surgery.

Use of Postoperative Peak Arterial Lactate Level to Predict Outcome After Cardiac Surgery.

OBJECTIVES: In the present study, the authors investigated the predictive value of postoperative peak arterial lactate levels for early and late mortality after cardiac surgery. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Single-center study in an academic hospital. PARTICIPANTS: Adult patients who underwent cardiac surgery between 2004 and 2014 (n = 16,376). INTERVENTIONS: Different cardiac surgical procedures. MEASUREMENTS AND RESULTS: Patients were classified according to the peak arterial lactate level (PALL) within 3 days postoperatively. Logistic regression analysis and Cox regression analysis were performed to identify postoperative peak arterial lactate level as a predictor for early and late mortality respectively. In 8460 patients (51.7%), lactate was not measured postoperatively because these patients were managed according to the fast-track protocol. These patients constituted group 1 in our population but were excluded from the regression analysis. The remaining patients (n = 7,916; 48.3%) were divided according to the postoperative peak arterial lactate level (PALL): PALL<5 mmol/L (group 2), PALL 5 to 10 mmol/L (group 3), and PALL of>10 mmol/L (group 4). Early mortality was 3.7%, 20.4%, and 62.9% in groups 2, 3, and 4 respectively (p<0.0001). This mortality rate was significantly higher than that of group 1 (1.6%); p<0.0001. Multivariate regression analyses revealed postoperative peak arterial lactate as a significant predictor of 30-day mortality (odds ratio = 1.44 [1.39-1.48], p<0.001) as well as for late mortality (hazard ratio = 1.05 [1.01-1.10], p<0.025). CONCLUSIONS: Postoperative peak arterial lactate level in patients undergoing cardiac surgery is an independent predictor for both early and late mortality.

Impaired Left Ventricular Function Does Not Predict Worse Late Outcome after Isolated Mitral Valve Surgery.

BACKGROUND AND AIM OF THE STUDY: The best timing for mitral valve surgery remains controversial. Decreased left ventricular function (LVF) is considered to be a predictor for increased mortality and is therefore an indication for surgery. The study aim was to investigate the independent effect of preoperative LVF on early and late mortality after mitral valve surgery. METHODS: Patients undergoing isolated mitral valve surgery between January 1998 and December 2010 at a single center were included for the analysis. Patients without recorded LVF, with active endocarditis, or patients lost to follow up were excluded. Patients were allocated to three groups based on their left ventricular ejection fraction (LVEF) measured using echocardiography as good (>50%), moderate (35-50%) or poor (<35%). A Cox regression analysis was performed to identify independent risk factors for late survival. RESULTS: A total of 549 patients underwent isolated mitral valve surgery. The 30-day mortality was not statistically different between groups (p = 0.579), and late survival was similar in all groups (log-rank, p = 0.130). A moderate or poor LVF was not identified as a risk factor for late mortality (HR 1.4 [0.9-2.2], p = 0.179; HR 1.8 [0.7-4.4], respectively, p = 0.213). The difference remained insignificant after correction for other risk factors (HR 1.4 [0.8-2.3], p = 0.192; HR 2.4 [0.9-6.7], respectively, p = 0.09). CONCLUSION: A reduced LVF is not an independent risk factor for short- and long-term all-cause mortality in patients undergoing isolated mitral valve surgery for non-ischemic mitral valve disease.

Mid-term haemodynamic and clinical results after aortic valve replacement using the Freedom Solo stentless bioprosthesis versus the Carpentier Edwards Perimount stented bioprosthesis.

OBJECTIVES: The aim of this study was to investigate the mid-term haemodynamic and clinical results after aortic valve replacement (AVR) using the Sorin Freedom Solo (SFS) stentless bioprosthesis, compared with the standard Carpentier Edwards Perimount (CEP) stented bioprosthesis. METHODS: In this retrospective cohort study of prospectively collected data, 116 patients were included in the SFS group (53 males; median age 74 years, range 56-85 years), and 122 patients in the CEP group (85 males; median age 73 years, range 43-88 years) between July 2007 and January 2013. Echocardiography was performed at 6 weeks after surgery in our centre, and the most recent echocardiography (in our centre or in referring cardiology departments) was requested. Between September 2013 and April 2014, all patients were called by the same researcher to gain clinical follow-up data. RESULTS: Mid-term mortality was 16.4% in the SFS group (19 patients) and 21.3% in the CEP group (26 patients); (P = 0.3). The mean transvalvular gradient was 7.4 ± 3.1 mmHg in the SFS group, and 11.6 ± 3.2 mmHg in the CEP group at 6 weeks postoperatively (P < 0.001). When stratified by labelled valve size, mean gradients were significantly lower in the SFS group for every size (P ≤ 0.03). After 3.3 ± 1.4 years of follow-up, the mean gradient was still significantly lower in the SFS group than that in the CEP group (P < 0.001). Clinical follow-up showed relatively low complication rates. CONCLUSION: These data suggest that the Sorin Freedom Solo stentless bioprosthesis is as safe as the Carpentier Edwards bioprosthesis, and provides better short- and mid-term haemodynamic performance than the Carpentier Edwards bioprosthesis.