Development of a Risk Score for Long-term Survival and MACCE After Coronary Artery Bypass Grafting Surgery.

OBJECTIVE: To develop risk scoring models predicting long-term survival and major adverse cardiovascular and cerebrovascular events (MACCE) including myocardial infarction and stroke after coronary artery bypass grafting (CABG). METHODS: All-consecutive 4,821 patients undergoing isolated CABG at Lankenau between 01/2005-07/2021 were included. MACCE was defined as all-cause mortality+myocardial infarction (MI)+stroke. Variable selection for both outcomes was obtained using a double selection logit Lasso with adaptive selection. Models performance was internally evaluated by calibration and accuracy using bootstrap cross-validation. Mortality and MACCE were compared among patients split into three groups based on the predicted risk scores for all-cause mortality and MACCE. An external validation of our database was performed with 665 patients from the University of Brescia, Italy. RESULTS: Pre-operative risk predictors were found to be predictors for all-cause mortality and MACCE. In addition, being of African American ethnicity is a significant predictor for MACCE after isolated CABG. The AUC which measures the discrimination of the models were 80.4%, 79.1%, 81.3%, and 79.2% for mortality at 1,2,3, and 5 years follow-up. The AUC for MACCE were 75%, 72.5%, 73,8%, and 72.7% at 1, 2, 3, and 5-years follow-up. For external validation, AUC for all-cause mortality and MACCE at 1, 2, 3, and 5 years was 73.7%, 70.8%, 68.7%, and 72.2% and 72.3%, 68.2%, 65.6%, 69.6%, respectively. CONCLUSIONS: The Advanced (AD) Coronary Risk Score for All-Cause Mortality and MACCE provide good discrimination of long-term mortality and MACCE after isolated CABG. External validation observed a more AUC's above 70%.

Periprocedural Risk Predictors Affecting Long-Term Prognosis in Patients With Chronic Obstructive Pulmonary Disease Undergoing Coronary Artery Bypass Grafting.

OBJECTIVE: This study sought to identify periprocedural risk predictors that affect long-term prognosis in patients with chronic obstructive pulmonary disease (COPD) undergoing isolated coronary artery bypass grafting (CABG). METHODS: All consecutive 4,871 patients undergoing isolated CABG between May 2005 and June 2021 were included. Patients with and without COPD were compared for baseline demographics and preoperative characteristics. A propensity-matched analysis was used to compare the 2 groups. The primary outcome was long-term incidence of all-cause death. RESULTS: After matching, 767 patients each were included in the COPD and non-COPD groups; mean age was 71.6 and 71.4 years (P = .7), respectively; 29.3% and 32% (P = .2) were women, respectively. Intraoperatively, median (IQR) operating room time was higher in the COPD group than in the non-COPD group (5.9 [5.2-7.0] hours vs 5.8 [5.1-6.7] hours, respectively; P = .01). Postoperatively, intensive care unit stay (P = .03), hospital length of stay (P = .0004), and fresh frozen plasma transfusion units (P = .012) were higher in the COPD group than in the non-COPD group. Thirty-day mortality was not different between groups (1.3% in the COPD group vs 1% in the non-COPD group; P = .4). Median follow-up time was 4.0 years. The rate of all-cause death was higher in the COPD group than in the non-COPD group (138 patients [18.3%] vs 109 patients [14.5%], respectively; P = .042). Periprocedural risk predictors for all-cause death in patients with COPD were atrial fibrillation, diabetes, male sex, dialysis, ejection fraction less than 50%, peripheral vascular disease, and Society of Thoracic Surgeons Predicted Risk of Mortality score greater than 4%. CONCLUSION: Patients with COPD undergoing isolated CABG had a significantly higher incidence of all-cause death than those without COPD. Herein, risk predictors are provided for all-cause death in patients undergoing isolated CABG.

Hybrid robotic-assisted coronary revascularization and transcatheter aortic valve replacement: a single-center experience.

OBJECTIVES: The efficacy of hybrid robotic-assisted coronary artery bypass grafting (CABG) and transcatheter aortic valve replacement (TAVR) for coronary and aortic valve disease is poorly reported. Herein, we report our experience with this hybrid approach. METHODS: Between January 2018 and June 2022, 10 (7 male, 3 female) patients with a mean age of 81 years underwent the hybrid procedure. Coronary revascularization was performed prior to TAVR with robotic-assisted left internal mammary artery-to-left anterior descending (LAD) bypass grafting for left main or proximal LAD lesions with or without multivessel disease with or without hybrid percutaneous coronary intervention (PCI). RESULTS: Five patients had left main disease, and 5 had proximal LAD disease with or without multivessel disease. All patients tolerated the robotic-assisted CABG procedure well; 9 patients were extubated in the operating room and all patients were ambulatory on postoperative day 1. Five patients underwent hybrid PCI for non-LAD lesions. TAVR was subsequently performed at intervals ranging from 3 days to 5 months after CABG. One patient with end-stage renal disease on hemodialysis required hospitalization for heart failure during the interval period. The 1-year mortality rate was 0%, and 3 patients died during late follow-up (24-43 months). CONCLUSIONS: This innovative, less invasive approach demonstrates the potential for early recovery in appropriately selected patients with complex coronary and aortic valve disease with promising mid-term outcomes.

Midterm Clinical Outcomes of Robotic-Assisted Reverse Hybrid Coronary Revascularization: A Single-Center Experience.

Outcomes of robotic-assisted reverse hybrid coronary revascularization (HCR) remain hindered. We aimed to analyze midterm clinical outcomes of robotic-assisted reverse HCR. All consecutive 285 patients who underwent reverse robotic-assisted HCR between September 2005 and July 2021 were included. Reverse HCR comprises percutaneous coronary intervention with stent implantation in non-left anterior descending (LAD) coronary arteries was performed within 30 days before robotic-assisted left internal thoracic artery (LITA) harvesting and LITA-to-LAD manual anastomosis through a 4-cm left minithoracotomy. Dual antiplatelet therapy was not interrupted in any patient. Preoperatively, mean age was 70.2 years (±11.2). Before surgery, 168 patients received 1 stent, 112 patients 2 stents, and 5 patients 3 stents. Intraoperatively, mean operating room time was 5.9 hours (±1); no case was converted to full sternotomy, whereas 9 patients (3.1%) received intraoperative blood product transfusions. Postoperatively, a small incidence of stroke, 1 (0.3%), reoperation for bleeding, 7 (2.4%), blood product transfusions, 48 (16.8%), and hospital stay (4.8 days) was observed. At 30-day follow-up, 1 patient (0.3%) underwent percutaneous coronary intervention with stent on a surgical LITA-LAD anastomosis owing to graft failure. Mean follow-up was 4.2 years. Reported midterm outcomes included all-cause death in 31 patients (10.9%), major adverse cardiovascular and cerebrovascular events in 102 of 285 (35.9%), nonfatal stroke in 2 of 285 (0.7%), myocardial infarction in 17 of 285 (5.9%), and repeat intervention in 50 of 285 patients (17.5%). This single-center study reports effective and safe clinical outcomes at midterm follow-up of reverse HCR procedures for treating multivessel coronary artery disease.

Risk predictors of race disparity in patients undergoing coronary artery bypass grafting: a propensity-matched analysis.

OBJECTIVES: The aim of this study was to compare long-term prognosis after isolated coronary artery bypass grafting between white and black patients and to investigate risk factors for poorer outcomes among the latest. METHODS: All consecutive 4766 black and white patients undergoing isolated coronary artery bypass grafting between May 2005 and June 2021 at our institution were included. Primary outcomes were long-term incidence of all-cause death and major adverse cardiovascular and cerebrovascular events in black versus white patients. A propensity-matched analysis was used 2 compare groups. RESULTS: After matching, 459 patients were included in each black and white groups while groups were correctly balanced. The mean age was 70.4 vs 70.6 years old (P = 0.7) in black and white groups, respectively. Intraoperatively, mean operating room time and blood product transfusion, were higher in the black group while incidence of extubation in the operating room was higher in the white one. Postoperatively, hospital length of stay was higher in the black cohort. Thirty-day all-cause mortality was not different among groups. The median follow-up time was 4 years. Primary outcome of all-cause death was higher in the black versus the white, respectively. Major adverse cardiovascular and cerebrovascular events incidence was twice higher in the black compared to the white cohort (7.6% vs 3.7%, P = 0.013). Risk predictors for all-cause death and major adverse cardiovascular and cerebrovascular events in blacks were creatinine level, chronic obstructive pulmonary disease, ejection fraction <50% and preoperative atrial fibrillation. CONCLUSIONS: Racial disparities persist in a high-volume centre. Despite no preoperative difference, black minority has a higher incidence of major adverse cardiovascular and cerebrovascular events.

Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation.

BACKGROUND: Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets. AIMS: We aimed to analyse clinical outcomes of robotic-assisted CABG. METHODS: A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients. RESULTS: The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001). CONCLUSIONS: Robotic-assisted CABG and HCR provide good long-term outcomes in patients who are not candidates for conventional CABG.

Robotic-assisted versus conventional off-pump coronary surgery in women: A propensity-matched study.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) previously demonstrated its potential benefits in women; however, robotic-assisted OPCAB was scarcely studied. OBJECTIVES: To investigate whether robotic-assisted OPCAB could further improve the outcomes in women and the potential impact of hybrid approaches with stents and completeness of revascularization on the late outcomes. METHODS: Women who underwent robotic-assisted or conventional OPCAB (with sternotomy) between May 2005 and January 2021 at Lankenau Heart Institute were included. Propensity score matching was used to match 273 pairs on 27 characteristics. RESULTS: In the intraoperative period, women who underwent robotic-assisted OPCAB presented longer operative times (6.00 vs. 5.38 h; p < 0.001), higher rates of extubation in the operating room (83.9% vs. 75.5%; p = 0.019) and lower rates of blood transfusion (13.2% vs. 32.2%; p < 0.001). In the postoperative period, women who underwent robotic-assisted OPCAB presented lower rates of new onset atrial fibrillation (16.8% vs. 25.6%; p = 0.016), need of blood transfusion (33.0% vs. 54.9%; p < 0.001), shorter intensive care unit (ICU) (46.1 vs. 49.8 h; p = 0.006) and hospital length of stay (5.0 vs. 6.0 days; p < 0.001). We observed no statistically significant differences in the rates of operative death between the groups (1.47% vs. 1.47%; p = 0.771). In the follow-up, we observed no differences in terms of overall survival regardless of hybrid procedures with stents and completeness of revascularization. CONCLUSIONS: Robotic-assisted OPCAB in women is as safe as conventional OPCAB and may further improve outcomes. Hybrid coronary revascularization was a valuable adjunct in the robotic scenario and completeness of revascularization did not play a role in this setting.

Hybrid robotic off-pump versus conventional on-pump and off-pump coronary artery bypass graft surgery in women.

OBJECTIVE: To compare outcomes of three methods of coronary artery bypass graft surgery (CABG): robotic off-pump hybrid coronary revascularization (HCR) versus conventional CABG off-pump (off-pump coronary artery bypass [OPCAB]) and on-pump (on-pump coronary artery bypass [ONCAB]) in women. METHODS: Data on women who underwent robotic off-pump HCR or conventional OPCAB or conventional ONCAB between May 2005 and January 2021 were collected. Inverse probability of treatment weighting (IPTW) with doubly robust method was used to analyze the data. RESULTS: A total of 731 women were included (181 robotic off-pump HCR, 138 conventional ONCAB, and 412 conventional OPCAB cases). IPTW-adjusted analyses revealed the following: (1) for operative times, robotic off-pump HCR presented longer times when compared with OPCAB, but shorter times when compared with ONCAB; (2) compared with ONCAB and OPCAB, robotic off-pump HCR presented lower rates of reintervention for bleeding, intra- and postoperative blood transfusions, higher rates of extubation in the OR with less prolonged ventilation, lower rates of postoperative atrial fibrillation, and shorter intensive care unit and hospital length of stay; (3) no statistically significant differences for operative mortality were observed comparing robotic off-pump HCR with ONCAB (IPTW-adjusted odds ratio [OR]: 0.77; 95% confidence interval [CI]: 0.07-7.85; p = .822) and with OPCAB (IPTW-adjusted OR: 4.27; 95% CI: 0.27-66.88; p = .301); 4. long-term survival was similar with HCR compared with ONCAB (hazard ratio [HR]: 0.74, 95% CI: 0.36-1.50, p = .401) and OPCAB (HR: 0.89, 95% CI: 0.50-1.58, p = .683). CONCLUSIONS: In our local experience, robotic off-pump HCR in women was as safe as conventional ONCAB and OPCAB and may further improve postoperative outcomes when performed frequently by a dedicated team, producing better perioperative outcomes without compromising survival in the long run.

Robotic hybrid coronary revascularization versus conventional off-pump coronary bypass surgery in women with two-vessel disease.

BACKGROUND: Hybrid coronary revascularization (HCR) treats coronary artery disease (CAD) by combining a minimally invasive surgical approach with the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery and percutaneous coronary intervention (PCI) for non-LAD vessels. This study aimed to compare immediate and long-term outcomes between robotic HCR and off-pump coronary artery bypass (OPCAB) via sternotomy in women with two-vessel CAD. METHODS AND RESULTS: We compared all robotic HCR (LIMA-to-LAD plus stent; n = 55) and OPCAB (LIMA-to-LAD plus saphenous vein graft; n = 54) performed at a single institution between May 2005 and January 2021. To adjust for the selection bias of receiving either HCR or OPCAB, we performed a propensity score analysis of 31 matched pairs. In the immediate postoperative period, no statistically significant difference was observed for operative mortality and HCR was associated with lower rates of blood transfusion (25.8% vs. 54.8%; p = .038), and shorter hospital length of stay (4.0 vs. 6.0 days; p = .009). After a mean follow-up of 7.0 ± 4.9 years, we observed no statistically significant differences between the groups for overall survival (hazard ratio [HR]: 0.48, 95% confidence interval [CI]: 0.09-2.64, p = .401), myocardial infarction (HR: 1.60, 95% CI: 0.14-17.64, p = .703), stroke (HR not assessable; almost zero events), target vessel revascularization (HR: 0.45, 95% CI: 0.08-2.47, p = .359), angina (HR: 0.64, 95% CI: 0.20-2.01, p = .444) and major adverse cardiac and cerebrovascular events (HR: 0.46, 95% CI: 0.14-1.52, p = .202). CONCLUSIONS: Robotic HCR provides for women with two-vessel CAD a shorter postoperative recovery with fewer blood transfusions, with similar long-term outcomes when compared with conventional OPCAB via sternotomy.

Safe implementation of robotic-assisted minimally invasive direct coronary artery bypass: application of learning curves and cumulative sum analysis.

BACKGROUND: Learning curves are inevitably encountered when first implementing an innovative and complex surgical technique. Nevertheless, a cluster of failures or complications should be detected early, but not deter learning, to ensure safe implementation. Here, we aimed to examine the presence and impact of learning curves on outcome after robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB). METHODS: A retrospective analysis of the first 300 RA-MIDCAB surgeries between July 2015 and December 2020 was performed. Learning curves were obtained via logarithmic regression for surgical time. Cumulative sum (CUSUM) analysis was performed for (I) major complications including MI, stroke, repeat revascularization, and mortality, and (II) other complications, including prolonged ventilation, pneumonia, pleura puncture, lung herniation, pericarditis, pleuritis, arrhythmia, wound complications, and delirium. Expected and unacceptable rates were set at 12% and 20%, respectively, for major complications, and at 40% and 60% for other complications, based on historical data in conventional coronary artery bypass grafting (CABG). RESULTS: Demographic characteristics did not differ between terciles, except for more smokers in the first tercile, and less hypercholesterolemia and more complex procedures in the third tercile. The mean surgical time for all operations was 258±81 minutes, ranging from 127 to 821 minutes. A learning curve was only observed in the first tercile. Subgroup analysis revealed that this learning curve was only observed for procedures consisting of single internal mammary artery (SIMA) with 1 or 2 distal anastomoses but not with bilateral internal mammary arteries (BIMA) or more than 2 distal anastomoses. CUSUM analysis showed that the cumulative rate of major and other complications never crossed the lines for unacceptable rates. Rather, the lower 95% confidence boundary was crossed after 50 cases, indicating improvement in safety. CONCLUSIONS: These results suggest that integration of RA-MIDCAB in the surgical landscape can be safely achieved and complication rates can quickly be reduced below those expected in traditional CABG. Collective experience plays a key role in overcoming the learning curve when more complex procedures and cases are introduced.

Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

Precision incision: robotic coronary revascularization via 3.9-cm minithoracotomy.

Coronary artery bypass grafting remains the treatment choice for coronary artery disease; but sternotomy, the most commonly used approach, compromises its benefits with postoperative morbidity, higher complication rates, and prolonged length of hospital stay. Despite this, minimally invasive and robotic-assisted technology has not been adopted or widely embraced because supporting literature on robotic-assisted coronary artery bypass grafting is extremely limited. Since 2005, the cardiothoracic surgical team at our institution has been developing and maturing an effective method using robotic harvesting of the left internal mammary artery (LIMA) and beating heart surgery through a minithoracotomy for coronary revascularization. This surgical technique involves precisely placing the robotic endoscopic port immediately over the left anterior descending (LAD) artery target site. The robotically harvested LIMA is secured to the epicardium at the LAD target, the robotic instruments are removed, and the endoscopic port site is enlarged slightly greater than 1 cm to become the minithoracotomy and allow for LIMA-to-LAD anastomosis. The other two robotic ports are used to complete the procedure without a need for additional incisions. This standardized method has been used in more than 750 patients, and since 2009, the last 377 consecutive non-rib-spreading minithoracotomy incisions measured a median of 3.9 cm (mean [SD], 4.16 [1.2748] cm; range, 2.3-12.0 cm). This "How I Do It" article describes our methods in detail and associated robotic nuances.

The impact of immediate extubation in the operating room after cardiac surgery on intensive care and hospital lengths of stay.

OBJECTIVE: To determine if lengths of stay in intensive care and the hospital are associated with extubation in the operating room at the conclusion of cardiac surgery. DESIGN: A nonrandomized, observational study with propensity score-guided case-control matching of prospectively collected data. SETTING: Three interrelated, university-affiliated, community hospitals. PARTICIPANTS: Three thousand three hundred seventeen patients undergoing elective or urgent coronary artery, valve repair or replacement, or combined surgery between 2000 and 2006. INTERVENTIONS: Tracheal extubation occurred, based on history and intraoperative events, either immediately in the operating room or in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Of 3,317 patients in the institutions' Society of Thoracic Surgeons database, 3,089 were extubated within 24 hours, 69% of them in the operating room. Only 0.6% of patients extubated in the operating room required reintubation, compared with 5.9% extubated in the intensive care unit (p < 0.0001). By logistic regression, 12 of 25 preoperative and intraoperative factors generated a propensity score for each of the 2,595 patients with complete data, representing the likelihood of immediate extubation (c-statistic = 0.727). A "greedy 5 to 1" propensity score-matching technique created 713 matched pairs of patients by extubation pathway. Those undergoing immediate extubation had reductions in intensive care duration by 23 hours on average (median from 46 to 27 hours, p < 0.0001) and in hospital length of stay by 0.8 days on average (median = 6 for each, p < 0.0001). Cox regression, using matched pairs as strata, identified the following independent predictors of length of stay in the intensive care unit and hospital: immediate extubation in the operating room, need for reintubation, postoperative renal failure, and postoperative atrial fibrillation. CONCLUSIONS: Selection of patients for immediate extubation in the operating room by experienced clinicians was associated with shorter ICU and hospital stays. Immediate extubation rarely resulted in tracheal re-intubation.

Outcome improvement and cost reduction in an increasingly morbid cardiac surgery population.

Two studies assessed initiatives to improve the quality and the cost-effectiveness of cardiac surgery. The first evaluated a system for access and stabilization (SAS), with coronary stabilization, and a clinical effectiveness quality initiative (CEQI) in off-pump coronary artery bypass grafting. The SAS + CEQI cohort showed significantly lower mortality, a lower percentage of patients requiring prolonged ventilation, and a shorter mean postoperative length of hospital stay than the pre-SAS cohort who underwent on-pump coronary artery bypass grafting. The second study assessed the potential for noninvasive cerebral oximetry to reduce strokes related to all cardiac surgery by optimizing cerebral oxygen delivery. The incidence of permanent stroke was significantly lower in the cerebral oximetry group than in an earlier control group in which cerebral oximetry was not used, despite the fact that the study group had a significantly greater number of patients in New York Heart Association classes III and IV. The proportion of patients requiring prolonged ventilation was significantly lower, and the length of postoperative hospital stay was significantly shorter in the study group than in the control group. The incidence of cerebrovascular accident in the study group was 0.97%, compared with 2.03% in the controls. This translated to a potential avoidance of 12 cerebrovascular accidents and approximately $254,214 in direct costs and more than $425,000 in total costs. The results show that specific measures can improve outcomes and reduce costs in cardiac surgery. Therefore, the use of a clinical effectiveness quality initiative and cerebral oximetry in all cardiac surgery, with the SAS system for off-pump surgery, should be advocated.

Outcomes after usage of a quality initiative program for off-pump coronary artery bypass surgery: a comparison with on-pump surgery.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) may be associated with improved outcomes when compared with on-pump coronary artery bypass. This study evaluates the use of a system for access and stabilization (SAS) with a coronary stabilizer as well as a clinical effectiveness quality initiative (CEQI) process regarding outcomes. This included the development of an expanded heart care team as well as standardization and refinement of perioperative care at The Lankenau Hospital (TLH). Our aim was to evaluate morbidity and mortality of on-pump coronary artery bypass grafting (CABG) compared with OPCAB surgery using SAS in addition to a CEQI initiative. METHODS: A retrospective consecutive cohort study using the Society of Thoracic Surgery (STS) National Database was conducted. Three cohorts were analyzed: pre-SAS (December 1, 1999-August 31, 2000); use of SAS only (September 1, 2000-April 30, 2001), and the use of SAS + CEQI process (May 1, 2001-September 30, 2002). Morbidity and mortality for all on-pump CABG procedures performed over the time period of December 1, 1999-September 30, 2002 were compared with the SAS and SAS + CEQI groups only. RESULTS: One-thousand two-hundred sixty-seven procedures were performed; 405 on-pump CABGs, 90 OPCABs pre-SAS, and 772 OPCABs with SAS, of which 552 were in the SAS + CEQI group. Statistically mortality was significantly lower in the SAS + CEQI vs the on-pump group (0.7% vs 3.0%, p < 0.01). The percentage of patients with prolonged ventilation was significantly lower statistically in the SAS + CEQI vs the on-pump group (4.2% vs 9.7%, p < 0.01). Statistically the length of stay was significantly lower in both SAS groups compared with the on-pump group (p < 0.01). CONCLUSIONS: OPCAB surgery using SAS in conjunction with a CEQI initiative improves outcomes for patients compared with on-pump CABG surgery.