Background: Psoas muscle cross-sectional area predicts morbidity and mortality as a surrogate for frailty in cardiac surgery patients, but routine preoperative abdominal imaging is uncommon. We hypothesized that pectoralis and psoas muscle cross-sectional area correlate, and pectoralis area may predict morbidity and mortality for patients undergoing surgical aortic valve replacement (SAVR). Methods: A psoas muscle area validation cohort of moderate to high-risk patients undergoing SAVR (1/2009–12/2016) were identified from the University of Virginia. Pectoralis muscle area identified on preoperative computed tomography (CT) was indexed to body surface area to define pectoralis index. Sarcopenia was defined as pectoralis index below sex-specific 25th percentile. Patients were stratified by sarcopenic status, and regression analysis identified risk-adjusted associations utilizing Society of Thoracic Surgeons (STS) predicted risk scores. Results: Preoperative chest imaging was available for 228 patients. Sarcopenic patients were significantly older (median 82 vs 80 years, p = 0.041) and had greater mean society of thoracic surgeons predicted risk of mortality (STS PROM) (7.0% vs 5.7%, p = 0.047). There was no difference by sarcopenic status for operative mortality (8.8% vs 4.1%, p = 0.171) or major morbidity (21.1% vs 19.9%, p = 0.849). Risk-adjusted pectoralis index was associated with greater STS major morbidity (OR 0.998, p = 0.021), likelihood of discharge to a facility (OR 0.998, p = 0.014), and one-year mortality (OR 0.997, p = 0.025). Conclusion: Lower pectoralis index may be associated with worse risk-adjusted outcomes after SAVR. Pectoralis defined sarcopenia may serve as a useful measure of frailty in cardiac surgery patients.

OBJECTIVES:Prolonged cardiopulmonary bypass (CPB) time during coronary artery bypass grafting (CABG) is associated with poor outcomes, however, the association of other operating room (OR) times is less understood. We studied the impact of OR times on outcomes and resource utilization after CABG. METHODS:Patients undergoing isolated primary CABG from a large multicentre regional collaborative were analysed. The impact of risk-adjusted total OR, surgery, non-surgery, CPB, and off-CPB times on morbidity, extubation time, ICU and hospital length of stay (LOS), cost, and mortality, was studied. Multivariable regressions were performed adjusting for STS predicted risk of morbidity or mortality, intraoperative blood transfusion, CPB time, cross-clamp time, presence of a cardiothoracic surgery fellowship program, and year of surgery. Our adjustment accounted for patient and intraoperative factors that contribute to complexity and intraoperative course of surgery. All models incorporated centre as a random effect to account for hospital-level variations. RESULTS:Among 29 206 patients (mean age 64.8 years, 76% male), median OR, surgery, non-surgery, and CPB times were 308, 235, 72, and 141 minutes, respectively. Longer surgery times were significantly associated with complications, prolonged ventilation, longer ICU and hospital LOS, and mortality. Similarly, increasing non-surgery OR time was significantly associated with worse outcomes, including longer LOS and complications. Each additional 15 minutes in the OR was associated with increased odds of complications, mortality, and cost. CONCLUSIONS:Longer non-surgical OR times are associated with adverse outcomes and increased cost. Improving OR efficiency may contribute to better patient outcomes.

Background: Venous thromboembolism (VTE) is a rare complication after coronary artery bypass surgery (CABG), leading to increased morbidity and mortality. There are no current societal guidelines directing prophylaxis. Utilizing a regional database, we sought to determine the prevalence of VTE and characterize regional center practices. Methods: We identified all patients undergoing on‐pump, isolated CABG (2010–2020). Patients on oral therapeutic anticoagulation or requiring mechanical circulatory support were excluded. Participating centers were surveyed to determine center level practices. Multivariable regression and hierarchical logistic regression were utilized for risk‐adjusted outcomes and influence of center practices on VTE rates, respectively. Results: Of 20,719 CABG patients, the overall prevalence of postoperative VTE was 1.3% (266/20,719). Patients developing VTE were more often female (30.1% vs. 23.4%, p = 0.01), had higher STS predicted risk of mortality (1.2% [0.7%, 2.2%] vs. 0.9% [0.5%, 1.7%], p < 0.001) and higher unadjusted operative mortality (4.1% vs. 1.0%, p < 0.001). Risk‐adjusted analysis demonstrated pulmonary embolism as an independent predictor of mortality (OR = 3.4 [1.06, 11.0], p = 0.04). Increasing time from admission to surgery (OR = 1.05 [1.01, 1.09], p = 0.001), preoperative heparin use (OR = 1.47 [1.13, 1.90], p = 0.004), and intraoperative prothrombin complex concentrate (PCC) (OR = 4.85 [1.47, 15.96], p = 0.009) were predictors of VTE. Regional practices were mainly homogenous with no specific center‐level protocol associated with decreases in VTE. Conclusion: VTE following CABG is an infrequent postoperative complication with pulmonary embolism as an independent predictor of mortality. Increasing time from admission to surgery and intraoperative PCC may increase the risk of VTE.

Background Our thoracic enhanced recovery program (ERP) decreased the use of postoperative morphine equivalents and hospital costs 1 year after implementation at our tertiary center. The sustainability and potential increasing benefit of this program were evaluated. Methods From 2015 to 2021, we prospectively analyzed the outcomes of patients who underwent elective pleural, pulmonary, or mediastinal operations at our institution. Patients were separated on the basis of the incision (video-assisted thoracoscopic surgery [VATS] or thoracotomy). The ERP protocol was initiated on May 1, 2016, and includes preoperative education, carbohydrate loading, opioid-sparing analgesia, conservative fluid management, protective ventilation, and early ambulation. Outcomes of patients before (2015, pre-VATS and pre-thoracotomy) and after (May 1, 2016, to December 31, 2021, ERP-VATS and ERP-thoracotomy) ERP implementation were compared. Results The cohort included 1079 patients (pre-ERP era, n = 224 [21%]; ERP era, n = 855 [79%]). There was a median reduction of 1.5 hospital days per patient for ERP-thoracotomy and 1 hospital day per patient for ERP-VATS. Median postoperative morphine equivalents decreased in both groups (125 vs 45 mg, in ERP-thoracotomy; 84 vs 23 mg, ERP-VATS; P < .001), as did total admission cost ($32,118 vs $23,775, ERP-thoracotomy; $17,367 vs $11,560, ERP-VATS; P < .001). Median total fluid balance during the hospital stay decreased significantly. Rates of postoperative atrial fibrillation and urinary retention decreased across both subgroups. Conclusions ERP for thoracic surgery is sustainable and has been demonstrated to improve patient outcomes, to decrease opioid use, and to lower hospital costs. Therefore, it has the potential to become the standard of care.

OBJECTIVE:Intensive care unit length of stay (ICU LOS) accounts for a large percentage of inpatient cost after cardiac surgery. The Society of Thoracic Surgeons risk calculator predicts total LOS but does not discriminate between ICU and non-ICU time. We sought to develop a predictive model of prolonged ICU LOS. METHODS:Adult patients undergoing Society of Thoracic Surgeons index operations within a regional collaborative (2014-2021) were included. Prolonged ICU LOS was defined as ICU care for ≥72 hours postoperatively. A logistic regression model was used to develop a prediction model for the prolonged ICU LOS with prespecified risk factors identified from our previous single-center study. Internal prediction model validation was determined by bootstrapping resampling method. The prediction model performance was assessed by measures of discrimination and calibration. RESULTS:We identified 37,519 patients that met inclusion criteria with 11,801 (31.5%) patients experiencing prolonged ICU stay. From the logistic regression model, there were significant associations between prolonged ICU LOS and all pre-specified factors except sleep apnea (all P < .05). Model for End-Stage Liver Disease, preoperative intra-aortic balloon pump use, and procedure types were the most significant predictors of prolonged ICU LOS (all P < .0001). Our prediction model had not only a good discrimination power (bootstrapped-corrected C-index = 0.71) but also excellent calibration (bootstrapped-corrected mean absolute error = 0.005). CONCLUSIONS:Prolonged ICU stay after cardiac surgery can be predicted with good predictive accuracy using preoperative data and may aid in patient counseling and resource allocation. Through use of a state-wide database, the application of this model may extend to other practices.

Background: Cardiac surgery-associated acute kidney injury (AKI) is associated with increased postoperative morbidity and mortality. Evidence suggests an association between perioperative acetaminophen administration and decreased incidence of postoperative AKI in pediatric cardiac surgery patients; however, an effect in adults is unknown. Methods: All patients (n = 6192) undergoing coronary and/or valve surgery with a recorded Society of Thoracic Surgeons (STS) risk score at our institution between 2010 and 2018 were stratified by acetaminophen exposure on the day of surgery using institutional pharmacy records. AKI was determined using the Kidney Disease: Improving Global Outcomes (KDIGO) staging criteria. Logistic regression was used to analyze the association between perioperative acetaminophen and postoperative kidney injury or STS major morbidity. A sensitivity analysis using propensity score matching on the STS predicted risk of renal failure and cardiopulmonary bypass time was performed to account for time bias. Results: Perioperative acetaminophen exposure was associated with lower odds of stage 1 to 3 acute kidney injury (odds ratio [OR], 0.68; 95% CI, 0.56-0.83; P <.001) and decreased prolonged postoperative ventilation (OR, 0.53; 95% CI, 0.37-0.76; P < .001). A sensitivity analysis provided well-balanced (standard mean difference <0.10) groups of 401 pairs, in which acetaminophen was associated with a decreased incidence of postoperative AKI (OR, 0.7; 95% CI, 0.52-0.94; P = .016). Conclusions: Exposure to acetaminophen on the day of surgery was associated with a decreased incidence of AKI in our patients undergoing cardiac surgery. These data serve as a measure of effect size to further explore the therapeutic potential of acetaminophen to reduce postoperative AKI after cardiac surgery and to elucidate the mechanisms involved.

Objective: Our understanding of the impact of a center ' s case volume on failure to rescue (FTR) after cardiac surgery is incomplete. We hypothesized that increasing center case volume would be associated with lower FTR. Methods: Patients undergoing a Society of Thoracic Surgeons index operation in a regional collaborative (2011-2021) were included. After we excluded patients with missing Society of Thoracic Surgeons Predicted Risk of Mortality scores, patients were stratified by mean annual center case volume. The lowest quartile of case volume was compared with all other patients. Logistic regression analyzed the association between center case volume and FTR, adjusting for patient demographics, race, insurance, comorbidities, procedure type, and year. Results: A total of 43,641 patients were included across 17 centers during the study period. Of these, 5315 (12.2 % ) developed an FTR complication, and 735 (13.8 % of those who developed an FTR complication) experienced FTR. Median annual case volume was 226, with 25th and 75th percentile cutoffs of 136 and 284 cases, respectively. Increasing center -level case volume was associated with signi fi cantly greater center -level major complication rates but lower mortality and FTR rates (all P values < .01). Observed -to -expected FTR was significantly associated with case volume ( P = .040). Increasing case volume was independently associated with decreasing FTR rate in the final multivariable model (odds ratio, 0.87 per quartile; confidence interval, 0.799-0.946, P = .001). Conclusions: Increasing center case volume is significantly associated with improved FTR rates. Assessment of low -volume centers ' FTR performance represents an opportunity for quality improvement. (J Thorac Cardiovasc Surg 2024;168:165-74)

ObjectiveTransient receptor potential vanilloid 4 (TRPV4) is a nonselective cation channel important in many physiological and pathophysiological processes, including pulmonary disease. Using a murine model, we previously demonstrated that TRPV4 mediates lung ischemia-reperfusion injury, the major cause of primary graft dysfunction after transplant. The current study tests the hypothesis that treatment with a TRPV4 inhibitor will attenuate lung ischemia-reperfusion injury in a clinically relevant porcine lung transplant model.MethodsA porcine left-lung transplant model was used. Animals were randomized to 2 treatment groups (n = 5/group): vehicle or GSK2193874 (selective TRPV4 inhibitor). Donor lungs underwent 30 minutes of warm ischemia and 24 hours of cold preservation before left lung allotransplantation and 4 hours of reperfusion. Vehicle or GSK2193874 (1 mg/kg) was administered to the recipient as a systemic infusion after recipient lung explant. Lung function, injury, and inflammatory biomarkers were compared.ResultsAfter transplant, left lung oxygenation was significantly improved in the TRPV4 inhibitor group after 3 and 4 hours of reperfusion. Lung histology scores and edema were significantly improved, and neutrophil infiltration was significantly reduced in the TRPV4 inhibitor group. TRPV4 inhibitor-treated recipients had significantly reduced expression of interleukin-8, high mobility group box 1, P-selectin, and tight junction proteins (occludin, claudin-5, and zonula occludens-1) in bronchoalveolar lavage fluid as well as reduced angiopoietin-2 in plasma, all indicative of preservation of endothelial barrier function.ConclusionsTreatment of lung transplant recipients with TRPV4 inhibitor significantly improves lung function and attenuates ischemia-reperfusion injury. Thus, selective TRPV4 inhibition may be a promising therapeutic strategy to prevent primary graft dysfunction after transplant.

Objective: Failure to rescue (FTR) is an emerging measure in cardiac surgery, defined as mortality after a postoperative complication. We hypothesized that establishing a medical emergency team (MET) reduced rates of FTR in adults under-going cardiac surgery.Methods: All patients (N =11,218) undergoing a The Society of Thoracic Surgeons index operation at our center (1994-2018) were stratified by pre-MET or MET era based on the 2009 institutional implementation of a MET to respond to clinical decompensation in non-intensive-care patients. Patients missing The Society of Thoracic Surgeons predicted risk of mortality were excluded from all cohorts. Risk adjusted multivariable regression analyzed the association of postoperative complications, operative mortality, and FTR by era. Nearest neighbor propensity score matching utilizing patients' The Society of Thoracic Surgeons predicted risk of mortality was performed to create balanced control and exposure groups for secondary subgroup analysis.Results: In the risk-adjusted multivariable analysis, surgery during the MET era was associated with decreased mortality (odds ratio [OR], 0.51; 95% CI, 0.45-0.77; P <.001), postoperative renal failure (OR, 0.57; 95% CI, 0.46-0.70; P <.001), reop-eration (OR, 0.75; 95% CI, 0.59-0.95; P = .017), and deep sternal wound infection (OR, 0.16; 95% CI, 0.04-0.45; P = .002). Surgery performed during the MET era was associated with a decreased rate of FTR in the risk-adjusted analysis (OR, 0.46; 95% CI, 0.34-0.70; P < .001).Conclusions: The development of an institutional MET program was associated with a decrease in major complications and FTR. These findings support the devel-opment of MET programs to improve FTR after cardiac surgery. (J Thorac Cardio-vasc Surg 2023;165:1861-72)

Background Adults undergoing heart surgery are particularly vulnerable to respiratory complications, including COVID‐19. Immunization can significantly reduce this risk; however, the effect of cardiopulmonary bypass (CPB) on immunization status is unknown. We sought to evaluate the effect of CPB on COVID‐19 vaccination antibody concentration after cardiac surgery. Methods and Results This prospective observational clinical trial evaluated adult participants undergoing cardiac surgery requiring CPB at a single institution. All participants received a full primary COVID‐19 vaccination series before CPB. SARS‐CoV‐2 spike protein‐specific antibody concentrations were measured before CPB (pre‐CPB measurement), 24 hours following CPB (postoperative day 1 measurement), and approximately 1 month following their procedure. Relationships between demographic or surgical variables and change in antibody concentration were assessed via linear regression. A total of 77 participants were enrolled in the study and underwent surgery. Among all participants, mean antibody concentration was significantly decreased on postoperative day 1, relative to pre‐CPB levels (−2091 AU/mL, P<0.001). Antibody concentration increased between postoperative day 1and 1 month post CPB measurement (2465 AU/mL, P=0.015). Importantly, no significant difference was observed between pre‐CPB and 1 month post CPB concentrations (P=0.983). Two participants (2.63%) developed symptomatic COVID‐19 pneumonia postoperatively; 1 case of postoperative COVID‐19 pneumonia resulted in mortality (1.3%). Conclusions COVID‐19 vaccine antibody concentrations were significantly reduced in the short‐term following CPB but returned to pre‐CPB levels within 1 month. One case of postoperative COVID 19 pneumonia‐specific mortality was observed. These findings suggest the need for heightened precautions in the perioperative period for cardiac surgery patients.

Background Cardiac postoperative intensive care unit (ICU) beds are a limited resource, and when a patient no longer requires this level of care they are quickly transferred out. We hypothesized that complications and ICU readmission increased when transfer occurred during off-hours compared with regular work hours. Methods From 2010 to 2021, patients who underwent a Society of Thoracic Surgeons index operation at a single center were assigned a group based on their ICU transfer time, defined as when they physically arrived on the acute care floor. Patients were stratified into off-hours vs regular hours by their transfer time. Off-hours was defined as 9 pm to 5 am. Risk-adjusted multivariable logistic regression analyzed the association of ICU readmission, postoperative complications, operative mortality, and failure to rescue by group. Results The cohort included 5951 patients (off-hours n = 292 [4.9%], regular-hours n = 5659 [95.1%]). Patients in the off-hours group had significantly greater odds of risk-adjusted ICU readmission (odds ratio 1.99, 95% CI 1.25-3.04, P < .002) and mortality (odds ratio 3.88, 95% CI 2.27-6.33, P < .001). In the major complications subgroup (Off-hours n = 55, Regular-hours n = 603), Off-hours transfer was associated with increased mortality (failure to rescue) (odds ratio 3.05, 95% CI 1.58-5.69, P = .001). Conclusions Off-hours ICU to floor transfer was associated with increased postoperative complications, ICU readmission, and mortality, suggesting that the timing of ICU transfer may impact outcomes. This elucidates targets for quality and process improvement for our center and others facing the same resource constraints.

Objectives The optimal method for monitoring of anticoagulation in patients on extracorporeal life support (ECLS) is unknown. The objective of this study was to assess the relationship between anti-factor Xa level (anti-Xa; IU/mL) and activated partial thromboplastin time (aPTT; seconds) for monitoring intravenous unfractionated heparin anticoagulation in adult ECLS patients. Methods Charts of all adult patients cannulated for ECLS from 2015 through 2017 were reviewed and laboratory and heparin infusion data were extracted for analysis. Time matched pairs of anti-Xa and aPTT were considered concordant if both laboratory values were within the same clinically utilized range. A hierarchical logistic regression model was used to determine factors associated with discordance while accounting for patient level effects. Results A total of 1016 paired anti-Xa and aPTT values from 65 patients were evaluated. 500 (49.2%) paired samples were discordant with a degree of variability on linear regression (r( 2 ) = 0.315). The aPTT fell into a higher therapeutic range compared to the anti-Xa in 31.6% and lower in 17.3%. Logistic regression demonstrated that discordance was independently associated with time from initiation of ECLS (OR 1.17 per day, p < 0.001), average heparin infusion rate (OR 1.25 per U/kg/hr, p < 0.001), and INR (OR 3.22, p < 0.001). Conclusions Nearly half of all aPTT and anti-Xa values were in discordant ranges and discordance is more likely as the time on ECLS and the INR level increase. The use of either assay in isolation to guide heparin anticoagulation may lead to misestimation of the degree of anticoagulation in complex ECLS patients.

BACKGROUND Racial disparities in outcomes after cardiac surgery are well reported. We sought to determine whether variation by race exists in controllable practices during coronary artery bypass graft surgery (CABG). We hypothesized that racial disparities exist in CABG quality metrics, but have improved over time.METHODS All patients undergoing isolated CABG (2000 to 2019) in a multiple state database were stratified into three eras by race. Analysis included propensity matched White Americans and Black Americans. Primary outcomes included left internal mammary artery use, multiple arterial grafting, revascularization completeness, and guideline-directed medication prescription.RESULTS Of 72 248 patients undergoing CABG, Black American patients (n = 10270, 15%) had higher rates of dia-betes mellitus, hypertension, prior stroke, and myocardial infarction. After matching, 19806 patients (n = 9903 per group) were well balanced. Left internal mammary artery use was significantly different early (era 1, Black Americans 84.7% vs White Americans 86.6%; P = .03), but equalized over time. Importantly, multiarterial grafting differed between Black Americans and White Americans over the entire study (9.1% vs 11.5%, P < .001) and within each era. Black Americans had more incomplete revascularization during the study period (14% vs 12.8%, P = .02) driven by a large disparity in era 1 (9.5% vs 7.2%, P < .001). Despite similar rates of preoperative use, Black Americans were more often discharged on a regimen of b-blockers (91.8% vs 89.6%, P < .001).CONCLUSIONS Coronary artery bypass graft surgery metrics of left internal mammary artery use and optimal medical therapy have improved over time and are similar despite patient race. Black Americans undergo less frequent multi-arterial grafting and greater discharge b-blocker prescription. Identifying changes in controllable CABG quality practices across races supports a continued focus on standardizing such efforts.

Central MessageWho decides how we treat coronary artery disease? Do they have information to make the decision? Are they using it?See Article page 106. Who decides how we treat coronary artery disease? Do they have information to make the decision? Are they using it? See Article page 106. The continued evolution of cardiothoracic surgery and cardiology requires a constant reassessment of long-term outcomes. The debate over the most appropriate treatment for coronary artery disease continues; however, several populations have been identified as having the greatest benefit through randomized control trials, namely those with 3-vessel disease,1Thuijs D.J. Kappetein A.P. Serruys P.W. Mohr F.W. Morice M.C. Mack M.J. et al.Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.Lancet. 2019; 394: 1325-1334Abstract Full Text Full Text PDF PubMed Scopus (339) Google Scholar diabetic multivessel disease,2Farkouh M.E. Domanski M. Sleeper L.A. Siami F.S. Dangas G. Mack M. et al.Strategies for multivessel revascularization in patients with diabetes.N Engl J Med. 2012; 367: 2375-2384Crossref PubMed Scopus (1438) Google Scholar low ejection fraction,3Velazquez E.J. Lee K.L. Jones R.H. Al-Khalidi H.R. Hill J.A. Panza J.A. et al.Coronary-artery bypass surgery in patients with ischemic cardiomyopathy.N Engl J Med. 2016; 374: 1511-1520Crossref PubMed Scopus (613) Google Scholar and left main disease.4Shlofmitz E. Généreux P. Chen S. Dressler O. Ben-Yehuda O. Morice M.C. et al.Left main coronary artery disease revascularization according to the SYNTAX Score.Circ Cardiovasc Interv. 2019; 12: e008007Crossref PubMed Scopus (16) Google Scholar Early data on outcomes by Yusuf and colleagues5Yusuf S. Zucker D. Peduzzi P. Fisher L.D. Takaro T. Kennedy J.W. et al.Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the coronary artery bypass graft surgery Trialists Collaboration.Lancet. 1994; 344: 563-570Abstract PubMed Scopus (1827) Google Scholar demonstrated improved mortality out to 12 years in patients who underwent coronary artery bypass grafting (CABG). Loop and colleagues6Loop F.D. Lytle B.W. Cosgrove D.M. Stewart R.W. Goormastic M. Williams G.W. et al.Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events.N Engl J Med. 1986; 314: 1-6Crossref PubMed Scopus (2310) Google Scholar and Cameron and colleagues7Cameron A. Davis K.B. Green G. Schaff H.V. Coronary bypass surgery with internal-thoracic-artery grafts—effects on survival over a 15-year period.N Engl J Med. 1996; 334: 216-219Crossref PubMed Scopus (755) Google Scholar demonstrated improved long-term patency when using the internal thoracic artery (ITA) compared with saphenous vein grafting. Atherosclerosis is rarely seen in the ITA conduit, and it is less susceptible to spasm due to manipulation, likely due to its reactivity to endogenous vasodilators.8Takeuchi K. Sakamoto S. Nagayoshi Y. Nishizawa H. Matsubara J. Reactivity of the human internal thoracic artery to vasodilators in coronary artery bypass grafting.Eur J Cardiothorac Surg. 2004; 26: 956-959Crossref PubMed Scopus (26) Google Scholar These excellent outcomes data have led to practice patterns shifting to favor ITA grafting whenever possible. Ohno9Ohno T. The magnitude of the survival benefit of internal thoracic artery grafting: absolute risk reduction.J Thorac Cardiovasc Surg Open. 2022; 9: 106-111Scopus (2) Google Scholar is to be commended for the thoughtful interpretation of the history and current state of CABG surgery and makes some interesting points about future directions. He describes a survival benefit to CABG with ITA over decades. He draws this conclusion based on the aforementioned studies on specific populations1Thuijs D.J. Kappetein A.P. Serruys P.W. Mohr F.W. Morice M.C. Mack M.J. et al.Percutaneous coronary intervention versus coronary artery bypass grafting in patients with three-vessel or left main coronary artery disease: 10-year follow-up of the multicentre randomised controlled SYNTAX trial.Lancet. 2019; 394: 1325-1334Abstract Full Text Full Text PDF PubMed Scopus (339) Google Scholar, 2Farkouh M.E. Domanski M. Sleeper L.A. Siami F.S. Dangas G. Mack M. et al.Strategies for multivessel revascularization in patients with diabetes.N Engl J Med. 2012; 367: 2375-2384Crossref PubMed Scopus (1438) Google Scholar, 3Velazquez E.J. Lee K.L. Jones R.H. Al-Khalidi H.R. Hill J.A. Panza J.A. et al.Coronary-artery bypass surgery in patients with ischemic cardiomyopathy.N Engl J Med. 2016; 374: 1511-1520Crossref PubMed Scopus (613) Google Scholar, 4Shlofmitz E. Généreux P. Chen S. Dressler O. Ben-Yehuda O. Morice M.C. et al.Left main coronary artery disease revascularization according to the SYNTAX Score.Circ Cardiovasc Interv. 2019; 12: e008007Crossref PubMed Scopus (16) Google Scholar as well as historical data looking at more general populations.5Yusuf S. Zucker D. Peduzzi P. Fisher L.D. Takaro T. Kennedy J.W. et al.Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the coronary artery bypass graft surgery Trialists Collaboration.Lancet. 1994; 344: 563-570Abstract PubMed Scopus (1827) Google Scholar,7Cameron A. Davis K.B. Green G. Schaff H.V. Coronary bypass surgery with internal-thoracic-artery grafts—effects on survival over a 15-year period.N Engl J Med. 1996; 334: 216-219Crossref PubMed Scopus (755) Google Scholar He also suggests that age could be an important factor in determining appropriateness for CABG. The first conclusion is reasonable, given the data. While the oldest studies may not reflect current medical therapy, patient demographics, or interventional techniques, follow-up from recent studies continue to support that ITA grafting has superior patency over 8 to 10 years. The author frequently uses number needed to treat statistics (1/absolute risk reduction) to help illustrate the benefits of CABG on mortality and compare findings across studies. Figure 2 is nicely illustrative of the benefit demonstrated by Yusuf and colleagues5Yusuf S. Zucker D. Peduzzi P. Fisher L.D. Takaro T. Kennedy J.W. et al.Effect of coronary artery bypass graft surgery on survival: overview of 10-year results from randomised trials by the coronary artery bypass graft surgery Trialists Collaboration.Lancet. 1994; 344: 563-570Abstract PubMed Scopus (1827) Google Scholar on a population who only underwent saphenous vein grafting. However, we recommend caution when interpreting the Central Figure. The method for creating the outcomes curve is unclear and described as “conceptual” and appears to extrapolate on the first data point derived from a Lancet meta-analysis.10Head S.J. Milojevic M. Daemen J. Ahn J.M. Boersma E. Christiansen E.H. et al.Mortality after coronary artery bypass grafting versus percutaneous coronary intervention with stenting for coronary artery disease: a pooled analysis of individual patient data.Lancet. 2018; 391: 939-948Abstract Full Text Full Text PDF PubMed Scopus (417) Google Scholar Thus, while the concept behind the figure is appealing, it may be unintentionally misleading at first glance. A major challenge in informing our colleagues and patients about long-term outcomes is that it will be difficult to ever obtain lifetime data on percutaneous coronary intervention versus ITA graft outcomes. In addition, the decision of whether to proceed with CABG or percutaneous coronary intervention is directed by the first person who sees the patient. We are curious to hear the author elaborate on how he would like age to factor into CABG decision-making and his supporting evidence. It will require long-term results from large data sets to determine the best procedure for young patients with coronary artery disease. The magnitude of the survival benefit of internal thoracic artery grafting: Absolute risk reductionJTCVS OpenVol. 9PreviewThe magnitude of the survival benefit of CABG with internal thoracic artery graft increases with time over decades. Full-Text PDF Open Access

Intensive care unit (ICU) costs comprise a significant proportion of the total inpatient charges for cardiac surgery. No reliable method for predicting intensive care unit length of stay following cardiac surgery exists, making appropriate staffing and resource allocation challenging. We sought to develop a predictive model to anticipate prolonged ICU length of stay (LOS). All patients undergoing coronary artery bypass grafting (CABG) and/or valve surgery with a Society of Thoracic Surgeons (STS) predicted risk score were evaluated from an institutional STS database. Models were developed using 2014-2017 data; validation used 2018-2019 data. Prolonged ICU LOS was defined as requiring ICU care for at least three days postoperatively. Predictive models were created using lasso regression and relative utility compared. A total of 3283 patients were included with 1669 (50.8%) undergoing isolated CABG. Overall, 32% of patients had prolonged ICU LOS. Patients with comorbid conditions including severe COPD (53% vs 29%, P < 0.001), recent pneumonia (46% vs 31%, P < 0.001), dialysis-dependent renal failure (57% vs 31%, P < 0.001) or reoperative status (41% vs 31%, P < 0.001) were more likely to experience prolonged ICU stays. A prediction model utilizing preoperative and intraoperative variables correctly predicted prolonged ICU stay 76% of the time. A preoperative variable-only model exhibited 74% prediction accuracy. Excellent prediction of prolonged ICU stay can be achieved using STS data. Moreover, there is limited loss of predictive ability when restricting models to preoperative variables. This novel model can be applied to aid patient counseling, resource allocation, and staff utilization.

Introduction: Mainstays of current treatment for acute respiratory distress syndrome (ARDS) focus on supportive care and rely on intrinsic organ recovery. Animal models of ARDS are often limited by systemic injury. We hypothesize that superimposing gastric aspiration and ventilator-induced injury will induce a lung-specific injury model of severe ARDS. Materials and methods: Adult swine (n = 8) were subject to a 12 h injury development period followed by 24 h of post-injury monitoring. Lung injury was induced with gastric secretions (3 cc/kg body weight/lung, pH 1-2) instilled to bilateral mainstem bronchi under direct bronchoscopic vision. Ventilator settings within the injury period contradicted baseline settings using high tidal volumes and low positive end-expiratory pressure. Baseline settings were restored following the injury period. Arterial oxygenation and lung compliance were monitored. Results: At 12 h, PaO2/FiO(2) ratio and static and dynamic compliance were significantly reduced from baseline (P < 0.05). During the postinjury period, animals showed no signs of recovery in PaO2/FiO(2) ratio and lung compliance. Lung edema (wet/dry weight ratio) of injured lungs was significantly elevated versus noninjured lungs (8.5 & PLUSMN; 1.7 versus 5.6 & PLUSMN; 0.3, P = 0.009). Expression of proinflammatory cytokines IL-6 and IL-8 were significantly elevated in injured lungs (P < 0.05). Conclusions: Twelve hours of high tidal volume and low positive end-expiratory pressure in conjunction with low-pH gastric content instillation produces significant acute lung injury in swine. This large animal model may be useful for testing severe ARDS treatment strategies. (c) 2022 Elsevier Inc. All rights reserved.

BACKGROUND Lung ischemia-reperfusion injury (IRI), involving severe inflammation and edema, is a major cause of primary graft dysfunction after transplant. Activation of transient receptor potential vanilloid 4 (TRPV4) channels modulates vascular permeability. Thus, this study tests the hypothesis that endothelial TRPV4 channels mediate lung IRI. METHODS A left lung hilar-ligation model was used to induce lung IR in C57BL/6 wild-type (WT), Trpv4(-/-,) tamoxifeninducible endothelial Trpv4 knockout (Trpv4(EC)(-/-)), and tamoxifen-treated control (Trpv4(fl/fl)) (n >= 6 mice/group). WT mice were also treated with GSK2193874 (WT+GSK219), a TRPV4-specific inhibitor (1 mg/kg). Partial pressure of arterial oxygen, edema (wet-to-dry weight ratio), compliance, neutrophil infiltration, and cytokine concentrations in bronchoalveolar lavage fluid were assessed. Pulmonary microvascular endothelial cells were characterized in vitro after exposure to hypoxia-reoxygenation. RESULTS Compared with WT, partial pressure of arterial oxygen after IR was significantly improved in Trpv4(-/-) mice (133.1 +/- 43.9 vs 427.8 +/- 83.1 mm Hg, P < .001) and WT+GSK219 mice (133.1 +/- 43.9 vs 447.0 +/- 67.6 mm Hg, P < .001). Pulmonary edema and neutrophil infiltration were also significantly reduced after IR in Trpv4(-/-) and WT+GSK219 mice vs WT. Trpv4(EC)(-/-) mice after IR demonstrated significantly improved oxygenation vs control (109.2 +/- 21.6 vs 405.3 +/- 41.4 mm Hg, P < .001) as well as significantly improved compliance and significantly less edema, neutrophil infiltration, and proinflammatory cytokine production (tumor necrosis factor-a, chemokine [C-X-C motif] ligand 1, interleukin 17, interferon -y). Hypoxia-reoxygenation-induced permeability and chemokine (C-X-C motif) ligand 1 expression by pulmonary microvascular endothelial cells were significantly attenuated by TRPV4 inhibitors. CONCLUSIONS Endothelial TRPV4 plays a key role in vascular permeability and lung inflammation after IR. TRPV4 channels may be a promising therapeutic target to mitigate lung IRI and decrease the incidence of primary graft dysfunction after transplant. (c) 2022 by The Society of Thoracic Surgeons

INTRODUCTION: Advances in therapies to treat sepsis beyond source control, antibiotics, and supportive care are lacking. Systemic hypothermia has been suggested but remains difficult to implement. Using a swine model of intra-abdominal sepsis, we hypothesize that topical neck cooling (TNC) can inhibit inflammation to preserve organ function and prolong the therapeutic window for intervention via a vagus nerve–mediated pathway. METHODS: Domestic pigs underwent laparotomy and induction of severe feculent peritonitis (FP) by extraction of autologous stool (2 g/kg swine weight) via colotomy, dilution in saline, and subsequent injection into the peritoneal cavity. Pigs were randomized to control and TNC groups, with TNC applied to the ventral neck for a 2-hour period 30 minutes after FP. Hemodynamic monitoring and serial bloodwork was performed for 6 hours. Organs were then harvested. RESULTS: TNC significantly attenuated FP-induced tachycardia by 127% (54% ± 8% increase from TNC baseline vs 181% ± 44% increase from control baseline, p < 0.05). Metabolic acidosis and lactic acidemia at 6 hours were significantly increased from pre-septic baseline in control pigs (pH 7.29 ± 0.03 vs pH 7.41 ± 0.03 and 2.42 ± 0.40 mmol/L vs 0.61 ± 0.22 mmol/L, respectively, p < 0.05), but not in TNC-treated pigs. Proinflammatory cytokines IL-1β and IL-6 were significantly reduced by TNC treatment (p < 0.05; Figure).Figure.: FP, feculent peritonitis; TNC, topical neck cooling.CONCLUSION: In a swine model of severe FP, TNC significantly inhibited FP-induced severe tachycardia, potentially via vagal activation. TNC also improved tissue perfusion and metabolic acidosis and inhibited proinflammatory responses. TNC is an easily implemented novel therapy that can potentially delay sepsis progression and extend the therapeutic window for surgical source control.

Time-directed extubation (fast-track) protocols may decrease length of stay and cost but data on operating room (OR) extubation is limited. The objective of this study was to compare the outcomes of extubation in the OR versus fast-track extubation within 6 hours of leaving the operating room. Patients undergoing nonemergent STS index cases (2011-2021) who were extubated within 6 hours were identified from a regional STS quality collaborative. Patients were stratified by extubation in the OR versus fast track. Propensity score matching (1:n) was performed to balance baseline differences. Of the 24,962 patients, 498 were extubated in the OR. After matching, 487 OR extubation cases and 899 fast track cases were well balanced. The rate of reintubation was higher for patients extubated in the OR [21/487 (4.3%) vs 16/899 (1.8%), P = 0.008] as was the incidence of reoperation for bleeding [12/487 (2.5%) vs 8/899 (0.9%), P = 0.03]. There was no significant difference in the rate of any reoperation [16/487 (3.3%) vs 15/899 (1.6%), P = 0.06] or operative mortality [4/487 (0.8%) vs 6/899 (0.6%), P = 0.7]. OR extubation was associated with shorter hospital length of stay (5.6 vs 6.2 days, P < 0.001) and lower total cost of admission ($29,602 vs $31,565 P < 0.001). OR extubation is associated with a higher postoperative risk of reintubation and reoperation due to bleeding, but lower resource utilization.Future research exploring predictors of extubation readiness may be required prior to widespread adoption of this practice.