Excessive bleeding is a common and prognostically important complication of cardiac surgery. For bleeding related to coagulation factor deficiency, frozen plasma is the most used therapy. Preliminary trials indicate that 4-factor prothrombin complex concentrate (PCC) may be a suitable alternative. To compare the efficacy and safety of PCC with frozen plasma in patients undergoing cardiac surgery with coagulopathic bleeding. Unblinded randomized noninferiority controlled clinical trial at 12 hospitals in Canada and the US involving adults (≥18 years) who had developed bleeding related to coagulation factor deficiency after termination of cardiopulmonary bypass during surgery (November 30, 2022, to May 28, 2024). Final 30-day follow-up visit was completed on June 28, 2024. A total of 265 patients were randomized to receive PCC (1500 IU ≤60 kg; 2000 IU >60 kg) and 263, frozen plasma (3 U ≤60 kg; 4 U >60 kg) in the operating room. A second dose was allowed over the next 24 hours if indicated; thereafter, only frozen plasma could be used. The primary outcome was hemostatic response (effective if no hemostatic interventions occurred from 60 minutes to 24 hours after treatment initiation). The noninferiority of PCC vs frozen plasma was assessed using a 10% margin and a 1-sided α of .025, with subsequent testing for superiority if noninferiority was demonstrated. Secondary outcomes included allogeneic blood transfusions and adverse events. Patients were followed up until postoperative day 30. Of 538 enrolled patients, 420 patients (median age, 66 years [IQR, 57-73 years]; 74%, male; 10%, Asian; 1%, Black; and 65%, White) were included in the primary analysis; of those, 296 (70%) underwent complex surgeries. Compared with the 207 patients in the frozen plasma group, the 213 patients in the PCC group had higher hemostatic effectiveness (166 [77.9%] vs 125 [60.4%]; difference, 17.6%; 95% CI, 8.7%-26.4%; P < .001 for noninferiority and superiority) and had received fewer transfusions including red blood cells, platelets, and noninvestigational frozen plasma units (mean, 6.6 units; 95% CI, 5.7-7.7 vs 9.3 units; 95% CI, 8.0-10.8; difference, 2.7; 95% CI, 1.0-4.4; P = .002). Seventy-seven patients (36.2%) in the PCC group vs 98 (47.3%) in the frozen plasma group experienced serious adverse events (relative risk [RR], 0.76; 95% CI, 0.61-0.96; P = .02). Twenty-two patients (10.3%) in the PCC group and 39 (18.8%) in the frozen plasma group had acute kidney injury (RR, 0.55; 95% CI, 0.34-0.89; P = .02). In this unblinded randomized clinical trial, PCC had superior hemostatic efficacy and safety advantages to frozen plasma among patients requiring coagulation factor replacement for bleeding during cardiac surgery. ClinicalTrials.gov Identifier: NCT05523297.

Sternal surgical site infections after cardiac surgery can lead to significant morbidity, mortality, and cost. The effects of negative pressure wound management and adding vancomycin as perioperative antimicrobial prophylaxis are unknown. The PICS-PREVENA pilot/vanguard trial, a 2x2 factorial, open label, cluster-randomized crossover trial with 4 periods, was conducted at two major cardiac surgery hospitals in Ontario, Canada. Sites were randomized to one of eight sequences of the four study arms (Cefazolin or Cefazolin + Vancomycin (not analyzed) and standard wound dressing or a negative pressure 3M Prevena incision management system (Prevena). Only diabetic or obese patients were eligible for the latter comparison. This trial investigated feasability including adherence to protocol of each intervention (goal: > 90% each) and loss to follow-up (goal: < 10%). Among the 4107 included patients, 2230 were obese/diabetic (1208 standard wound dressing period, 1022 during Prevena period). Compliance to wound management and antimicrobial prophylaxis was 68.1% and 98.7%, respectively. Loss to follow-up was 3.6%. Deep/organ-space sternal surgical site infections occurred in 16 (1.6%) patients in the Prevena allocated periods and in 17 (1.4%) patients in the standard wound dressing allocated periods (OR= 1.11, 95% CI: 0.56-2.20). Other clinical outcomes did not suggest a difference and a post-hoc as-treated analysis showed similar results. This study showed challenges with introducing a novel technology as standard of care, with non-compliance mostly driven by one of the sites. No firm conclusions should be drawn regarding the effectiveness of Prevena, as this vanguard trial was not powered for clinical outcomes.

Introduction: Studies indicate that learning surgical skills on low-fidelity models is equally beneficial to learning on high-fidelity models in terms of skills retention and transfer. However, it is unclear how low-fidelity simulation training impacts retention and transfer in novice learners, particularly on complex surgical tasks that incorporate multiple challenging skills. This study explores the capacity of complete novices to learn and transfer complex surgical skills from a low-fidelity model to a high-fidelity simulation after a delay. Methods: Task-naive medical and nonmedical undergraduate students (n = 62) participated in a three-phase prospective double-arm randomized (2:1) experimental study. Participants completed two skills training sessions (end-to-side anastomosis) on a low-fidelity bench model. After a 4-week delay, participants completed the task again either using the low-fidelity model or a high-fidelity model (cadaver) and were assessed using a validated checklist. Results: There was a significant time x fidelity group interaction (P = 0.004). Simple effects analysis indicated the high-fidelity group (M-diff = 4.18, P < 0.001) performed significantly worse (P = 0.003) in phase 3 relative to phase 2 compared to the low-fidelity group (M-diff = 0.75, P = 0.39). Post hoc logistic regression analysis indicated that radial suturing technique and economy of motion skills were less likely to be completed correctly for those in the high-fidelity group. Conclusions: These findings suggest that for novice populations, relying on low-fidelity simulation training as a source of teaching complex skills may not provide a reliable transfer to high-fidelity models and in turn clinical settings. (c) 2022 Elsevier Inc. All rights reserved.

Contemporary studies have the imperative to investigate important sex-related differences.

Plots showing a relationship between (A) leukocyte TL and age and (B) skeletal muscle TL and age, (C) but not the right atrium TL and age. Abbreviation as in Figure 1.

BACKGROUND: Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS: We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007–2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 μmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS: Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION: Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388

Background Hypertrophic pyloric stenosis (HPS) is a common neonatal condition treated with open or laparoscopic pyloromyotomy. 3D-printed organs offer realistic simulations to practice surgical techniques. The purpose of this study was to validate a 3D HPS stomach model and assess model reliability and surgical realism. Methods Medical students, general surgery residents, and adult and pediatric general surgeons were recruited from a single center. Participants were videotaped three times performing a laparoscopic pyloromyotomy using box trainers and 3D-printed stomachs. Attempts were graded independently by three reviewers using GOALS and Task Specific Assessments (TSA). Participants were surveyed using the Index of Agreement of Assertions on Model Accuracy (IAAMA). Results Participants reported their experience levels as novice (22%), inexperienced (26%), intermediate (19%), and experienced (33%). Interrater reliability was similar for overall average GOALS and TSA scores. There was a significant improvement in GOALS (p < 0.0001) and TSA scores (p = 0.03) between attempts and overall. Participants felt the model accurately simulated a laparoscopic pyloromyotomy (82%) and would be a useful tool for beginners (100%). Conclusion A 3D-printed stomach model for simulated laparoscopic pyloromyotomy is a useful training tool for learners to improve laparoscopic skills. The GOALS and TSA provide reliable technical skills assessments. Level of Evidence II.

Leukocyte telomere shortening reflects stress burdens and has been associated with cardiac events. However, the patient-specific clinical value of telomere assessment remains unknown. Moreover, telomere shortening cannot be inferred from a single telomere length assessment. The authors investigated and developed a novel strategy for gauging leukocyte telomere shortening using autologous cardiac atrial referencing. Using multitissue assessments from 163 patients who underwent cardiovascular surgery, we determined that the cardiac atrium-leukocyte telomere length difference predicted post-operative complexity. This constituted the first evidence that a single-time assessment of telomere dynamics might be salient to acute cardiac care. (C) 2018 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation.

Endoscopic radial artery harvest (ERAH) for coronary artery bypass grafting (CABG) offers the potential for decreased pain, infection, neurological complications of the arm with dramatically improved cosmesis compared to an open/conventional harvest. Because of these potential benefits and our experience with endoscopic saphenous vein harvest (ESVH), we adopted ERAH as standard of care for CABG patients at our institution. Here we present our experience and outcomes with this technique after more than 1000 harvests. From July 2004 to present, our centre performed endoscopic radial artery harvest (ERAH) in 1003 patients. We adapted a reusable ESVH system (Karl Storz Endoscopy) with the addition of a harmonic ultrasonic scalpel/shears (Ethicon Endosurgery) to facilitate the removal of the radial artery (RA) for use in our CABG patients. Data was collected prospectively regarding harvest technique (harvest times, graft length, incision length, histology) and patient outcomes (infection, cosmesis, hematomas, gross neurological impairment, patient satisfaction and all MACE’s). Thirty-two patients underwent angiographic assessment of their RA grafts at >5 years. RA Harvest times ranged from 21-125 minutes with a median harvest time of 37min +/- 4 in the first quartile of our series and greatly decreased with experience. Average length of artery extracted was 17.2 cm +/- 1.2 cm through a mean incision length of 2.3 cm +/- 0.7cm. All RA grafts harvested were deemed suitable for grafting. Six patients were converted to open harvest and 15 patients required the addition of a second proximal arm incision. There were 17 ERAH wound infections (1.7%). Neurological impairments were infrequent and mostly consisted of transient numbness over the thenar eminence, index finger and lateral forearm. Five patients manifested clinically significant chronic neuralgias post-operatively. Histological examination of multiple samples of harvested RA’s revealed no signs of intimal trauma or thermal injury. There were no clinically significant hematomas post-operatively and no arm required operative re- intervention. There were 7 postoperative deaths (0.7%), 12 post-op MI’s (1.2%), 22 central neurological complications (2.2%) and no cases of renal failure requiring dialysis. Long-term follow-up on angiography and CT/Angiography revealed a patency rate of 91.3%. ERAH can be effectively and safely adopted as a harvest technique for the RA for CABG. Our results demonstrate ERAH provides adequate length conduits in a timely manner through much smaller incisions, resulting in low rates of infection, neurological impairment, excellent long-term patency and no evidence of histological damage.

Objectives Microembolic signals (MES) on transcranial Doppler (TCD) predict stroke and cognitive decline. Plasma levels of total homocysteine (tHcy), a prothrombotic factor, are higher in patients with microemboli in carotid stenosis and in patients with paradoxical embolism. In this study we assessed the association between the level of tHcy and the number of MES in patients with mechanical heart valves (MHVs). Methods TCD monitoring was performed to detect MES before and after breathing 100% oxygen and repeated every 2–4 weeks up to six times. Results Twenty-five patients with MHVs (mean age: 63.60±10.15 years) participated in this study; 15 were men (66.47±7.25 years) and 10 were women (59.30±12.60 years). In total, there were 126 study visits. In multiple regression, higher tHcy was associated with more MES in both preoxygenation (OR 1.34 (95% CI 1.07 to 1.68, P=0.009)) and postoxygenation (OR 1.40 (95% CI 1.07 to 1.83, P=0.01)) phases. Current smoking and the length of time between the operation and monitoring also correlated with a higher number of MES before and after breathing oxygen, particularly in women. Conclusions Higher tHcy and smoking were associated with a higher MES count in both preoxygenation and postoxygenation phases. Because smoking can be stopped and hyperhomocysteinaemia is treatable, these are clinically important findings.

Management of cardiac surgery health human resources (HHR) has been challenging, with recent graduates struggling to secure employment and a shortage of cardiac surgeons predicted as early as 2020. The length of cardiac surgery training prevents HHR supply from adapting in a timely fashion to changes in demand, resulting in a critical need for active workforce management. This study details the results of the 2015 Canadian Society of Cardiac Surgeons (CSCS) workforce survey undertaken as part of the CSCS strategy for active workforce management. The 38-question survey was administered electronically to all 96 trainees identified as being registered in a Canadian cardiac surgery residency program for the 2015-2016 academic year. Eighty-four of 96 (88%) trainees responded. The majority of participants were satisfied with their training experience. However, 29% stated that their clinical and operative exposure needed improvement, and 57% of graduating trainees did not believe that they would be competent to practice independently at the conclusion of their training. Although 51% of participants believe the job market is improving, 94% of senior trainees found it competitive or extremely difficult to secure an attending staff position. Participants highlighted a need for improved career counselling and formal mentorship. Although the job market is perceived to be improving, a mismatch in the cardiac surgery workforce supply and demand remains because current trainees continue to experience difficulty securing employment after the completion of residency training. Trainees have identified improved career counselling and mentorship as potential strategies to aid graduates in securing employment.

Objective The aims of the study were to determine whether endoscopic harvesting of the radial artery (RA) reduces morbidity due to pain, infection, and disability with improvement in satisfaction and cosmesis compared to the conventional technique and (2) to compare the 6-month angiographic patency of the RA harvested conventionally and endoscopically. Methods In a prospective randomized study, 119 patients undergoing coronary artery bypass grafting using the RA were randomized to have RA harvested either conventionally (n = 59) or endoscopically (n = 60). Results Radial artery harvest time (open wound time) was significantly reduced in the endoscopic group (36.5 ± 9.4 vs 57.7 ± 9.4 minutes, P < 0.001). Only one patient developed wound infection (1.6%) in the endoscopic group compared with six patients (10.2%), P = 0.061, in the conventional group. Although this was not statistically significant, clinically this was relevant in terms of reduction in postoperative morbidity. Postoperative pain in the arm incision was significantly lower in the endoscopic group at postoperative day 2 (P < 0.001) and at discharge (P < 0.001) and similar to the conventional open group at 6 weeks’ follow-up (P = 0.103). Overall patient satisfaction and cosmesis were significantly better in the endoscopic group at postoperative day 2 (P < 0.001), at discharge (P < 0.001), and at 6 weeks’ follow-up (P < 0.001). There was no difference in the arm disability postoperatively (P = 0.505) between the two groups. Six-month angiographic assessment of 23 patients (12 endoscopic and 11 open) revealed no difference in the patency rate (10/12 in endoscopic and 9/11 in open group). Conclusions Endoscopic RA harvesting reduced the incidence of postoperative wound infection and wound pain and improved patient satisfaction and cosmesis compared with conventional harvesting technique. There was no difference in the 6-month angiographic patency of the RA harvested conventionally and endoscopically.

Introduction: Ascertaining the biological age of patients with advanced vascular disease could advance risk assessment and management. The extent to which telomeres shorten in leukocytes could be a marker of biological age because it reflects the accumulation of replication stresses imposed on leukocyte progenitors. However, because of wide, genetic variability in leukocyte telomere length (TL), a single leukocyte TL measurement does not reliably indicate telomere shortening. Hypothesis: We hypothesized that the difference in length of telomeres in “non-replicating” muscle-rich tissue and that of circulating leukocytes provides a patient-specific index of telomere shortening in patients with advanced vascular disease. Methods: TL in leukocytes, skeletal muscle, and right atrial cardiac muscle were measured from 134 patients undergoing coronary or thoracic aortic surgery, using quantitative polymerase chain reaction. Relationships between leukocyte TL or the muscle-leukocyte TL difference (ΔTL) and early post-operative outcomes were tested using Cox proportional hazard and binary logistic regression analyses. Results: Telomeres in cardiac muscle and skeletal muscle were significantly longer than those in leukocytes (p<0.001) but with synchrony among these measures in an individual (p<0.001). Leukocyte TL and skeletal muscle TL inversely correlated with chronological age (p<0.001) however cardiac muscle TL did not (p=0.283). There was no relationship between leukocyte TL and either the post-operative length of stay in the intensive care unit (ICU) or major complications. However, cardiac-leukocyte ΔTL was associated with length of ICU stay (hazard ratio 1.26, p=0.043) and post-operative complications (odds ratio 3.03, p=0.029). Conclusions: Right atrium-leukocyte ΔTL provides an index of telomere shortening and may inform outcomes in patients with advanced vascular disease. This two-component telomere measurement may reflect the biological age of individuals with chronic vascular disease.

OBJECTIVE Peripheral nerve injury (PNI) is a common and potentially devastating complication in cardiac surgery. Somatosensory evoked potential (SSEP) monitoring is one of the modalities for PNI; however, its application is limited by complicated logistics. This study aimed to assess the feasibility of using a novel, automated SSEP device (EPAD; SafeOp Surgical, Hunt Valley, MD) for detection of intraoperative PNI during cardiac surgery. DESIGN Prospective, observational study. SETTING Single university hospital. PARTICIPANTS Cardiac surgical patients. INTERVENTIONS After Ethics Board approval and written consent, study participants were monitored using the EPAD automated SSEP device during cardiac surgery. All patients with prolonged and abnormal SSEP changes were evaluated postoperatively, and if they were symptomatic, they were referred for further nerve conduction and electromyographic assessment. MEASUREMENTS AND MAIN RESULTS Of the 43 patients who consented to study inclusion, 33 were monitored successfully. With increasing clinical experience the authors encountered minimal technical issues, and satisfactory signals were obtained in most patients. Abnormal SSEP signal changes, which were encountered in 5 (15.2%) patients, were interpreted as impending PNI; 3 patients experienced prolonged signal changes (>1 h), and 2 (6.1%) of these developed symptomatic peripheral neuropathy that was confirmed with nerve conduction studies. CONCLUSIONS The EPAD automated SSEP device is a viable option for detecting PNI during cardiac surgery. A high incidence of intraoperative peripheral nerve compromise and a 6.1% incidence of postoperative peripheral neuropathy were observed. This study reports the clinical feasibility of using the EPAD automated SSEP device; additional studies are required to evaluate the diagnostic test accuracy and the outcome benefit of routine SSEP monitoring in cardiac surgical patients.

Background Cardiopulmonary bypass initiates a systemic inflammatory response syndrome that is associated with postoperative morbidity and mortality. Steroids suppress inflammatory responses and might improve outcomes in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass. We aimed to assess the effects of steroids in patients at high risk of morbidity and mortality undergoing cardiopulmonary bypass.Methods The Steroids In caRdiac Surgery (SIRS) study is a double-blind, randomised, controlled trial. We used a central computerised phone or interactive web system to randomly assign (1: 1) patients at high risk of morbidity and mortality from 80 hospital or cardiac surgery centres in 18 countries undergoing cardiac surgery with the use of cardiopulmonary bypass to receive either methylprednisolone (250 mg at anaesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients were assigned with block randomisation with random block sizes of 2, 4, or 6 and stratified by centre. Patients aged 18 years or older were eligible if they had a European System for Cardiac Operative Risk Evaluation of at least 6. Patients were excluded if they were taking or expected to receive systemic steroids in the immediate postoperative period or had a history of bacterial or fungal infection in the preceding 30 days. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcomes were 30-day mortality and a composite of death and major morbidity (ie, myocardial injury, stroke, renal failure, or respiratory failure) within 30 days, both analysed by intention to treat. Safety outcomes were also analysed by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00427388.Findings Patients were recruited between June 21, 2007, and Dec 19, 2013. Complete 30-day data was available for all 7507 patients randomly assigned to methylprednisolone (n= 3755) and to placebo (n= 3752). Methylprednisolone, compared with placebo, did not reduce the risk of death at 30 days (154 [4%] vs 177 [5%] patients; relative risk [RR] 0.87, 95% CI 0.70-1.07, p= 0.19) or the risk of death or major morbidity (909 [24%] vs 885 [24%]; RR 1.03, 95% CI 0.95-1.11, p= 0.52). The most common safety outcomes in the methylprednisolone and placebo group were infection (465 [12%] vs 493 [13%]), surgical site infection (151 [4%] vs 151 [4%]), and delirium (295 [8%] vs 289 [8%]).Interpretation Methylprednisolone did not have a significant effect on mortality or major morbidity after cardiac surgery with cardiopulmonary bypass. The SIRS trial does not support the routine use of methylprednisolone for patients undergoing cardiopulmonary bypass.

OBJECTIVE:From 2005 to 2007, 119 patients were enrolled in a prospective randomized controlled trial comparing open and endoscopically harvested radial arteries for coronary artery bypass grafting. The objective of the current study was to compare graft patency between intervention groups at more than 5 years from the initial trial. We hypothesized that endoscopically harvested radial arteries would show equivalent patency to those conventionally harvested.METHODS:At 5 years or greater from their operation, all consenting patients underwent a single-day anatomic and functional cardiac assessment with coronary computed tomography angiography and sestamibi myocardial perfusion scanning. Medical Outcomes Study 36-Item Short-Form Health Surveys and Seattle Angina Questionnaires were completed to assess the overall quality of life. All patients had received calcium channel blocker therapy for at least 6 months postoperatively.RESULTS:The mean (SD) duration of follow-up was 79.2 (8.6) months for all patients. One death occurred within 30 days of coronary artery bypass grafting in each treatment group, and eight additional noncardiac deaths occurred during the study time frame. Of 119 patients, 66 consented to follow-up. Thirty-two had open radial artery harvest, and 34 had endoscopic radial artery harvest. At more than 5 years, there were 28 patent conventionally harvested radial arteries (87.5%) and 31 patent endoscopically harvested radial arteries (91.2%) (P = 0.705). Measured quality of life was comparable between groups.CONCLUSIONS:Endoscopic radial artery harvest is safe and effective when compared with open radial artery harvest, with excellent graft patency demonstrated at more than 5 years. Patency results are noninferior in endoscopic radial artery harvest.

The Radial Artery (RA) is commonly utilized as a conduit for CABG at many cardiac centres. Endoscopic radial artery harvest (ERAH) offers the potential for decreased pain, infection, neurological complications of the arm with dramatically improved cosmesis compared to an open/conventional harvest. Because of these potential benefits and our experience with endoscopic harvest of the saphenous vein (ESVH), we adopted ERAH as standard of care for CABG patients at our institution. Here we present our experience and outcomes with this technique over more than 10 years. From July 2004 to May 2015, our centre performed ERAH in 793 patients. We adapted a reusable ESVH system (Karl Storz Endoscopy) with the addition of a harmonic ultrasonic scalpel/shears (Ethicon Endosurgery) to facilitate the removal of the RA for use in our CABG patients. Data was collected prospectively regarding harvest technique (harvest times, graft length, incision length, histology) and patient outcomes (infection, cosmesis, hematomas, gross neurological impairment, patient satisfaction and all MACE's). Thirty-four patients underwent angiographic assessment of their RA grafts at >5 years. RA Harvest times ranged from 21-125 minutes with a median harvest time of 37min +/- 4 in the first quartile of our series and greatly decreased with experience. Average length of artery extracted was 17.2 cm +/- 1.2 cm through a mean incision length of 2.3 cm +/- 0.7cm. All RA grafts harvested were deemed suitable for grafting. Six patients were converted to open harvest and 8 patients required the addition of a second proximal arm incision. There were 6 ERAH wound infections. Neurological impairments were infrequent and mostly consisted of transient numbness over the thenar eminence, index finger and lateral forearm. Five patients manifested clinically significant chronic neuralgias post-operatively. Histological examination of multiple samples of harvested RA's revealed no signs of intimal trauma or thermal injury. There were no clinically significant hematomas post-operatively and no arm required operative re- intervention. There were 6 post-operative deaths, 10 post-op MI's, 21 central neurological complications and no cases of renal failure requiring dialysis. Long-term follow-up on angiography and CT/Angiography revealed a patency rate of 91.3%. ERAH can be effectively and safely adopted as a harvest technique for the RA for CABG. Our results demonstrate ERAH provides adequate length conduits in a timely manner through much smaller incisions without intimal trauma resulting in low rates of infection and neurological impairment and excellent long-term patency.

The Impella is a left ventricular assist device (LVAD) placed across the aortic valve to provide mechanical circulatory support for high-risk coronary procedures or cardiogenic shock. It is commonly implanted via femoral access, which consigns patients to complete bed-rest during device insertion. Prolonged immobility can result in profound deconditioning and critical illness myopathy / neuropathy that carry significant morbidity. Axillary cannulation offers a potential viable alternative for avoiding these sequelae. Our objective was to report our two-centre experience with axillary insertion of the Impella device, and its impact on patient outcomes. All adult patients that underwent Impella device implantation via the axillary route since 2010 were identified at our institutions. Data were collected on baseline characteristics (i.e., age, cardiovascular risk factors, INTERMACS profile, and ejection fraction), device implantation (i.e., site and indication), and patient outcomes (i.e., mortality, discharge, access complications, and early mobility). Twelve patients, with a mean age of 56 ± 10 years, underwent axillary device implantation of the 5.0 L/min Impella. Fifty percent were inserted emergently for cardiogenic shock due to ischemic cardiomyopathy in 42%, or non-ischemic cardiomyopathy or fulminant myocarditis in 33% each of patients. An INTERMACS 1-2 profile from critical cardiogenic shock or progressive decline in heart function associated with an EF <35% was evident in 75% of these patients. Sixty-six percent were bridged to more robust LVADs or heart transplant, with only 8% weaned off any mechanical circulatory support device. Half suffered 30-day mortality, and 33% had bleeding complications, with one case each of device failure and malposition. Vascular access complications were noted in 25% of patients, with 17% having arterial thrombi. Mobilization was attempted in ten patients; half attained early mobility with up-to-chair status by post-operative days 1-2. Independent mobilization, by pushing the system console while ambulating in the hall accompanied by a nurse, was achieved in the minority of these patients. Reduced sedation requirements compared to our experience with femoral implantation was also noted. Our experience highlights the feasibility, safety and marked rehabilitation potential of mechanical circulatory support via axillary artery implantation of the Impella device in a very critically ill patient cohort. This has important clinical implications for resource allocation, cost-effectiveness, and improving patient outcomes.

BACKGROUND Although often short-Lived and self-limiting, postoperative atrial fibrillation (POAF) is a well-recognized postoperative complication of cardiac surgery and is associated with a 2-fold increase in cardiovascular mortality and morbidity.OBJECTIVE Our aim was to determine whether intraoperative bilateral pulmonary vein radiofrequency ablation decreases the incidence of POAF in patients undergoing coronary artery bypass grafting (CABG).METHODS A total of 175 patients undergoing CABG was prospectively randomized to undergo adjuvant bilateral radiofrequency pulmonary vein ablation in addition to CABG (group A; n = 89) or CABG alone (group B; n = 86). Intraoperative pulmonary vein isolation was confirmed by the inability to pace the heart via the pulmonary veins after ablation. All patients received postoperative beta-blocker.RESULTS There was no difference in the incidence of POAF in the treatment group who underwent adjuvant pulmonary vein ablation (group A; 37.1%) compared with the control group who did not (group B; 36.1 A)) (P = .887). There were no differences in postoperative inotropic support, antiarrhythmic drug use, need for oral anticoagulation, and complication rates. The mean Length of postoperative hospital stay was 8.2 +/- 6.5 days in the ablation group and 6.7 +/- 4.6 days in the control group (P < .001).CONCLUSION Adjuvant pulmonary vein isolation does not decrease the incidence of POAF or its clinical impact but increases the mean Length of stay in the hospital. The mechanism of POAF does not appear to depend on the pulmonary veins.

BackgroundCardiac surgery is a technically demanding specialty where precise placement of sutures is essential for success. Due to restrictions in duty hours, decreased operative time, and increased public scrutiny; there is a growing trend for increased utilization of simulation to augment training of surgical residents.MethodsA novel suture simulation device was designed and distributed to 8 cardiac surgery residents. The simulator was a 3D printed hemisphere inside a box; mimicking a heart in the chest. The hemisphere had 12 regions which contained polymer inserts for suturing. A website was developed with a unique login for each resident. The website would randomly select a series of specific suture throws at specific regions to create surgical tasks. Each resident received a simulator for 30 days. The frequency of participation was voluntary at the preference of the resident. The time to complete each task was recorded using the website. All residents were filmed completing a task on the first and last day of the 30 day trial. At the conclusion, each resident’s opinion on the usefulness of the simulator was assessed through a survey.ResultsUse of the simulator ranged from 2 to 26 tasks; with a median of 7.5 tasks. The time required to complete a task was significantly shorter after the 30 day period with a mean of 312 and 202 seconds for the initial and final tasks, respectively (p = 0.005). Increased use of the simulator was associated with a decreased time required to complete a task (p < 0.001). More experienced residents performed tasks significantly faster than junior residents with a mean of 169 and 252 seconds for the senior and junior residents, respectively (p < 0.001). All the residents stated the simulator was beneficial, would recommend it for other residents, and felt the skills learned would translate to the operating room.ConclusionA low fidelity simulator was created to help cardiac surgery residents practice suturing skills. The time required to perform specific tasks improved through use of the simulator. Residents who used the simulator more frequently showed a greater improvement in measured times. Although the voluntary use was relatively low, the residents believed it was helpful in improving their technical skills and would translate to improved skill in the operating room. The use of this simulator may be a helpful adjunct in the training of surgical residents. BackgroundCardiac surgery is a technically demanding specialty where precise placement of sutures is essential for success. Due to restrictions in duty hours, decreased operative time, and increased public scrutiny; there is a growing trend for increased utilization of simulation to augment training of surgical residents. Cardiac surgery is a technically demanding specialty where precise placement of sutures is essential for success. Due to restrictions in duty hours, decreased operative time, and increased public scrutiny; there is a growing trend for increased utilization of simulation to augment training of surgical residents. MethodsA novel suture simulation device was designed and distributed to 8 cardiac surgery residents. The simulator was a 3D printed hemisphere inside a box; mimicking a heart in the chest. The hemisphere had 12 regions which contained polymer inserts for suturing. A website was developed with a unique login for each resident. The website would randomly select a series of specific suture throws at specific regions to create surgical tasks. Each resident received a simulator for 30 days. The frequency of participation was voluntary at the preference of the resident. The time to complete each task was recorded using the website. All residents were filmed completing a task on the first and last day of the 30 day trial. At the conclusion, each resident’s opinion on the usefulness of the simulator was assessed through a survey. A novel suture simulation device was designed and distributed to 8 cardiac surgery residents. The simulator was a 3D printed hemisphere inside a box; mimicking a heart in the chest. The hemisphere had 12 regions which contained polymer inserts for suturing. A website was developed with a unique login for each resident. The website would randomly select a series of specific suture throws at specific regions to create surgical tasks. Each resident received a simulator for 30 days. The frequency of participation was voluntary at the preference of the resident. The time to complete each task was recorded using the website. All residents were filmed completing a task on the first and last day of the 30 day trial. At the conclusion, each resident’s opinion on the usefulness of the simulator was assessed through a survey. ResultsUse of the simulator ranged from 2 to 26 tasks; with a median of 7.5 tasks. The time required to complete a task was significantly shorter after the 30 day period with a mean of 312 and 202 seconds for the initial and final tasks, respectively (p = 0.005). Increased use of the simulator was associated with a decreased time required to complete a task (p < 0.001). More experienced residents performed tasks significantly faster than junior residents with a mean of 169 and 252 seconds for the senior and junior residents, respectively (p < 0.001). All the residents stated the simulator was beneficial, would recommend it for other residents, and felt the skills learned would translate to the operating room. Use of the simulator ranged from 2 to 26 tasks; with a median of 7.5 tasks. The time required to complete a task was significantly shorter after the 30 day period with a mean of 312 and 202 seconds for the initial and final tasks, respectively (p = 0.005). Increased use of the simulator was associated with a decreased time required to complete a task (p < 0.001). More experienced residents performed tasks significantly faster than junior residents with a mean of 169 and 252 seconds for the senior and junior residents, respectively (p < 0.001). All the residents stated the simulator was beneficial, would recommend it for other residents, and felt the skills learned would translate to the operating room. ConclusionA low fidelity simulator was created to help cardiac surgery residents practice suturing skills. The time required to perform specific tasks improved through use of the simulator. Residents who used the simulator more frequently showed a greater improvement in measured times. Although the voluntary use was relatively low, the residents believed it was helpful in improving their technical skills and would translate to improved skill in the operating room. The use of this simulator may be a helpful adjunct in the training of surgical residents. A low fidelity simulator was created to help cardiac surgery residents practice suturing skills. The time required to perform specific tasks improved through use of the simulator. Residents who used the simulator more frequently showed a greater improvement in measured times. Although the voluntary use was relatively low, the residents believed it was helpful in improving their technical skills and would translate to improved skill in the operating room. The use of this simulator may be a helpful adjunct in the training of surgical residents.