Intercostal Cryo Nerve Block in Minimally Invasive Cardiac Surgery: The Prospective Randomized FROST Trial.

INTRODUCTION: Intercostal cryo nerve block has been shown to enhance pulmonary function recovery and pain management in post-thoracotomy procedures. However, its benefit have never been demonstrated in minimal invasive thoracotomy heart valve surgery (Mini-HVS). The purpose of the study was to determine whether intraoperative intercostal cryo nerve block in conjunction with standard of care (collectively referred to hereafter as CryoNB) provided superior analgesic efficacy in patients undergoing Mini-HVS compared to standard-of-care (SOC). METHODS: FROST was a prospective, 3:1 randomized (CryoNB vs. SOC), multicenter trial in patients undergoing Mini-HVS. The primary endpoint was the 48-h postoperative forced expiratory volume in 1 s (FEV1) result. Secondary endpoints were visual analog scale (VAS) scores for pain at the surgical site and general pain, intensive care unit and hospital length-of-stay, total opioid consumption, and allodynia at 6 months postoperatively. RESULTS: A total of 84 patients were randomized to the two arms of the trial CryoNB (n = 65) and SOC (n = 19). Baseline Society of Thoracic Surgeons Predictive Risk of Mortality (STS PROM) score, ejection fraction, and FEV1 were similar between cohorts. A higher 48-h postoperative FEV1 result was demonstrated in the CryoNB cohort versus the SOC cohort (1.20 ± 0.46 vs. 0.93 ± 0.43 L; P = 0.02, one-sided two-sample t test). Surgical site VAS scores were similar between the CryoNB and SOC cohorts at all postoperative timepoints evaluated, but VAS scores not related to the surgical site were lower in the SOC group at 72, 94, and 120 h postoperatively. The SOC cohort had a 13% higher opioid consumption than the CryoNB cohort. One of 64 CryoNB patients reported allodynia that did not require pain medication at 10 months. CONCLUSIONS: The results of FROST demonstrated that intercostal CryoNB provided enhanced FEV1 score at 48 h postoperatively with optimized analgesic effectiveness versus SOC. Future larger prospective randomized trials are warranted to determine whether intercostal CryoNB has an opioid-sparing effect in patients undergoing Mini-HVS. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02922153.

Failure to rescue: variation in mortality after cardiac surgery.

OBJECTIVES: Measures to prevent surgical complications are critical components of optimal patient care, and adequate management when complications occur is equally crucial in efforts to reduce mortality. This study aims to elucidate clinical realities underlying in-hospital variations in failure to rescue (FTR) after cardiac surgery. METHODS: Using a statewide database for a quality improvement program, we identified 62 450 patients who had undergone adult cardiac surgery between 2011 and 2018 in 1 of the 33 Michigan hospitals performing adult cardiac surgery. The hospitals were first divided into tertiles according to their observed to expected (O/E) ratios of 30-day mortality: low-mortality tertile (O/E 0.46-0.78), intermediate-mortality tertile (O/E 0.79-0.90) and high-mortality tertile (O/E 0.98-2.00). We then examined the incidence of 15 significant complications and the rates of death following complications among the 3 groups. RESULTS: A total of 1418 operative deaths occurred in the entire cohort, a crude mortality rate of 2.3% and varied from 1.3% to 5.9% at the hospital level. The death rates also diverged significantly according to mortality score tertiles, from 1.6% in the low-mortality group to 3.2% in the high-mortality group (P < 0.001). Hospitals ranked in a high- or intermediate-mortality tertile had similar rates of overall complications (21.3% and 20.7%, P = 0.17), while low-mortality hospitals had significantly fewer complications (16.3%) than the other 2 tertiles (P < 0.001). FTR increased in a stepwise manner from low- to high-mortality hospitals (8.3% vs 10.0% vs 12.7%, P < 0.001, respectively). Differences in FTR were related to survival after cardiac arrest, multi-system organ failure, prolonged ventilation, reoperation for bleeding and severe acute kidney disease that requires dialysis. CONCLUSIONS: This study demonstrates that timely recognition and appropriate treatment of complications are as important as preventing complications to further reduce operative mortality in cardiac surgery. FTR tools may provide vital information for quality improvement initiatives.

Surgical Explantation of Transcatheter Aortic Valve Bioprostheses: A Statewide Experience.

BACKGROUND: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) since its initial approval in 2011, the frequency and outcomes of surgical explantation of TAVR devices (TAVR-explant) is poorly understood. METHODS: Patients undergoing TAVR-explant between January 2012 and June 2020 at 33 hospitals in Michigan were identified in the Society of Thoracic Surgeons Database and linked to index TAVR data from the Transcatheter Valve Therapy Registry through a statewide quality collaborative. The primary outcome was operative mortality. Indications for TAVR-explant, contraindications to redo TAVR, operative data, and outcomes were collected from Society of Thoracic Surgeons and Transcatheter Valve Therapy databases. Baseline Society of Thoracic Surgeons Predicted Risk of Mortality was compared between index TAVR and TAVR-explant. RESULTS: Twenty-four surgeons at 12 hospitals performed TAVR-explants in 46 patients (median age, 73). The frequency of TAVR-explant was 0.4%, and the number of explants increased annually. Median time to TAVR-explant was 139 days and among known device types explanted, most were self-expanding valves (29/41, 71%). Common indications for TAVR-explant were procedure-related failure (35%), paravalvular leak (28%), and need for other cardiac surgery (26%). Contraindications to redo TAVR included need for other cardiac surgery (28%), unsuitable noncoronary anatomy (13%), coronary obstruction (11%), and endocarditis (11%). Overall, 65% (30/46) of patients underwent concomitant procedures, including aortic repair/replacement in 33% (n=15), mitral surgery in 22% (n=10), and coronary artery bypass grafting in 16% (n=7). The median Society of Thoracic Surgeons Predicted Risk of Mortality was 4.2% at index TAVR and 9.3% at TAVR-explant (P=0.001). Operative mortality was 20% (9/46) and 76% (35/46) of patients had in-hospital complications. Of patients alive at discharge, 37% (17/37) were discharged home and overall 3-month survival was 73±14%. CONCLUSIONS: TAVR-explant is rare but increasing, and its clinical impact is substantial. As the utilization of TAVR expands into younger and lower-risk patients, providers should consider the potential for future TAVR-explant during selection of an initial valve strategy.

Transfemoral Transcatheter Aortic Valve Replacement Using Fascia Iliaca Block as an Alternative Approach to Conscious Sedation as Compared to General Anesthesia.

BACKGROUND/PURPOSE: General Anesthesia (GA) and conscious sedation (CS) are anesthetics for transfemoral transcatheter aortic valve replacement (TF-TAVR). We compared TF-TAVR outcomes using a novel anesthetic approach with fascia iliaca block (FIB) plus minimal CS (MCS) versus GA. METHODS: This retrospective propensity-matched study included consecutive TF-TAVR patients from January 2013 to December 2017 and dichotomized into FIB-MCS vs. GA. Data were collected from electronic records, Society of Thoracic Surgery (STS) database, and the Transcatheter Valve Therapies (TVT) Registry. Primary endpoints were operating room (OR) time, intensive care unit (ICU) and hospital length of stay (LOS). Secondary endpoints were 30-day, 1-year mortality, quality of life, 30-day re-hospitalization rate, failure of FIB-MCS, and hospital safety outcomes. RESULTS: A total of 304 TF-TAVR patients; FIB-MCS (n = 219) vs. GA (n = 85). Propensity matched 162 patients; FIB-MCS (n = 108) vs. GA (n = 54). FIB-MCS had shorter OR time (197.6 ±â€¯56.3 vs. 248.2 ±â€¯46.3 min, p < 0.001), ICU (67.8 ±â€¯71.7 vs. 84.9 ±â€¯72.1 h, p = 0.004) and hospital LOS (3.2 ±â€¯3.7 vs. 5.9 ±â€¯3.5 d, p < 0.001). FIB-MCS had lower rate of blood transfusion. FIB-MCA vs. GA 30-day and 1-year mortality were similar in the entire (2.3 vs. 2.4%, p = 1.0; and 8.2 vs. 5.9%, p = 0.49) and matched cohorts (0 vs. 3.7%, p = 0.11 and 7.4 vs. 5.6%, p = 0.75). FIB-MCS were less likely to be re-hospitalized [Odd Ratio: 0.32, CI:0.13-0.76] and 2% to 3% higher KCCQ-12 score. CONCLUSION: TF-TAVR using FIB-MCS is feasible and safe with shorter OR time, ICU and hospital LOS, lower risk of 30-day re-hospitalization, similar 30-day and 1-year mortality with better quality of life at 1-year follow-up.

Single-dose cardioplegia protects myocardium as well as traditional repetitive dosing: A noninferiority randomized study.

OBJECTIVE: The present prospective noninferiority randomized trial was designed to demonstrate the safety and efficacy of a single dose of Custodiol histidine-tryptophan-ketoglutarate compared with repetitive cold-blood cardioplegia. METHODS: From October 2012 to May 2014, 110 patients were randomly assigned to 1 of 2 groups: Group 1 (55 patients) received repetitive cold-blood cardioplegia, and group 2 (55 patients) received single-dose Custodiol histidine-tryptophan-ketoglutarate. Isolated aortic valve replacement, isolated mitral valve replacement, and multivalve procedures represented the most frequent operations, with 39 cases (71%) in group 1 and 49 cases (89%) in group 2. There was no difference in cardiopulmonary bypass time (102 ± 26 minutes vs 99 ± 19 minutes, P = .70) or aortic crossclamp time (77 ± 19 minutes vs 74 ± 17 minutes, P = .33). All patients underwent preoperative electrocardiogram and determination of creatine kinase-MB, troponin I, left ventricular ejection fraction, and regional wall motion. Postoperative cardiac biomarkers were checked at 7, 24, and 48 hours, and an echocardiogram was obtained to check for left ventricular function abnormalities. RESULTS: There was no difference in cardiac biomarkers release between the 2 groups at baseline and 7, 24, and 48 hours postoperatively (creatine kinase, P = .18, troponin P = .23). Left ventricular function was similar between groups preoperatively and at 24 hours after surgery. No death or myocardial infarction was observed in either group. There were no differences in intensive care unit length of stay, incidence of atrial fibrillation, use of inotropes or vasopressors support, time of intubation, or creatinine levels. CONCLUSIONS: A single dose of Custodiol histidine-tryptophan-ketoglutarate cardioplegia is not inferior to repeated cold-blood cardioplegia during elective cardiac surgery.

Transcatheter Versus Surgical Aortic Valve Replacement Episode Payments and Relationship to Case Volume.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has increased in volume as an alternative to surgical aortic valve replacement (SAVR). Comparisons of total episode expenditures, although largely ignored thus far, will be key to the value proposition for payers. METHODS: We evaluated 6,359 Blue Cross Blue Shield of Michigan and Medicare fee-for-service beneficiaries undergoing TAVR (17 hospitals, n = 1,655) or SAVR (33 hospitals, n = 4,704) in Michigan between 2012 and 2016. Payments through 90 post-discharge days between TAVR and SAVR were price-standardized and risk-adjusted. Centers were divided into terciles of procedural volume separately for TAVR and SAVR, and payments were compared between lowest and highest terciles. RESULTS: Payments (± SD) were higher for TAVR than SAVR ($69,388 ± $22,259 versus $66,683 ± $27,377, p < 0.001), while mean hospital length of stay was shorter for TAVR (6.2 ± 5.6 versus 10.2 + 7.5 days, p < 0.001). Index hospitalization payments were $4,374 higher for TAVR (p < 0.001), whereas readmission and post-acute care payments were $1,150 (p = 0.001) and $739 (p = 0.004) lower, respectively, and professional payments were similar. For SAVR, high-volume centers had lower episode payments (difference: 5.0%, $3,255; p = 0.01) and shorter length of stay (10.0 ± 7.5 versus 11.1 ± 7.9 days, p = 0.002) than low volume centers. In contrast, we found no volume-payment relationship among TAVR centers. CONCLUSIONS: Episode payments were higher for TAVR, despite shorter length of stay. Although not a driver for TAVR, center SAVR volume was inversely associated with payments. These data will be increasingly important to address value-based reimbursement in valve replacement surgery.

Psoas Muscle Area as a Predictor of Outcomes in Transcatheter Aortic Valve Implantation.

Frailty is a powerful predictor of outcomes after transcatheter aortic valve implantation (TAVI). Sarcopenia as assessed by psoas muscle area (PMA) is a validated tool to assess frailty before surgical procedures. We evaluated PMA as a predictor of outcomes after TAVI in 152 consecutive patients who underwent this procedure at our institution from 2011 to 2014. Preoperative computed tomography scans were used to measure PMA, which then was indexed to body surface area. Outcomes evaluated included (1) early poor outcome (30 days mortality, stroke, dialysis, and prolonged ventilation), (2) 1-year mortality, and (3) high-resource utilization (length of stay >7 days, discharge to rehabilitation, or readmission within 30 days). Indexed PMA (odds ratio [OR] 3.19, confidence interval [CI] 1.30 to 7.83; p = 0.012) and age (OR 1.92, CI 1.87 to 1.98; p = 0.012) predicted early poor outcome. Society of Thoracic Surgeons score predicted 1-year mortality (hazard ratio 3.07, CI 1.93 to 6.23; p = 0.011). High-resource utilization was observed more frequently in patients with PMA less than the median (73% vs 51%, OR 2.65, CI 1.32 to 5.36; p = 0.006). In conclusion, indexed PMA predicts early poor outcome and high-resource utilization after TAVI.

The Midterm Impact of Transcatheter Aortic Valve Replacement on Surgical Aortic Valve Replacement in Michigan.

BACKGROUND: We characterized the midterm impact of transcatheter aortic valve replacement (TAVR) on surgical aortic valve replacement (SAVR) volume, patient profiles, and outcomes in Michigan. METHODS: We analyzed data obtained after SAVR (n = 15,288) and TAVR (n = 1,783) using the Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative from 2006 to 2015. During this period, 17 of 33 hospitals developed TAVR programs. RESULTS: Annual SAVR volume increased by 38.1% at TAVR hospitals and by 20.4% at non-TAVR hospitals, (p trend < 0.001). In TAVR hospitals, the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) decreased before (4.7% ± 5.1%) and after (3.5% ± 3.6%) initiation of TAVR (p < 0.001). Rates of 30-day mortality (pre-TAVR, 3.9% vs post-TAVR, 2.7%; p < 0.001) and renal failure (pre-TAVR, 5.2% vs post-TAVR, 3.3%; p < 0.001) but not stroke (pre-TAVR, 1.9% vs post-TAVR, 1.7%; p = 0.47) were lower after TAVR implementation. Length of stay decreased from 9.0 to 8.5 days (p < 0.001). When analyzing high-risk patients undergoing SAVR (ie, PROM >8%), neither mortality, stroke, nor renal failure was different (all p > 0.15). Despite a reduction in the STS-PROM, non-TAVR hospitals did not display changes in mortality, stroke, or renal failure for either the entire or the high-risk SAVR cohorts after initiation of TAVR in Michigan. CONCLUSIONS: TAVR implementation in Michigan has dramatically increased overall SAVR volume. This phenomenon has occurred with a concomitant decrease in preoperative risk profile and has improved early SAVR outcomes, particularly at TAVR hospitals, but surprisingly not in patients considered at high preoperative risk. As TAVR use increases, these issues may be further clarified and elucidated.

Mitral valve repair after annuloplasty ring dehiscence using MitraClip.

Dehiscence of a surgical mitral annuloplasty ring for repair of functional mitral regurgitation (MR) is an infrequently reported complication that often manifests as recurrent MR and heart failure. Re-do mitral valve surgery to correct ring dehiscence may not be feasible for patients at high risk of operative mortality or serious morbidity. We report two cases of mitral annular ring dehiscence and severe mitral regurgitation in patients at prohibitive risk for re-do mitral valve surgery who were successfully treated with MitraClip. © 2015 Wiley Periodicals, Inc.

Red blood cells and mortality after coronary artery bypass graft surgery: an analysis of 672 operative deaths.

BACKGROUND: Prior studies have implicated transfusion as a risk factor for mortality in coronary artery bypass graft surgery (CABG). To further our understanding of the true association between transfusion and outcome, we specifically analyzed the subgroup of patients who died after undergoing CABG. METHODS: A total of 34,362 patients underwent isolated CABG between January 2008 and September 2013 and were entered into a statewide collaborative database; 672 patients (2.0%) died and form the basis for this study. Univariate analysis compared preoperative and intraoperative variables, as well as postoperative outcomes, between those with and without transfusion in both unadjusted cohorts and those matched by predicted risk of mortality (PROM). Mortality was further evaluated with phase of care analysis. RESULTS: Of the 672 deaths, 566 patients (84.2%) received a transfusion of red blood cells. The PROM was 7.5% for the transfused patients versus 4.3% for those not transfused (p < 0.001). Transfused patients were older, more often female, had more emergency, on-pump, and redo procedures, and had a lower preoperative and on-bypass nadir hematocrit. Most other demographics were similar between the groups. Postoperatively, transfused patients were ventilated longer, had more renal and multisystem organ failure, and were more likely to die of infectious and pulmonary causes after longer intensive care unit and overall lengths of stay. CONCLUSIONS: Significant differences in PROM and the postoperative course leading to death between those with and without transfusion suggest the role of transfusion may be secondary to other patient-related factors. Recognizing that the relationship between transfusion and outcome after CABG remains incompletely understood, these findings are suggestive of a complex interaction of many variables.

Effect of cardiorespiratory fitness on short-term morbidity and mortality after coronary artery bypass grafting.

Although preoperative risk assessment for coronary artery bypass grafting (CABG) has been evaluated with multiple predictive models, none have incorporated a low level of cardiorespiratory fitness, which represents one of the strongest predictors of all-cause and cardiovascular mortality in subjects with and without heart disease. The aim of the present study was to evaluate preoperative cardiorespiratory fitness, expressed as METs (1 MET = 3.5 ml O2/kg/min), and short-term morbidity and mortality after CABG. The Society of Thoracic Surgeons database was queried for patients who underwent CABG from January 2002 to December 2010 at Beaumont Health Systems. Electronic medical records were reviewed for peak or symptom-limited exercise testing <90 days before CABG. Peak METs were estimated from the achieved treadmill speed, grade, and duration or the cycle ergometer workload, corrected for body weight. Patients who met eligibility criteria (n = 596) were categorized into 2 groups: those with reduced aerobic capacity (<5 METs [n = 78]) and those achieving ≥5 METs (n = 518). Fisher's exact tests were used to compare preoperative aerobic capacity and short-term postoperative morbidity and mortality between the 2 groups. After adjusting for potential confounding variables, an inverse relation was found between cardiorespiratory fitness and complications after CABG. Specifically, low preoperative cardiorespiratory fitness (<5 METs) was associated with higher operative and 30-day mortality after CABG (p <0.05). In conclusion, these data suggest that preoperative cardiorespiratory fitness provides an independent and additive marker for mortality after CABG.

Analyzing "failure to rescue": is this an opportunity for outcome improvement in cardiac surgery?

BACKGROUND: In the setting of a statewide quality collaborative approach to the review of cardiac surgical mortalities in intensive care units (ICUs), variations in complication-related outcomes became apparent. Utilizing "failure to rescue" methodology (FTR; the probability of death after a complication), we compared FTR rates after adult cardiac surgery in low, medium, and high mortality centers from a voluntary, 33-center quality collaborative. METHODS: We identified 45,904 patients with a Society of Thoracic Surgeons predicted risk of mortality who underwent cardiac surgery between 2006 and 2010. The 33 centers were ranked according to observed-to-expected ratios for mortality and were categorized into 3 equal groups. We then compared rates of complications and FTR. RESULTS: Overall unadjusted mortality was 2.6%, ranging from 1.5% in the low-mortality group to 3.6% in the high group. The rate of 17 complications ranged from 19.1% in the low group to 22.9% in the high group while FTR rates were 6.6% in the low group, 10.4% in the medium group, and 13.5% in the high group (p < 0.001). The FTR rate was significantly better in the low mortality group for the majority of complications (11 of 17) with the most significant findings for cardiac arrest, dialysis, prolonged ventilation, and pneumonia. CONCLUSIONS: Low mortality hospitals have superior ability to rescue patients from complications after cardiac surgery procedures. Outcomes review incorporating a collaborative multi-hospital approach can provide an ideal opportunity to review processes that anticipate and manage complications in the ICU and help recognize and share "differentiators" in care.

Dynamic annuloplasty for mitral regurgitation.

OBJECTIVE: The MiCardia DYANA annuloplasty system (MiCardia Corp, Irvine, Calif) is a nitinol-based dynamic complete ring that allows modification of the septal-lateral diameter under transesophageal echocardiography guidance in the loaded beating heart after mitral valve repair. Shape alteration is induced by radiofrequency via detachable activation wires. This multicenter study reports the first human experience with this device. METHODS: Patients (n = 35, 67 ± 8 years) with degenerative (n = 29), functional/ischemic (n = 5), or rheumatic (n = 1) mitral regurgitation underwent mitral valve repair using the new device. We analyzed the occurrence of death, endocarditis, ring dehiscence, systolic anterior motion, thromboembolism, pulmonary edema, heart block, ventricular arrhythmia, hemolysis, or myocardial infarction at 30 days (primary end point) and 6 months (secondary end point) postprocedure. RESULTS: All patients exhibited mitral regurgitation of 2 or less early postoperatively and at 6 months follow-up. In 29 patients, the initial mitral valve repair result was satisfactory and no ring activation was required. In 6 patients, the nitinol-based ring was deformed intraoperatively postrepair with further improvement of mitral regurgitation in all cases (preactivation: 0.9 ± 0.2, postactivation: 0.2 ± 0.3; P = .001). One death (2.9%, multisystem organ failure, non-device related), 2 ventricular arrhythmias (5.7%), and 1 heart block (2.9%) occurred, all in the first 30 days after surgery. No additional major adverse clinical events occurred later than 1 month postprocedure (total observed major adverse clinical event rate 11.5%). CONCLUSIONS: The implantation of the new dynamic annuloplasty ring allows for safe mitral valve repair. The option of postrepair modification of the septal-lateral diameter by radiofrequency may further optimize repair results.

A method to evaluate cardiac surgery mortality: phase of care mortality analysis.

BACKGROUND: This is a study of a method of mortality review, adopted by the Michigan Society of Thoracic and Cardiovascular Surgeons, to enhance understanding of mortality and potentially avoidable deaths after cardiac surgery, utilizing a voluntary statewide database. METHODS: A system to categorize mortality was developed utilizing a phase of care mortality analysis approach as well as providing criteria to classify mortality as potentially "avoidable." For each mortality, the operating surgeon categorized a cardiac surgery mortality trigger into 1 of 5 time frames: preoperative, intraoperative, intensive care unit (ICU), postoperative floor, and discharge. RESULTS: A total of 53,674 adult cardiac operations were performed from January 1, 2006 to June 30, 2010 with a crude mortality of 3.5% (1,905 of 53,674). Of the mortalities analyzed, 35% (618 of 1,780) were preoperative, 25% (451 of 1,780) were ICU, 19% (333 of 1,780) were intraoperative, 11% (198 of 1,780) were floor, and 10% (180 of 1,780) were discharge phase. "Avoidable" mortality triggers occurred in 53% (174 of 333) of the intraoperative, 41% (253 of 618) and (184 of 451) of the preoperative and ICU phases, 42% (83 of 198) of the floor, and 19% (35 of 180) of the discharge phase. Overall potentially avoidable mortality was 41% (729 of 1780). Thirty-six percent (644 of 1,780) of the mortalities were coronary artery bypass grafting patients and 29% (188 of 644) of these were in the preoperative phase, with a mean predicted risk of 16%. CONCLUSIONS: This analysis identifies the occurrence of potentially avoidable mortalities in the 4 hospital phases of care, with the largest absolute number of avoidable mortalities occurring in the preoperative phase. A focus on these phases of care provides significant opportunity for quality improvement initiatives. Utilizing phase of care mortality analysis stimulates surgeons and hospitals to develop and refine mortality reviews and provides a structured statewide platform for discussion, education, quality improvement, and enhanced outcomes.

Left ventricular myxoma resection with minimally invasive mitral valve reconstruction.

Ventricular myxomas are rare, accounting for less than 5% of all benign cardiac tumors. Although histologically benign, myxomas can be a source of significant morbidity and mortality. The case is presented of a left ventricular myxoma involving the posterior papillary muscle that was resected using a minimally invasive transmitral approach. A radical mitral valve reconstruction was performed, including the replacement of two chordae tendineae, annuloplasty and valvuloplasty, resulting in excellent postoperative mitral valve function. Precise preoperative imaging and surgical planning are necessary to achieve adequate tumor margins and to minimize the likelihood of recurrence.

Cardiac surgeons and the quality movement: the Michigan experience.

The Michigan Society of Thoracic and Cardiovascular Surgeons created a voluntary quality collaborative with all the cardiac surgeons in the state and all hospitals doing adult cardiac surgery. Utilizing this collaborative over the last 3 years and creating a unique relationship with a payor, an approach to processes and outcomes has produced improvements in the quality of care for cardiac patients in the state of Michigan.

Coronary artery bypass grafting with a minimized cardiopulmonary bypass circuit: a prospective, randomized trial.

OBJECTIVE: The study was designed to determine differences in blood loss and transfusion associated with a minimized cardiopulmonary bypass circuit versus a standard bypass circuit. METHODS: From February 2005 through April 2006, 199 patients were randomized to undergo coronary artery bypass grafting with a standard cardiopulmonary bypass circuit (Medtronic, Inc., Minneapolis, Minn) or a minimized bypass circuit, the Medtronic Resting Heart Circuit. Laboratory perimeters (hemoglobin and platelet count), were measured at baseline, after initiation of cardiopulmonary bypass, and on intensive care unit admission. Lowest values recorded were noted. Blood administration was controlled by study-specific protocol orders, (transfusion for hemoglobin <8mg%). Patient demographic data were retrieved from the Society of Thoracic Surgeons database. Blood product administration was recorded during hospital admission, and chest tube drainage as total output collected from operating room to discontinuation. Continuous variables were tested with a Wilcoxin rank test, and categoric variables with X(2) and Fisher's exact tests. RESULTS: Hematocrit, equivalent at baseline, was higher in minimized circuit cohort at lowest point during cariopulmonary bypass (31.5% +/- 3.9% vs. 25.5% +/- 3.7%), after protamine (31.6% +/- 3.9% vs 29.2% +/- 3.7%), and on intensive care unit arrival (35.2% +/- 4.1% vs 31.8% +/- 3.5%, P < .001). Similarly, platelet count was higher in minimized circuit group on intensive care unit arrival, as was lowest platelet count recorded (170 x 10(3) +/- 48 cells/mm(3) vs 107 x 10(3) +/- 28 cells/mm(3), P < .0001). Time to extubation was shorter in minimized circuit group (848 +/- 737 minutes vs. 526 +/- 282 minutes, (P < .01), and total chest tube drainage was lower (1124 +/- 647 mL vs. 506 +/- 214 mL, P < .01). Fewer red blood cells (148 vs 19 units) were given in minimized circuit group (P < .0001). CONCLUSIONS: A minimized cardiopulmonary bypass circuit provides less hemodilution, platelet consumption, chest tube output and lower post-operative blood loss than standard cardiopulmonary bypass. Red blood cell usage was also less. All differences are advantageous.