Introduction Administration of antibiotics before incising the skin ('surgical antimicrobial prophylaxis') is a critical infection prevention strategy in surgery. Extending doses of prophylaxis into the postoperative period is a common practice in cardiac surgery; however, the benefit has not been clearly established and may lead to emergence of antimicrobial resistance and patient harm. We present the protocol for a large international multicentre, adaptive, pragmatic, double-blind, three-arm, placebo-controlled, randomised, non-inferiority clinical trial to compare the incidence of surgical site infection after three different durations of postoperative surgical antimicrobial prophylaxis in patients undergoing cardiac surgery.Methods and analysis This adaptive, multi-arm multistage non-inferiority trial will compare intraoperative only (Arm A), to intraoperative and 24 hours (Arm B) and, to intraoperative and 48 hours (Arm C) of intravenous cefazolin and placebo as surgical antimicrobial prophylaxis in 9180 patients undergoing cardiac surgery. The adaptive design allows for potential dropping of any of the three arms if clear inferiority is indicated at any of the scheduled interim analyses. The trial will evaluate the clinical and cost-effectiveness of the three different antibiotic prophylaxis durations.Ethics and dissemination Ethics approval will be obtained at all participating sites. Results of the study will be submitted for publication in peer-reviewed journals and the key findings presented at national and international conferences. Patients and members of the public will also be involved in the dissemination and translation of the trial results.Trial registration number NCT05447559.

Background The predictive value of platelet indices, including the platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW), plateletcrit (PCT), and platelet–lymphocyte ratio (PLR) for postoperative atrial fibrillation (POAF) following cardiac surgery remains undetermined. Methods MEDLINE, Embase, and the Cochrane Library were searched from inception to October 2024. For each included study, median differences (MDs) and odds ratios (ORs) were tabulated with 95% confidence intervals (CIs). Pooled estimates were generated using random‐effects inverse‐variance modeling. Statistical analysis focused on cases of POAF. Results Six thousand five hundred and seventeen unique studies were screened and included 23 studies involving 12,375 patients in the subsequent analysis. Compared with patients who did not develop POAF, patients with POAF had higher preoperative MPV (MD: 0.30 fL, 95% CI: 0.07–0.53, and p = 0.0112) and PLR (MD: 40.42, 95% CI: 7.49–73.33, and p = 0.0161). Preoperative PLT (MD: 3.32, 95% CI: −5.87–12.51, and p = 0.4785) was not significantly different between groups. Study numbers were insufficient to assess the association between PCT with POAF. Conclusion Elevated preoperative MPV and PLR were associated with POAF after cardiac surgery. Further research is required to investigate the roles of these indices in the risk stratification of POAF in patients undergoing cardiac surgery.

OBJECTIVE:To evaluate the effects of intravenous iron on red cell transfusion and recovery after cardiac surgery. DESIGN:International, multicentre, double blind, placebo controlled randomised trial (ITACS). SETTING:33 hospitals across 10 countries. Participants were enrolled between July 2016 and December 2023. PARTICIPANTS:955 adults with anaemia undergoing elective cardiac surgery. Exclusion criteria included haemoglobinopathy or iron storage disorder, renal dialysis, and erythropoietin or intravenous iron given in the previous four weeks. INTERVENTION:A computer generated program randomised participants to intravenous iron 1000 mg or placebo 1-26 weeks before surgery. Participants, clinicians, and data collectors were masked to the intervention. MAIN OUTCOME MEASURES:The number of days alive and at home up to 90 days after surgery (primary outcome), red cell transfusion requirements and complications (secondary outcomes). RESULTS:Of 2993 screened participants, 955 were enrolled and 921 of the eligible 939 modified intention-to-treat participants were assessed for the primary outcome. The median number of days alive and at home up to 90 days after surgery was 81.1 (interquartile range 74.8-83.7) in patients assigned to intravenous iron and 80.0 (69.5-83.6) in those receiving placebo (adjusted median difference 1.0 day, 95.4% confidence interval 0.0 to 2.1 days, P=0.041). Red cell transfusions were given to 262 patients (61.1%) in the iron group and 302 (68.2%) in the placebo group during their hospital stay (relative risk 0.90, 95% confidence interval 0.82 to 0.99, P=0.027). No differences were observed for major complications or length of hospital stay. CONCLUSION:Among patients with anaemia undergoing elective cardiac surgery, preoperative intravenous iron was associated with a reduction in red cell transfusion and a small improvement in the number of days alive and at home in the first 90 days after surgery. Intravenous iron is an effective component of patient blood management in this setting. TRIAL REGISTRATION:ClinicalTrials.gov NCT02632760.

BACKGROUND:Percutaneous cholecystostomy is a critical intervention for patients with acute cholecystitis who are unsuitable for immediate surgery, yet long-term outcomes and prognostic indicators remain poorly defined. This largest single-centre study in New Zealand has been performed to evaluate percutaneous cholecystotomy outcomes and to investigate key predictors of mortality and morbidity. METHODS:A retrospective cohort study of all patients undergoing percutaneous cholecystostomy between January 2022 and December 2024 was performed. Clinical, radiological and procedural variables were analysed. Primary outcomes were 30-day, 90-day and 1-year mortality; secondary outcomes included sepsis resolution, readmissions, drain-related complications and subsequent completion cholecystectomy. RESULTS:Among 115 patients, mortality was 7.8% at 30 days, 11.3% at 90 days and 25.2% at 1 year. Acute acalculous cholecystitis conferred a fourfold greater 1-year mortality compared with calculous disease. Acute kidney injury predicted early mortality, while cardiovascular comorbidities predicted late mortality. Sepsis resolved within 72 h in 81.7% of patients, though after-hours procedures were associated with lower success rates. Readmissions and drain-related complications occurred in over half of patients. CONCLUSIONS:Patients undergoing percutaneous cholecystostomy face a substantial disease burden, with high rates of complications, readmissions and late mortality. Percutaneous cholecystostomy should be framed as a palliative or temporising measure rather than definitive therapy and patients must be counselled accordingly so expectations are realistic. In suitable candidates, interval cholecystectomy remains essential for definitive treatment. In acute acalculous cholecystitis, percutaneous cholecystostomy should not be the main treatment; priority must instead be given to addressing the underlying systemic illness.

RATIONALE:Circadian rhythms affect cardiovascular function, and the timing and severity of stroke and myocardial infarction (commonly known as a heart attack). Afternoon cardiac surgery may improve outcomes by reducing ischaemia-reperfusion injury (i.e. reducing tissue damage caused when blood supply returns to tissue (reperfusion) after a period of oxygen deprivation (ischaemia)). However, the evidence is conflicting. This systematic review assessed the impact of surgical timing on clinical outcomes after cardiac surgery. OBJECTIVES:To assess the effects of early versus late surgical start times for on-pump cardiac surgery on mortality, cardiac outcomes, and quality of life. SEARCH METHODS:We searched CENTRAL, MEDLINE, Embase, and Web of Science Conference Proceedings Citation Index - Science, along with ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform trials registers. We also conducted reference checking, citation searching, and contacted study authors to identify studies for inclusion. The latest search date was 26 January 2025. ELIGIBILITY CRITERIA:We included randomised controlled trials (RCTs) in adults undergoing cardiac surgery comparing late with early surgical start times. We excluded non-randomised studies and studies in children. OUTCOMES:Our critical outcomes were short-term mortality (≤ 30 days postoperative), long-term mortality (> 30 days postoperative), and perioperative myocardial infarction. Other important outcomes were perioperative myocardial injury, postoperative atrial fibrillation, left ventricular ejection fraction, lengths of intensive care unit (ICU) and hospital stays, and quality of life. RISK OF BIAS:We used the Cochrane Risk of Bias 2 tool to assess bias in the included RCTs. SYNTHESIS METHODS:As only one study met the inclusion criteria, we did not perform meta-analysis. We synthesised results descriptively, and used GRADE to assess the certainty of the evidence for specified outcomes. INCLUDED STUDIES:We included one study with 88 participants. The included study was conducted in France, and reported on differences in outcomes between morning and afternoon on-pump elective aortic valve replacement in adults. SYNTHESIS OF RESULTS:Critical outcomes No study reported short-term or long-term mortality data for early versus late surgical start times for on-pump cardiac surgery. In the included study, there was no evidence of a difference regarding in-hospital mortality between groups, with no deaths in both groups (risk ratio (RR) and 95% confidence interval (CI) not estimable; 1 study, 88 participants). The evidence is very uncertain about the effect of early versus late surgery on perioperative myocardial infarction (RR 0.29, 95% CI 0.06 to 1.30; 1 study, 88 participants, very low-certainty evidence). Important outcomes There was evidence of lower perioperative myocardial injury as measured by cumulative troponin release over 72 hours in those undergoing late surgery compared to early surgery (MD -46 ng/L × 72 h, 95% CI -79 to -13; 1 study, 88 participants). In the included study, there was no evidence of a difference in new-onset postoperative atrial fibrillation during hospital stay between groups (RR 0.75, 95% CI 0.40 to 1.40; 1 study, 88 participants). No study reported differences in left ventricular ejection fraction at discharge as a continuous variable for early versus late surgical start times for on-pump cardiac surgery. In the included study, there was no evidence of a difference in left ventricular ejection fraction < 45% at discharge between groups (RR 0.40, 95% CI 0.08 to 1.95; 1 study, 88 participants). No study reported differences in length of ICU admission for early versus late surgical start times for on-pump cardiac surgery. There was no evidence of a difference in need for inotropic support between groups in the included study (RR 0.25, 95% CI 0.03 to 2.15; 1 study, 88 participants). The evidence is very uncertain about the effect of late surgery on length of hospital stay (MD 0.00, 95% CI -1.48 to 1.48; 1 study, 88 participants, very low-certainty evidence). No study reported on the outcome of quality of life. AUTHORS' CONCLUSIONS:The evidence is very uncertain about the effects of early versus late surgical start time for the outcomes of perioperative myocardial infarction and length of hospital stay. We found no data for the outcomes of short-term or long-term mortality, left ventricular ejection fraction, length of ICU stay, or quality of life. Late surgical start time could reduce the risk of perioperative myocardial injury as estimated by cumulative troponin release over 72 hours. More research is needed to determine whether scheduling heart surgery later in the day improves patient outcomes. FUNDING:This Cochrane review had no dedicated funding. REGISTRATION:Protocol (2022) DOI: 10.1002/14651858.CD014901.

INTRODUCTION:Pulmonary artery catheters are used widely in cardiac surgery despite observed associations with worse outcomes and guidelines that recommend against their routine use. No adequately powered randomised trials are available. METHODS:The PUMA Pilot was a multicentre, randomised, parallel assignment, open-label, pilot and feasibility trial conducted at three tertiary cardiac surgery centres. Eligible patients were adults undergoing coronary artery bypass grafting, aortic valve replacement or surgery on the aortic root or ascending aorta with or without aortic valve replacement, with a predicted surgical mortality of < 2%. Patients were allocated randomly to receive a pulmonary artery catheter or a central venous catheter inserted immediately before surgery. The primary feasibility outcome was protocol compliance, defined as receiving the assigned intervention without crossover. Secondary feasibility outcomes were eligibility rate; recruitment proportion and rate; data completeness; and rate of clinician refusal. RESULTS:We screened 480 patients and 206 (43%) were eligible; 150/203 (74%) approached provided informed consent. Three of 206 (1%) eligible patients were not included due to clinician refusal. Of 149 patients who were randomised, 76 were assigned to the pulmonary artery catheter group and 73 to the central venous catheter group. For the primary feasibility outcome, 147 patients (99%) received the allocated intervention. Data were complete for 144 (97%) patients. Median (IQR [range]) days alive and at home at 30 days was 23.7 (21.9-24.7 [7.0-26.0]) in the pulmonary artery catheter group and 22.9 (20.8-23.9 [8.6-25.8]) in the central venous catheter group. Acute kidney injury occurred in 26/76 (34%) patients in the pulmonary artery catheter group and 14/73 (19%) in the central venous catheter group. DISCUSSION:A randomised trial of pulmonary artery catheters compared with central venous catheters in low-risk cardiac surgery is feasible. Such a trial would address significant practice variability and inform international guidelines.

Acute kidney injury is a common complication of cardiac surgery and may lead to kidney failure. In a large sample sourced from national registries, we estimated the risk of kidney failure up to nine years following cardiac surgery and the associations with acute kidney injury, comorbidities and preoperative estimated glomerular filtration rate. Data were linked probabilistically between population-based registries to identify adults with kidney failure (commencement of long-term kidney replacement therapy) following cardiac surgery. Risk of kidney failure accounting for the competing risk of death was estimated from 30 days following surgery using Fine-Gray models. Surgeries from 2010 to 2018 were included (n = 90 605) with follow-up until the end of 2018. A total of 465 adults (0.51

Background Arterial conduit strategies in coronary artery bypass grafting (CABG) have been associated with superior graft durability than saphenous vein grafts. However, the relative benefits of multiple arterial grafting (MAG) and total arterial revascularization (TAR) remain uncertain due to limited direct comparative evidence. Objective(s) This systematic review and Bayesian network meta-analysis (PROSPERO Registration CRD420251117898) evaluated long-term survival outcomes associated with single arterial grafting (SAG), MAG, and TAR. Methods MEDLINE, EMBASE, and the Cochrane Library were searched from inception to March 2026 for studies comparing CABG conduit strategies reporting adjusted hazard ratios for long-term all-cause mortality. Studies including adults undergoing isolated CABG with SAG, MAG, or TAR were eligible. A Bayesian random-effects network meta-analysis was performed to integrate direct and indirect evidence. This framework permitted quantification of TAR-versus-MAG comparisons, which had previously been limited by scarce direct evidence. Treatment ranking was assessed using the surface under the cumulative ranking curve. Results Fifty-four studies including 560,723 patients were analyzed. Compared with SAG, MAG was associated with lower long-term mortality (hazard ratio [HR] 0.83, 95% credible interval [CrI] 0.79–0.85), while TAR demonstrated a greater survival benefit (HR 0.75, 95% CrI 0.70–0.79). Indirect comparison within the network suggested an incremental survival advantage of TAR over MAG (HR 0.90, 95% CrI 0.85–0.96). Treatment ranking suggested a hierarchy in which TAR was associated with superior survival, followed by MAG and SAG. Conclusion Increasing use of arterial conduits during CABG is associated with progressively improved long-term survival, with TAR demonstrating the greatest benefit.

BACKGROUND:Pulmonary artery catheters are used widely in cardiac surgery despite conflicting associations with patient outcomes. We evaluated the associations between pulmonary artery catheter use and clinical outcomes following cardiac surgery using a large cohort of patients treated at a US academic center. METHODS:We performed a retrospective entropy-balanced cohort study of consecutive adults undergoing cardiac surgery from a single tertiary center in Boston, Massachusetts, from 2008 to 2022. We used entropy balancing to achieve exact covariate balance on prespecified baseline characteristics and then estimated the average treatment effect of pulmonary artery catheter use on clinical and mechanistic outcomes. The primary outcome was mortality measured 90 days after surgery. Secondary outcomes were acute kidney injury, hospital and intensive care unit (ICU) length of stay, time in postoperative organ dysfunction measured at 7 days, prolonged inotrope use (>4 hours), significant peak vasopressor requirement (>0.1 μg/kg/min in norepinephrine equivalents), net fluid balance at 24 hours, number of fluid boluses administered, volume of allogeneic red blood cells transfused, and total duration of mechanical ventilation. RESULTS:We included 10,044 patients, of whom 5850 (58.2%) were managed with a pulmonary artery catheter. Pulmonary artery catheter use was not associated with 90-day mortality (risk ratio [RR], 0.966; 95% confidence interval [CI], 0.719-1.30; P =.816) nor in-hospital mortality (RR, 0.921; 95% CI, 0.632-1.34; P =.670). There was no between-group difference in hospital length of stay (median difference [MD], 0.050 days; 95% CI, 0.0477-0.148; P =.269), but patients managed with a pulmonary artery catheter had greater ICU length of stay (MD = 13.1 hours; 95% CI, 9.74-16.4; P <.001). Pulmonary artery catheters were also associated with increased incidence of acute kidney injury (RR, 1.12; 95% CI, 1.07-1.17; P <.001). Patients who received a pulmonary artery catheter were more likely to have prolonged inotrope requirements (RR, 4.13; 95% CI, 3.42-4.98; P <.001), significant vasopressor requirements (RR, 1.37; 95% CI, 1.28-1.46; P <.001), higher positive fluid balances (MD, 566 mL; 95% CI, 453-678; P <.001), higher volumes of allogeneic RBCs transfused (MD, 226 mL; 95% CI, 183-269; P <.001), higher time in postoperative organ dysfunction (MD, 3.96 hours; 95% CI, 3.01-4.90; P <.001), and longer durations of mechanical ventilation (MD, 11.3 hours; 95% CI, 7.33-15.2; P <.001). CONCLUSIONS:In a large entropy-balanced cohort study of adults undergoing cardiac surgery, pulmonary artery catheter use was not associated with mortality, but was linked with a higher treatment intensity and longer ICU stay.

Objectives: Whether patients with kidney failure who undergo cardiac surgery have a survival advantage with previous kidney transplantation is unclear. This study evaluated long-term outcomes after cardiac surgery for kidney transplant recipients and patients dependent on dialysis using national registries. Methods: Probabilistic data linkage was undertaken between registries for the period 2010-2019. Time-to-event analyses were used to estimate the risk after cardiac surgery of (1) survival for kidney-replacement therapy recipients (n = 1250), and (2) graft survival for kidney transplant recipients (n = 225). Using cardiac surgery as a time-varying covariate, kidney graft survival was compared among the national contemporary kidney transplant population (n = 7934). Results: Five-year survival probabilities after cardiac surgery for patients with kidney transplants and receiving dialysis were 70% (95% confidence interval [CI], 61%-76%) and 49% (95% CI, 45%-53%), respectively. The benefit for kidney transplantation persisted in a multivariable Cox regression model (reference: facility hemodialysis; adjusted hazard ratio [HR], 0.53; 95% CI, 0.37-0.74; P < .001). Five-year kidney graft survival probability after cardiac surgery was 60% (95% CI, 52%-68%) and was lower with stage 3 acute kidney injury (reference: none; adjusted HR, 2.61; 95% CI, 1.32-5.16; P = .006). Among the national contemporary kidney transplant recipient population, cardiac surgery was associated with an increased risk of graft loss (adjusted HR, 1.70; 95% CI, 1.07-2.74; P = .026). Conclusions: Among adults with kidney failure undergoing cardiac surgery, kidney transplant recipients experienced a long-term survival advantage compared with patients dependent on dialysis. Transplant recipients undergoing cardiac surgery had greater risk of graft loss than the national contemporary kidney transplant population.

Objective: Prolonged mechanical ventilation after cardiac surgery contributes significantly to morbidity, mortality, and excessive hospital resource use. Accurate prediction of prolonged mechanical ventilation duration can improve decision-making and patient outcomes. We aimed to develop and validate time-to-event models to predict the duration of ventilation and prolonged mechanical ventilation. Methods: From the Medical Information Mart for Intensive Care III and IV databases, we extracted postoperative data from all cardiac surgery patients. We benchmarked 3 machine learning time-to-event algorithms (random survival forest, gradient boosted survival model, and survival support vector machine) against traditional Elastic-Net Cox regression. We evaluated model performance using weighted mean area under the curve (AUC¯wC,D), cumulative/dynamic area under the receiver operating characteristic curve (AUCC,D(t)), Concordance Index, and integrated Brier score. Permutation feature importance was reported for the best models. We conducted a sensitivity analysis to evaluate model fairness across different races and sexes. Results: Models were trained on data from 10,430 cardiac surgery patients ventilated for a median of 7.0 hours (interquartile range, 4.4-16.0). Random survival forest had the highest AUC¯wC,D (0.834, 95% CI, 0.832-0.836) and integrated Brier score (0.041), whereas gradient boosted survival model had the highest Concordance Index (0.721, 95% CI, 0.717-0.724). All machine learning models significantly outperformed Elastic-Net Cox Regression. Ventilatory settings, laboratory results, and Sequential Organ Failure Assessment score within 4 hours of intubation were identified as the most important features. Sensitivity analysis showed equal or improved performance for minority female and non-White cohorts. Conclusions: Machine learning time-to-event models for prolonged mechanical ventilation and the duration of ventilation, particularly random survival forest and gradient boosted survival model, have significantly improved performance compared with current state-of-the-art tools and may be valuable decision supports in the postoperative management of cardiac surgery patients.

BACKGROUND:Although clinical quality registries have been established worldwide to monitor cardiothoracic surgery outcomes through benchmarking to detect underperforming hospitals (outliers) and improve quality of care, the accuracy of such analyses remains unclear. This study aimed to compare and evaluate methods of outlier classification when applied to real-world and simulated data. METHODS:Data relating to isolated coronary artery bypass graft procedures were obtained from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database registry. Unadjusted and risk-adjusted operative mortality and new renal insufficiency were the key outcomes evaluated for two timeframes: cumulative (2018-2021) and rolling (2022); additional data were parametrically generated to simulate these datasets. Agreement in outlier flagging was compared between variations of control limit and confidence interval methods when applied to the real data, and the expected accuracy of the methods evaluated using the simulated data. RESULTS:While outlier flagging was similar between techniques, agreement between different risk-adjustment, timeframes and significance levels were moderate to poor. The expected accuracy of outlier classification also differed between these considerations, with high performance only reached for risk-adjusted outcomes using cumulative data. Of the methods, outliers flagged using exact binomial 95 % control limits had the highest accuracy. CONCLUSIONS:Clinical registries should consider their data parameters before commencing benchmarking to detect underperforming sites. To optimise accuracy of outlier flagging, outcomes should be risk-adjusted, cumulative datasets should be used in the case of low patient volumes and, where possible, outcomes with higher prevalence should be evaluated.

Background:Heart failure remains a significant cause of morbidity and mortality internationally. With significant disparities in supply and demand for donor organs and recipients, there has been a growing need to expand the donor pool. Donation after circulatory death (DCD) heart transplantation offers such a method, with ex-situ machine perfusion (ESMP) and thoracoabdominal normothermic reperfusion (NRP) offering two potential methods of procuring DCD organs. This systematic review and meta-analysis aims to evaluate the current literature and compare DCD with donation after brain death (DBD) as well as DCD methods of transplantation. Methods:A systematic literature review was performed according to PRISMA guidelines. Primary outcomes were 30-day, 6- and 12-month survival, as well as primary graft dysfunction (PGD) and acute rejection. Secondary outcomes were length of stay (LOS), intensive care unit (ICU) LOS and temporary dialysis. Weighted averages were utilised to summarise data with funnel plots utilised for comparisons. Reconstructed Kaplan-Meier curves were utilised to evaluate mid-term survival. Results:A total of 10 studies were included evaluating 923 DCD recipients and 7,236 DBD recipients. Survival for DCD and DBD patients at 6 months was 93% and 91% respectively [odds ratio (OR), 1.5; 95% confidence interval (CI): 1.0-2.2; P<0.05] and at 12 months 93% and 91% for DCD and DBD respectively (OR 0.77, 95% CI: 0.1-5.3, P=0.8). Acute rejection was 15% and 19% in DCD and DBD patients respectively (OR, 1.0; 95% CI: 0.6-1.8; P=0.9). Thirty-day survival was similar between NRP (96.9%) and direct procurement and perfusion (DPP) (97%) (OR, 0.8; 95% CI: 0.2-3.9; P=0.8). PGD was higher in DCD (17%) compared with DBD (8%) patients (OR, 1.9; 95% CI: 0.98-3.7; P=0.06) whilst PGD for DPP and NRP was 21% and 14% respectively. Conclusions:DCD may offer comparable outcomes to DBD in short and mid-term outcomes, although PGD remains a concern. Further comparative research is required to delineate the role of both techniques in the current transplant landscape.

Objective. Kidney failure increases people's risk of cardiovascular disease, sometimes requiring cardiac surgery. The aim of this study was to estimate the risk of cardiac surgery for adults with treated kidney failure in comparison with the general population in Australia. Methods. We performed a population-based retrospective cohort study by linking data between the Australia and New Zealand Dialysis and Transplant Registry and the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database, for 2010-2019. Age-sex-standardised surgery risk relative to the general population was estimated for adults receiving long-term dialysis and kidney transplant recipients, and subpopulations defined by procedure type, comorbidity, clinical status and dialysis-related factors. Results. Among 1541 adults receiving treatment for kidney failure at the time of cardiac surgery in 2010-2019, the prevalence of comorbidity and risk factors was usually highest in those receiving dialysis, followed by transplant recipients and the general population (n = 113,126). For all major cardiac surgical procedure types, the incidence of surgery for adults receiving dialysis and transplant recipients exceeded that for the general population (e.g. isolated coronary artery bypass grafting relative rates 15.3 [95% CI 13.7-17.0] and 2.0 [1.6-2.6] respectively). Relative incidence was especially high for the dialysis cohorts with insulin-treated diabetes and those with body mass index <25 kg/m(2). Conclusions. Adults with treated kidney failure had a higher risk of cardiac surgery than the general population in Australia in 2010-2019, especially when associated with diabetes. Data linkage between clinical quality registries enabled estimation of the extent of cardiac surgical burden.

ANZ Journal of SurgeryVolume 91, Issue 11 p. 2255-2256 PERSPECTIVE 25, 50, 75 years ago Julian A. Smith MBMS, MSurgEd, FRACS, Julian A. Smith MBMS, MSurgEd, FRACS Editor-in-Chief Department of Surgery, Monash University, Melbourne, Victoria, AustraliaSearch for more papers by this author Julian A. Smith MBMS, MSurgEd, FRACS, Julian A. Smith MBMS, MSurgEd, FRACS Editor-in-Chief Department of Surgery, Monash University, Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 12 November 2021 https://doi.org/10.1111/ans.17277Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume91, Issue11November 2021Pages 2255-2256 RelatedInformation

Since 1992, the Consultative Committee on Road Traffic Fatalities in Victoria has identified deficiencies and errors in the management of 559 road traffic fatalities in which the patients were alive on arrival of ambulance services. The Committee also assessed the preventability of deaths. The reproducibility of results using its methodology has been shown to be statistically significant. The Committee's findings and recommendations, the latter made in association with the learned Colleges and specialist Societies, led to the establishment of a Ministerial Taskforce on Trauma and Emergency Services. As a consequence, in 2000, a new trauma care system will be implemented in Victoria. This paper presents a case example demonstrating the Committee's methodology. The Committee has two 12-member multidisciplinary evaluative panels. A retrospective evaluation was made of the complete ambulance, hospital, and autopsy records of eligible fatalities. The clinical and pathological findings were analysed using a comprehensive data proforma, a narrative summary, and the complete records. Resulting multidisciplinary discussion problems were identified, and the potential preventability of death was assessed. In the present case example, the Committee identified 16 management deficiencies, of which 11 were assessed as having contributed to the patient's death; the death, however, was judged to be non-preventable. The presentation of this example demonstrating the Committee's methodology may be of assistance to hospital medical staff undertaking their own major trauma audit. Injuries caused by firearms account for only a small percentage of trauma admissions and deaths in Australia but are frequently the subject of media and public attention. The present study examines the epidemiology and management of firearm injuries presenting to St Vincent's Hospital, which is located at the edge of the central business district of Sydney. The medical records of all patients presenting to St Vincent's with a gunshot wound (GSW) from January 1988 to December 1998 were analyzed. Additional details were acquired from New South Wales State Coroner's Court reports and media archives, especially major newspapers. Seventy-four patients presented to St Vincent's Hospital with 103 GSWs. The age (mean ± SD) was 31 ± 11 years. Sixty-seven patients (91%) were male. Alcohol was identified as a factor in 24 cases (32%) while other drugs were indicated in four cases (5%). Ten patients (14%) had intentionally self-inflicted wounds, seven (9%) had accidental wounds, and 57 (77%) had wounds that were caused by crime-related violence. Sixty patients (81%) underwent surgery for their injury. Thirty complications were seen in 18 patients (24%). Eleven patients (15%) died. The length of hospital stay (mean ± SEM) was 18 ± 9 days. The incidence of trauma due to firearms has not increased at St Vincent's Hospital in the period 1988–1998. Most GSWs were inflicted in the setting of criminal violence, with a high proportion due to handguns. Patients were mostly young men, and alcohol or other drugs were frequently involved. Outcomes are comparable to other centers managing large volumes of penetrating trauma. A series of arterial embolectomies of the lower limb is reviewed, and the results are compared with those in a previous series reported from this hospital. There were 40 emboli in the 36 patients, with an operative mortality of 16% and a limb salvage rate of 85%. This represents a considerable improvement on the results reported from the first series and is attributed to the greater experience of surgeons with the Fogarty embolectomy catheter. However, there has been no decrease in the delay between the onset of symptoms and the embolectomy. If this aspect of management could be improved, then even better results should be obtained. Doctors, both within and outside hospitals, must be made more aware of the need for urgency in the management of arterial emboli of the lower limbs, for non-operative treatment with anticoagulants has no place in the management of this condition. A below-knee amputation will heal in most patients with atherosclerotic peripheral arterial disease, using no anterior flap and a long posterior myoplastic flap. The technique used by the authors (Fig. 1) is presented in detail, with their experience in 32 cases. Satisfactory healing can be achieved with a below-knee amputation in most severely ischaemic limbs. The elimination of an anterior flap with the construction of a long myoplastic posterior flap and the use of a non-traumatic technique allow most below-knee amputations to heal. The healed stump is well-padded and suitable for the fitting of a prosthesis. If dead muscle is present at the level of amputation, an above-knee amputation should be performed rather than an attempt to excise the muscles at a more proximal level. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians.

OBJECTIVES:To develop a model to predict post-cardiac surgery vasopressor administration and describe hospital variation in practice. DESIGN:Retrospective analysis. SETTING:Multi-institutional. PARTICIPANTS:All patients who underwent cardiac surgery with cardiopulmonary bypass between 2012 and 2021. INTERVENTIONS:Observational. MEASUREMENTS AND MAIN RESULTS:The study cohort was divided into a development set (80%) and a validation set (20%). Univariate logistic regression was used to identify variables associated with postoperative vasopressor administration. The least absolute shrinkage and selection operator was used to develop parsimonious models with variables known preoperatively only (preoperative model), as well as preoperative and immediate postoperative variables (postoperative model). Model discrimination and calibration were performed on both the development and validation sets. The study included 106,348 patients across 33 hospitals. The incidence of postoperative vasopressor administration was 29.3% (n = 31,157). Significant interhospital variability in the rate of the outcome was observed, ranging from 1.20% to 69.4% (median, 22.3%). Fixed effects models with patient and surgical variables were developed for postoperative vasopressor administration, with an area under the receiver operating curve of 0.56 and 0.60 preoperatively and postoperatively, respectively. Accounting for the hospital of admission through mixed effects multilevel modeling improved the area under the receiver operating curve to 0.75 and 0.76 preoperatively and postoperatively, respectively. CONCLUSIONS:Post-cardiac surgery vasopressor administration can only be predicted with poor to fair accuracy based on patient and surgical variables alone. Significant institutional variation in the rate of vasopressor administration exists, seemingly unrelated to measured patient and surgical factors, and predictive ability improves substantially when this is considered.

BACKGROUND:Despite the evidence of clinical benefit, total arterial revascularization (TAR) remains underutilized in elderly patients undergoing coronary artery bypass grafting due to concerns about perceived surgical complexity and limited life expectancy. OBJECTIVES:The objective of the study was to evaluate long-term survival of TAR vs conventional non-TAR grafting strategies in elderly (≥70 years) and younger (<70 years) patients using a binational cardiac surgery registry. METHODS:The study included patients who underwent primary isolated coronary artery bypass grafting with at least 2 grafts between 2001 and 2020. The endpoint was long-term all-cause mortality. Patients were stratified into 2 age groups, <70 years and ≥70 years. Within each cohort, survival outcomes were compared between those who received TAR, and those who received non-TAR involving at least 1 saphenous vein graft. Secondary analyses further divided the non-TAR group into patients receiving multiple arterial grafting or single arterial grafting. Baseline differences were adjusted using inverse probability treatment weighting, followed by Cox proportional hazard modeling. RESULTS:Among 59,641 patients, TAR was associated with significantly improved survival compared to non-TAR in both elderly (HR: 0.87; 95% CI: 0.81-0.92; P < 0.001) and younger age groups (HR: 0.80; 95% CI: 0.73-0.88; P < 0.001). A clear hierarchy in survival was also demonstrated, with the highest survival observed in patients undergoing TAR, followed by non-TAR-multiple arterial grafting, and the lowest in those receiving non-TAR-single arterial grafting. CONCLUSIONS:TAR improves long-term survival in both elderly and younger patients. These findings challenge the assumption that limited life expectancy precludes arterial grafting and support broader implementation of TAR in appropriately selected older patients. Randomized clinical trials evaluating TAR are warranted to validate these observational findings.

BACKGROUND:Management of primary spontaneous pneumothorax (PSP) has long been contentious. AIMS:To identify the factors influencing interventional versus conservative management and to assess current practice patterns for moderate-to-large PSP in emergency department (ED) patients. METHODS:Anonymous online survey of emergency medicine, respiratory medicine and thoracic surgery specialists and trainees in Australia and New Zealand. Data collected included rating the decision-making importance of potential drivers of interventional versus conservative management for PSP, initial management preference for stable patients with moderate-large PSP based on three X-ray-based scenarios (one moderate-large, one almost total collapse without mediastinal shift and one large with mediastinal shift) and awareness of evidence and current guidelines for the management of PSP. RESULTS:There were 456 responses; 85.5% were from Australia. The most commonly reported factors influencing treatment decision-making were vital signs (96.7%) and patient-reported dyspnoea (84.3%). There was variation between specialty groups in initial treatment preference for all scenarios (P < 0.001) and a reduction in preference for conservative treatment as the magnitude of radiological features increased (93.8% vs 61.5% vs 32.1% respectively). Guideline recommendation awareness was low except for the 2023 British Thoracic Society guideline (60.4%). CONCLUSION:This study demonstrates variation of opinion regarding the initial management of stable patients with moderate to large PSP and an increasing preference for intervention as the magnitude of radiological features increases. Guideline awareness was low, highlighting the need for an evidence-based approach to PSP management in the ED that is widely understood and accepted across speciality groups and that prioritises patient symptoms over X-ray findings.