As the professional society representing cardiac surgeons in Canada, the Canadian Society of Cardiac Surgeons (CSCS) recognizes the importance of maintaining a stable cardiac surgical workforce. The current reactive approach to health human resource management in cardiac surgery is inadequate and may result in significant misalignment of cardiac surgeon supply and demand. The availability of forecasting models and high quality, consistent data on productivity, workload, utilization, and demand is a prerequisite for our profession's capacity to predict and plan for changes in health human resources. The CSCS recognizes that improved workforce management is a key component to providing optimal cardiac surgical care for Canadians in the future and has developed the recommendations in this document as a call to action to interested stakeholders and policymakers to bring substantial improvements to health human resource management in cardiac surgery.

As the professional society representing cardiac surgeons in Canada, the Canadian Society of Cardiac Surgeons (CSCS) recognizes the importance of maintaining a stable cardiac surgical workforce. The current reactive approach to health human resource management in cardiac surgery is inadequate and may result in significant misalignment of cardiac surgeon supply and demand. The availability of forecasting models and high quality, consistent data on productivity, workload, utilization, and demand is a prerequisite for our profession’s capacity to predict and plan for changes in health human resources. The CSCS recognizes that improved workforce management is a key component to providing optimal cardiac surgical care for Canadians in

Background: Low cardiac output syndrome is defined as the need for a postoperative intra-aortic balloon pump or inotropic support for longer than 30 minutes in the intensive care unit. Mitral valve surgery is increasingly being performed in high-risk patients who might require mechanical circulatory support for low cardiac output syndrome. Therefore the aim of this study was to identify the preoperative predictors of low cardiac output syndrome after mitral valve surgery.Methods: We conducted a retrospective review of data prospectively entered into an institutional database. Between 1990 and February 2008, 3039 patients underwent isolated mitral valve surgery with or without coronary bypass surgery. The independent predictors of low cardiac output syndrome and operative mortality were determined by means of stepwise logistic regression analysis.Results: The overall prevalence of low cardiac output syndrome was 7%. The independent predictors of low cardiac output syndrome were urgency of the operation (odds ratio, 2.9), earlier year of operation (odds ratio, 2.4), left ventricular ejection fraction of less than 40% (odds ratio, 2.1), New York Heart Association class IV (odds ratio, 2), body surface area of 1.7 m(2) or less (odds ratio, 1.6), ischemic mitral valve pathology (odds ratio, 1.6), and cardiopulmonary bypass time (odds ratio, 1.02). The operative mortality was higher in patients with low cardiac output syndrome (30% vs 1.3%, P < .001). Overall operative mortality was 3.4%. The independent predictors of mortality were urgency of the operation (odds ratio, 7.1), renal failure (odds ratio, 4.3), nonuse of polytetrafluoroethylene sutures (Gore-Tex; W. L. Gore & Associates, Inc, Austin, Tex; odds ratio, 2.1), any reoperative surgical intervention (odds ratio, 1.8), increasing age (odds ratio, 1.03), and cardiopulmonary bypass time (odds ratio, 1.02).Conclusions: Low cardiac output syndrome is associated with significantly increased morbidity and mortality. Novel strategies to preserve renal function, optimization of pre-existing heart failure symptoms, and use of artificial polytetrafluoroethylene sutures might reduce the incidence of low cardiac output syndrome and lead to improved results after mitral valve surgery. (J Thorac Cardiovasc Surg 2010;140:790-6)

BACKGROUND:Elderly patients older than the age of 75 constitute 13% of the population that undergoes cardiac surgery at our institution and represent the fastest growing population in Ontario. We have witnessed an increasing proportion of elderly patients being referred for repeat surgical intervention for valvular heart disease. We determined the perioperative and long-term outcomes in elderly patients undergoing redo cardiac valve surgery.METHODS:A retrospective review of our institutional database identified 112 patients aged 75 years or older (mean age, 78 +/- 3 years; range, 75 to 89 years) who underwent redo valve surgery between 1990 and 2004. All patients presented with a previous surgical intervention on the valve of interest. The mean follow-up was 5 +/- 4 years and was 100% complete.RESULTS:Eighty-eight patients (79%) had isolated valve surgery at their primary operation whereas 24 patients (21%) had concomitant coronary artery bypass grafting at the time of their initial valve surgery. At reoperation, 74 patients (66%) underwent single valve surgery (40 aortic valve, 34 mitral valve), 33 patients (29.5%) required double valve surgery, and 5 patients (4.5%) had triple valve surgery. Thirty-three patients (29.5%) required concomitant coronary artery bypass grafting, among whom 14 patients had a previous coronary artery bypass graft surgery. There were 12 operative (10.7%) and 47 late deaths (42%). Cardiovascular events were the cause of death in 32 patients (54% of all deaths). Overall survival at 5 years was 67% +/- 5%. The freedom from valve-related mortality and morbidity was 86% +/- 4% at 5 years. Mean intensive care eunit stay was 3.7 +/- 4.5 days, and postoperative hospital stay was 15 +/- 12 days.CONCLUSIONS:Redo valvular surgery in an elderly cohort can be performed with acceptable morbidity and mortality. Although 5-year survival is lower than that observed with a younger patient population, it is still likely higher than expected survival without surgical intervention. Despite increased resource utilization, elderly patients should be offered redo surgical intervention for valvular heart disease.

BACKGROUND:The purpose of this study is to examine the effect of previously implanted valve type on hospital mortality in reoperative valve surgery.METHODS:From 1990 to 2005, 743 patients underwent redo valve surgery at our institution. Patients were divided into those who received a mechanical valve during their prior operation (n = 236) and those who received a biological (porcine or pericardial) valve (n = 507). Perioperative data were analyzed retrospectively.RESULTS:Patients with failing mechanical valves were younger, more likely to be female, and had a higher prevalence of preoperative stroke and atrial arrhythmias, whereas patients with failing biological valves had more hypertension, diabetes mellitus, hyperlipidemia, and chronic obstructive pulmonary disease (all p < 0.05). Mechanical valve explant patients had fewer prior coronary bypass and aortic valve operations, but more mitral surgeries (all p < 0.05). Mechanical patients also had a higher prevalence of endocarditis (p = 0.001) and urgent or emergent surgery (p < 0.001). Hospital mortality was higher among patients undergoing mechanical valve explant by univariate analysis (13% versus 8%, p = 0.04), but not by multivariate analysis (odds ratio 1.6, 95% confidence interval 0.9 to 2.7, p = 0.1). Logistic regression revealed chronic obstructive pulmonary disease, peripheral vascular disease, endocarditis, and urgency of reoperation as independent predictors of hospital mortality.CONCLUSIONS:Explanting mechanical valves are associated with higher perioperative mortality than are tissue valves, likely because of different modes of failure and presentation. A lower risk of mortality for tissue valve reoperation may be an additional factor to consider when patients and surgeons choose a valve prosthesis type.

Objective: The St. Jude Medical Silzone((R)) (Silzone((R))) mechanical heart valve was voluntarily recalled (January 2000) due to an unusually high incidence of paravalvular leaks. We present the first series of human morphological data on the failure of these valves.Methods: Nineteen Silzone((R)) valves were evaluated from the 176 Silzone((R)) valves implanted in 147 patients at our institution between 1997 and 1999. Explanted prostheses were fixed in 10% formalin, photographed, and X-rayed. Histological sections were collected from the sewing cuff, accompanying tissues, and thrombus. For comparison, six age-matched SJM-standard valves were similarly analyzed.Results: Nineteen Silzone((R)) valves from 16 patients (10 male, six female, 52.0 +/- 15.2 years) were examined. Significantly more mitral (15/95) prostheses were removed than aortic (4/81) despite the nearly equal number implanted (p = 0.027). Fifteen of the Silzone((R)) valves (13/16 patients) were explanted in the early postoperative period (within six months of implantation), although collection continued for eight years after our institution stopped implanting them. The common indications for surgical explantation were paravalvular leak (8/12) and clinically suspected infective endocarditis (IE) (four patients, five valves). IE was not confirmed by histology or culture in any valve. The sewing cuffs of many Silzone((R)) valves showed large regions of pannus, granulation tissue, and purulent exudate. Polymorphonuclear leukocytes were more common in the sewing cuff of Silzone((R)) valves; however, the cellular infiltrate was superficial when compared to SJM-standard valves.Conclusion: This is the largest morphologically analyzed series of Silzone((R)) explants. It demonstrates a consistent pattern of atypical tissue incorporation into the silver-coated sewing ring particularly in the mitral position. Clinical and morphologic features of IE (sterile) are seen in the early postimplant period. Prosthesis-related problems were almost wholly seen at the mitral site, in our group. Our current data indicate that although early failure due to dehiscence and paravalvular leak is a problem, Silzone((R)) valves that "survive" past six months will likely function as well as the SJM-standard prosthesis.

BACKGROUND:Triple valve surgery is usually complex and carries a reported operative mortality of 25% and 10-year survival of 40%. We examined surgical results in the modern era.METHODS:A total of 174 consecutive patients, mean age 58 +/-12 years underwent triple valve surgery from 1990 to 2004. The most common aortic and mitral valve disease was rheumatic disease (61%), followed by prosthetic valve dysfunction (22%). Tricuspid valve disease was functional regurgitation in 72% of patients. Ninety-four percent of patients were in New York Heart Association class III and IV, and 60% had had previous cardiac operations. The aortic valve procedures consisted of 160 replacements and 14 repairs, the mitral valve procedures, 153 replacements and 21 repairs, and the tricuspid valve procedures, 12 replacements and 162 repairs. Univariate and multivariable analyses were performed to identify predictors of early and late survival.RESULTS:Operative mortality was 13% (n = 22). Univariate factors associated with mortality included urgent surgery, shock, tricuspid valve replacement, preoperative renal failure, and peripheral vascular disease. Survival at 5 and 10 years was 75% and 61%, respectively. Seventy-three percent of patients were in New York Heart Association class I and II at their most recent follow-up. Ten-year freedom from thromboembolism was 88%, from anticoagulation-related hemorrhage, 83%, from endocarditis, 96%, and from cardiac reoperation, 92%.CONCLUSIONS:Patients with advanced rheumatic valve disease and prosthetic valve dysfunction are at risk for requiring triple valve surgery. Compared with historic reports, the results of triple valve surgery, primary and reoperative, have improved. Although early mortality is high, long-term and event-free survival are comparable with that of patients undergoing single valve replacement.

To develop strategies for the management of high-risk patients, contemporary risk factors for operative mortality and postoperative ventricular dysfunction were identified in 214 patients undergoing mitral valve surgery in 1982 and 1983. Thirty-eight preoperative and perioperative variables were prospectively collected and analyzed by univariate and multivariate statistics. The overall mortality was 4.6% and the incidence of postoperative low-output syndrome (LOS) was 18.7%. Fortyseven patients with coronary artery disease (CAD) had a higher mortality and incidence of LOS (as evidenced by the need for inotropic drugs or counterpulsation to maintain blood pressure) (those with CAD 15% mortality, 40% LOS; those without CAD 2% mortality, 13% LOS; p < .05). The presence of unstable angina and ischemic mitral regurgitation further increased the risk. Age was also a predictor of outcome. Patients who died or had LOS were older (those who died, 65 7 years, those with LOS, 58 11 years) than patients who survived and did not have postoperative dysfunction (those who survived, 53 + 11; those with no LOS, 53 + 11; p < .01). Mitral regurgitation was associated with a higher (p < .05) mortality and incidence of LOS (mortality 10.5%, LOS 36%; n 76) than was mitral stenosis (mortality 0%, LOS 4%; n = 74) or mixed lesions (mortality 3%, LOS 15%; n = 64). In patients without CAD, mitral regurgitation remained a significant predictor of mortality and ventricular dysfunction. Seventeen patients with tricuspid insufficiency required tricuspid valve annuloplasty, and were at higher risk (mortality 18%, LOS 53%) than patients who did not require tricuspid annuloplasty (mortality 4%, LOS 18%; p < .05). Symptoms at rest (NYHA class IV) were predictive of postoperative outcome (those in NYHA class IV 21% mortality, 42% LOS; those in classes I, II, and III 1% mortality, 14% LOS; p < .01). The surgeon, sex, rhythm, timing of surgery, previous valvular surgery, cause of lesion, pulmonary arterial pressure, pulmonary vascular resistance, and cardiac index did not influence the mortality or incidence of postoperative LOS. By stepwise logistic regression, NYHA class, age, presence of CAD or a mitral regurgitant lesion, and the need for tricuspid annuloplasty were, in descending order of significance, risk factors independently predictive of mortality or postoperative LOS. Circulation 72 (suppl II), 11-120, 1985. THE RISK of operative mortality after mitral valve surgery in the 1960s ranged between 18% and 40%.1-6 Recent reports suggest that the current risk to patients undergoing mitral valve surgery is less than 10%.7 8 The factors predictive of outcome have changed as the results of surgery have improved.71 The inclusion of patients operated on in the 1970s with those undergoing surgery in the 1980s7' 8,12 obscures the analysis of the factors influencing morbidity and mortality. We therefore instituted a prospective evaluation of the risk From the Divisions of Cardiovascular Surgery and Cardiology, the Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada. Supported by the Heart and Stroke Foundation of Ontario, the Canadian Heart Foundation, and the Medical Research Council of Canada. Address for correspondence: Richard D. Weisel, M.D., Cardiovascular Surgery, Toronto General Hospital, 200 Elizabeth St., Eaton North 13-224, Toronto, Ontario, Canada M5G 2C4. 11-120 factors of morbidity and mortality after mitral valve surgery. Ventrcular dysfunction after mitral valve surgery is the most common cause of mortality.8' 12, 13 This study was designed to assess current factors that contribute to mortality and ventricular dysfunction after mitral valve surgery to develop strategies to improve the results in high-risk subgroups.

We report the case of a 70-year-old woman with significant intermediate coronary artery stenosis who underwent a series of stent procedures, ultimately leading to compromise of the origin of the circumflex artery. Intraoperatively, identification of an obtuse marginal coronary artery was impossible due to a thick layer of epicardial fat, calcification of the posterior atrioventricular groove, and an adherent, thickened pericardium. Therefore, a saphenous vein graft to the posterior vein of the left ventricle was constructed with ligation of the vein cephalad. This uncommon approach to surgical revascularization effectively relieved the patient's angina and may be of use in other difficult cases.

The term ‘valvular heart disease’ incorporates a wide range of conditions. The gold-standard diagnostic techniques, the natural history, and the interventional, as well as surgical, techniques which are available for treatment should be known by the clinician. The surgical management of valvular heart disease involves a series of operations and techniques. The aim of this review is to describe valvular pathology and the available surgical techniques.

Between 1980 and 1983, 831 Bjork-Shiley 70-degrees convexo-concave prosthetic heart valves were implanted at five institutions in Sweden, Germany, The Netherlands, and Canada. As of January 1991, there were 34 outlet strut fractures occurring from 0.2 to 10.1 years (median = 4.6 years) after implantation. In addition, there were 28 sudden, unexplained deaths. The mortality after strut fracture was 84%. The mortality after emergency valve replacement for strut fracture was 50%. The 10-year actuarial fracture rate(standard error) was 10.5 (2.4)% for large (29-33 mm) valves vs. 3.3 (1.2)% for 21-27 mm valves (P < 0.001). Within valve size groups, fracture rates for aortic and mitral valves were similar. Cox regression analysis found only valve size to be significantly associated with strut fracture. There is a further subgrouping of the valves according to the manufacturer: group I are the earlier large size (29-33 mm) valves; group II are the later large valves; group III are the small size (21-27 mm) valves. The risk of strut fracture was highest in group I (12.3% at 10 years) with an approximatively constant hazard (1.4% per year). A comparison was made with a statistical model incorporating all cases reported to the manufacturer. This model estimates fracture rates approximately 63%-73% of those found in the present study. These findings lead us to recommend that group I patients should be considered for elective reoperation on an individual basis, giving careful attention to risk factors and contraindications.

It is apparent that in most countries outside the United States, cardiovascular services are limited to some extent by government, often with the participation and advice of physicians and the public. In many countries, fee-for-service amounts are negotiated between physician associations and paying agencies, whether they are government or sickness funds. In virtually all countries studied, emergencies and urgent cases are determined on a medical basis. Additional centers for either cardiac surgery or catheterization have, in Germany, the Netherlands, Sweden, United Kingdom, Canada and Australia, been added on the basis of perceived need (physician and public input). In all countries studied, other than the United States, provision is made to provide cardiovascular services to persons unable to afford them.

In the 1940s Canada and the United States had similar lack of structure and reimbursement for diagnostic, hospital, and physician services. In Canada over the next 40 years there evolved a complex system mandated and partially funded by the federal government, but administered and delivered through 10 provincial and 2 territorial jurisdictions. Each must negotiate with federal government on cost sharing and deal with hospital budgets and physician compensation at the provincial or territorial level. The Medical Care Act of 1966 enshrined in law the five principles of public administration, universality, comprehensiveness, portability, and accessibility, converting all medical services in Canada from a privilege to a right. Any patient participation in hospital or physician charges came under increasing political attack. In 1984 the Canada Health Act specified financial penalties in federal transfer payments to provinces that permitted any direct patient charges. While Canada has "contained" health expenditures at 8.7% of gross national product, universal access to quality care is increasingly subject to rationing. The relationship between the profession and governments hard pressed to fund escalating costs in a deteriorating economy has been one of increasingly bitter confrontations. There have been four acrimonious doctors' strikes. More optimistically, there is now an emerging recognition of society's need to have physicians actively participating with other providers and governments to create a balance between access to quality health services and both public and private funding.

Mechanical failure of artificial heart valves can be a catastrophic event. The problem of outlet strut fracture of the Björk-Shiley 60 degrees Convexo-Concave tilting disc prosthesis has received much attention in the medical literature and generated both concern and confusion among patients and physicians. Analysis of current data from the manufacturer, as well as a review of the medical literature, suggests that the overall risk of outlet strut fracture is low and that elective explantation of a well functioning Björk-Shiley 60 degrees Convexo-Concave valve prosthesis is not warranted. Diagnostic features of outlet strut fracture can be seen with overpenetrated chest X-ray films so that diagnosis can be established promptly. Early operation to replace the fractured prosthesis is essential for patient survival.