The cardiac Care Network of Ontario (CCN) Consensus Panel on Cardiac Surgical Services drew on the literature and its own expertise to recommend guidelines for expanding services. This report, which is not an official position paper of the Canadian Cardiovascular Society, presents these recommendations. Rates of surgery are linked to diagnostic capacity, requiring increases in interventional therapies to match increases in invasive diagnostic activity. For quality and efficiency, panel members recommend an annual minimum of 150 procedures per surgeon and 500 per centre; a centre should serve a minimum population of 500,000. Services should be as close to patients' homes as possible while maintaining recommended volumes. Expanding the CCN's cardiac surgery database to include other cardiac modalities will yield a more accurate assessment of waiting times. The panel recommends collaborative regional planning associations, mentorship arrangements between new and existing centres, prompt action on human resource shortages and exploration of alternative funding models.

The Cardiac Care Network of Ontario (CCN) Consensus Panel on Cardiac Surgical Services drew on the literature and its own expertise to recommend guidelines for expanding services. This report, which is not an official position paper of the Canadian Cardiovascular Society, presents these recommendations. Rates of surgery are linked to diagnostic capacity, requiring increases in interventional therapies to match increases in invasive diagnostic activity. For quality and efficiency, panel members recommend an annual minimum of 150 procedures per surgeon and 500 per centre; a centre should serve a minimum population of 500,000. Services should be as close to patients' homes as possible while maintaining recommended volumes. Expanding the CCN's cardiac surgery database to include other cardiac modalities will yield a more accurate assessment of waiting times. The panel recommends collaborative regional planning associations, mentorship arrangements between new and existing centres, prompt action on human resource shortages and exploration of alternative funding models.

Objectives: To assess the potential benefits of the hemodynamic superiority of stentless valves, we conducted a case-match study among patients who underwent aortic valve replacement with two types of porcine bioprostheses: the Toronto SPV and the stented Hancock II bioprosthesis. Methods: Preoperative clinical variables predictive of death after aortic valve replacement were determined by a stepwise logistic regression analysis in a series of 908 consecutive patients who received porcine aortic bioprostheses during a 14-year interval, Advanced age, New York Heart Association functional class IV, left ventricular ejection fraction of less than 30%, and coronary artery disease were independent predictors of death, On the basis of these four variables, 198 pairs of patients who survived aortic valve replacement with stentless and stented porcine valves were matched. The follow-up, truncated to the shortest interval for each matched pair, was 43 +/- 24 months for both groups. Results: At 8 years the actuarial survival was 91% +/- 4% for the Toronto SPV group and 69% +/- 8% for the Hancock II group (p = 0.006); the freedom from cardiac-related death was 95% +/- 4% for the Toronto SPV and 81% +/- 8% for the Hancock II (p = 0.01); the freedom from any valve-related complication was 81% +/- 5% for the Toronto SPV and 50% +/- 10% for the Nancock II (p = 0.008), A Cox proportional hazard model demonstrated a significant reduction in cardiac mortality rates and valve-related morbidity in patients who received the Toronto SPV bioprosthesis. Conclusions: Although it is possible that confounding factors may have played a role in the clinical outcomes of this case-control study, the study suggests that aortic valve replacement with a stentless porcine valve enhances survival. This is believed to be due to the hemodynamic superiority of these valves.

This study examined the relationship between gender and in-hospital mortality using data from patients undergoing coronary artery bypass surgery (CABS) in the province of Ontario. All patients who underwent CABS between April 1, 1991 and March 31, 1992 at the 9 cardiac surgery institutions were included for study (n = 5,175). The unadjusted in-hospital mortality rate was 3.3% and was higher among females (5.3%) than males (2.8%). Using logistic regression analysis to adjust for several predictors of in-hospital mortality the odds ratio estimate (OR) for female sex was 1.55 and was statistically significant (95% confidence interval (CI) 1.09 to 2.20). Women experienced rates of in-hospital mortality that are 1.6 times greater than males following bypass surgery after case-mix adjustment for age, anatomical disease severity, anginal class, and co-morbid conditions. Severe unstable angina had the greatest potential contribution to in-hospital mortality (OR = 7.51, 95% CI = 3.71-15.23) and was more prevalent in women, indicating that excess mortality may be due to delayed diagnosis in women.

Background A multicenter population-based study was conducted to develop and validate a risk index for mortality, intensive care unit (ICU) length of stay, and postoperative length of stay after cardiac surgery. Methods and Results Data were collected from 13 098 patients undergoing cardiac surgery between April 1, 1991, and March 31, 1993, at all nine adult cardiac surgery institutions in Ontario, Canada. A six-variable risk index (age, sex, left ventricular function, type of surgery, urgency of surgery, and repeat operation) was developed using logistic regression analysis to predict in-hospital mortality, ICU stay in days, and postoperative stay in days after cardiac surgery in a derivation set of 6213 patients who had cardiac surgery during fiscal year 1991 (April 1, 1991, to March 31, 1992). The index predicted mortality, prolonged ICU stay (≥6 days), and prolonged postoperative length of stay (≥17 days) after cardiac surgery with areas under the receiver-operating characteristic (ROC) curve of 0.75, 0.66, and 0.69, respectively, in an independent validation set of 6885 patients who had cardiac surgery during fiscal year 1992 (April 1, 1992, to March 31, 1993). Increasing risk scores were associated with greater mortality rates and longer ICU and postoperative stays at all nine institutions. Conclusions Mortality, ICU length of stay, and postoperative length of stay after cardiac surgery can be predicted using a simple six-variable risk index. The index has potential application as a risk stratification tool for comparing patient outcomes and resource use among different hospitals and surgeons.

Tricuspid valve replacement is not a common operation. The purpose of this study was to examine the early and late results in 60 patients who underwent 28 (47%) bioprosthetic and 32 (53%) mechanical tricuspid valve replacements. All operations took place between January 1978 and June 1993 during which period a total of 4741 patients underwent valve replacement operation. Mean patient age was 50 +/- 15 (18 to 75) years. Forty-one patients (68%) were female and 19 patients (32%) were male. Forty-nine patients (82%) were in New York Heart Association class III or IV before operation. Forty-five patients (75%) were undergoing repeat cardiac valve operation. Seventeen patients (28%) had complex congenital cardiac problems. Operation was urgent in 15 patients (25%). The hospital mortality rate was 27% (16 patients). All patients with hospital death were in New York Heart Association class III or IV, were having repeat operations, or had complex congenital disease. Low output syndrome was observed in 21 patients (35%). Reoperation because of bleeding was required in seven patients (12%). Thirteen patients (22%) required permanent (epicardial lead) pacemaker implantation. Mean follow-up is 75 +/- 45 months (maximum 173 months) and 100% complete for the 44 patients who left the hospital. There have been 14 deaths (32%). Nine of these patients (64%) had mechanical valves and five (36%) had bioprostheses. Of the 11 cardiac deaths, three were valve related (bioprostheses). Three patients (10%) required reoperation because of tricuspid valve prosthetic failure (1 thrombosed mechanical valve, 2 failed porcine valves). Of the remaining 30 patients, 20 (67%) are in New York Heart Association class I or II. Seventeen patients have mechanical valves and 13 have bioprostheses. Twenty-six patients (90%) are receiving warfarin. Thromboembolism (transient ischemic attack) has occurred in one patient with a mechanical valve who also had a previous cerebrovascular accident. In this group there has been no hemorrhage, endocarditis, or new pacemaker requirement. Actuarial survival for the whole series is 37% +/- 9% and for the hospital survivors is 50% +/- 12% at 15 years. Linearized rates of valve-related complications are not different between groups. Tricuspid valve replacement is a beneficial procedure for patients with structural tricuspid valve disease, many of whom have other valvular or congenital disease. Contemporary mechanical prostheses and bioprostheses are equally effective in the tricuspid position. Mechanical valves should be considered for tricuspid replacement in young patients and in patients with mechanical valves implanted in the left side of the heart.

The durability and function of bovine pericardial valves are dependent upon design, preservation, patient factors (age, sex), and site of valve implantation. In 1983, a shelf recall of all Hancock bovine pericardial valves (HPV) was instituted by the manufacturer. This report represents the results of an organized 5-year follow-up in a hospital Prosthetic Valve Registry of 129 HPV implanted in 122 patients (79 males, 43 females) between May 1982 and April 1985 using echo Doppler and careful clinical evaluation. Mean age was 56 +/- 15 years. There were 81 AVR, 33 MVR, 7 DVR, and 1 TVR. Concomitant coronary bypass was performed in 38 patients (31%). Surgery was on a redo basis in 25 patients (20%), urgent in 14 (11%), and for SBE in 8 patients (7%). There were seven hospital deaths (5.7%). Mean follow-up was 44 months (maximum 66 months) for 114 patients (99% complete), representing 417 patient years. There have been 20 late deaths (18%), of which 7 were directly valve related. Linearized frequency of major events (per pt-yr) was: thromboembolism, 1.6%; anticoagulant related hemorrhage, 0.8% (1 late death); prosthetic valve endocarditis 1.3%; primary tissue failure, 5.8%. Patient symptomatology was a more accurate predictor of bioprosthetic failure requiring reoperation than echo Doppler studies, which were completed in 74 of 97 patients examined during scheduled follow-up visits. Twenty-four of the 96 patients (25%) have required re-replacement at a mean interval of 44 months (27-59 months) from initial implantation. This was due to vertical shear starting at the top of the strut anchoring commissural attachments in every case.(ABSTRACT TRUNCATED AT 250 WORDS)

Between 1979 and 1985, 552 Ionescu-Shiley valves were implanted in 511 patients. The Hancock valve was implanted in 122 patients (129 valves) between 1982 and 1983. Sixty percent of procedures were isolated aortic valve replacements. In the Ionescu series, 59% of these were 19 or 21 mm valves while only 15% of the Hancock valves were of this size. For isolated mitral valve replacement, 76% of Ionescu-Shiley valves were 25 to 27 mm, compared to 36% of the Hancock valves. Patient age, sex, prior operations, concomitant surgery (usually coronary bypass), operative mortality and late deaths were similar for both valves. A mean follow-up of 38 months was obtained for each valve population (99% complete) representing a cumulative 1497 patient-years for the Ionescu-Shiley valve and 375.4 patient-years for the Hancock valve. Actuarial survival for the former was 73 +/- 4% at 72 months, and 65 +/- 14% for Hancock valves at 60 months. The frequency of major events during follow-up (thromboembolism, anticoagulant related hemorrhage, bland perivalvular leak and prosthetic valve endocarditis) were similar, but the frequency of primary tissue valve failure was markedly different for the two valves (1.1% per patient-year for Ionescu-Shiley valves and 5.9% for the Hancock valve). The mean interval to replacement of an Ionescu mitral prosthesis was significantly shorter (23.4 months) than for replacement of an aortic prosthesis (42 months) while the mean interval to replacement of an Ionescu aortic and/or a Hancock aortic or mitral were all similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Lung transplantation has become a successful method in the therapy for end-stage pulmonary disease. While single-lung transplantation provides benefit to patients with pulmonary fibrosis, bilateral lung transplants are required for septic or emphysematous lung disease. We describe the technique employed in 6 patients to transplant en bloc both lungs with the recipient heart left in place. The lungs are connected by a left atrial cuff, main pulmonary artery, and trachea. The completed implantation has a tracheal anastomosis securely wrapped in omentum, a left atrial anastomosis posterior to the heart, and a pulmonary artery anastomosis anteriorly. Airway ischemia resulted in the death of 1 patient. This procedure allows complete excision of all diseased pulmonary tissue, retention of the recipient's own heart, and separate excision of the donor heart for use in another recipient, thereby markedly increasing the supply of donor lungs for transplantation.

Repair of coarctation of the aorta has been performed in 164 patients since July, 1947. Eighteen were younger than 6 months of age, 44 were I to 11 years, 87 were 11 to 40 years, and 15 were older than 40 years of age. Resection and end-to-end anastomosis were performed in 92, interposition grafts in 59, and other procedures in 13. Four operative deaths occurred in infants with multiple anomalies (22 percent infant mortality rate). Ten late deaths were due to associated anomalies (three), myocardial infarction (two), cerebrovascular accident (one), rupture of an aneurysm at the graft site (one), and unrelated causes (three). No hospital deaths occurred in patients with isolated coarctation or in patients older than 1 year, including the 15 patients older than 40 years. Late complications were evaluated in 147 patients followed from 2 months to 28 years. Restenosis occurred in eight (three repaired when younger than 6 months) and false aneurysm at graft sites in two (fatal rupture in one). Residual hypertension occurred in 38 of 147 (25.9 percent) and was related to age at the time of repair: younger than 6 months (three of 13), 1 to 11 years (one of 43), 11 to 40 years (29 of 79), and older than 40 years (five of 13). Residual hemodynamic abnormality due to uncorrected associated anomalies, hypertension, ventricular hypertrophy, coronary artery disease, restenosis, or anastomotic aneurysm occurred in 56.1 percent of 98 patients followed at least 2 years. Of this group, 21.4 percent of those repaired before age 11 years and 70 percent of those repaired after age 11 had residual hemodynamic abnormality. Hypertension and other residual hemodynamic abnormalities occur frequently after coarctation repair, but significantly less often when repair is performed between the ages of 1 and 11 years. The incidence of mild hypertension is increased if repair is performed after 6 years of age.

An in situ heart lung preparation was developed to label lymphatics of the actively beating dog heart with subsequent fixation by vascular perfusion. Immediately after interstitial injections of trypan blue and colloidal carbon, a rich plexus of lymphatic vessels was visualized in the epicardium of the actively beating heart. With this method of fixation, tissue preservation is generally excellent and uniform throughout the heart. In thin sections examined with the electron microscope, lymphatic vessels are easily recognized by the content of plasma proteins which is preserved as an electron dense precipitate that is evenly dispersed throughout the lumen. An extensive plexus of thin walled lymphatic vessels is observed throughout the epicardial, myocardial and subendocardial regions. Numerous anchoring filaments are observed closely apposed to the abluminal endothelial surface which extend into the surrounding connective tissue. The distribution and ultrastructure of the cardiac lymphatic vessels are discussed in relation to their role in the removal of interstitial fluid from the heart.

Intra-aortic ballon pump assist (IABPA) was used over a 12-month period in the management of 41 patients: 5 patients with complications of myocardial infarction in shock whose circulation was supported by IABPA before operation immediately after angiographic and hemodynamic study (group 1); 14 patients with postcardiotomy low-output state who could not be weaned from cardiopulmonary bypass and required IABPA circulatory support either in the operating room or in the intensive care area (group 2); 19 patients with severe myocardial ischemia and unstable circulation in whom IABPA was instituted either before angiography or before saphenous vein bypass operation (group 3); and 3 patients with severe left ventricular dysfunction and left ventricular hypertrophy due to aortic valve or coronary artery disease, or both, in whom IABPA was used before, during and after cardiopulmonary bypass and a corrective operative procedure (group 4). Survival rates for patients in these groups were 2/5,8/14,18/19 and 2/3 respectively (overall survival, 73%). IABPA may increase the postoperative survival of certain high-risk patients with poor left ventricular function due to valvular disease or coronary artery disease, or both. The survival of patients with severe myocardial ischemia and complicated myocardial infarction is improved by IABPA, early angiography and appropriate surgical correction. Left ventricular ejection fraction and the estimate of subendocardial coronary flow by the ratio of the diastolic pressure time index to the tension time index appear to be significant in identifying patients who may benefit from the use of IABPA.