Robotic-assisted coronary artery bypass surgery: an 18-year single-centre experience.

BACKGROUND: Minimally invasive robot-assisted direct coronary artery bypass (RADCAB) has emerged as a feasible minimally invasive surgical technique for revascularization that might offer several potential advantages over conventional approaches. We present our 18-year experience in RADCAB. METHODS: Between February 1998 and February 2016, 605 patients underwent RADCAB. Patients underwent post-procedural selective graft patency assessment using cardiac catheterization. RESULTS: The mortality rate was 0.3%. The rate of conversion to sternotomy for any cause was reduced from 16.0% of the first 200 cases to 6.9% of the last 405 patients. The patency rate of the LITA-to-LAD anastomosis was 97.4%. Surgical re-exploration for bleeding occurred in 1.8% of patients, and the transfusion rate was 9.2%. Average ICU stay was 1.2 ± 1.4 days, and average hospital stay was 4.8 ± 2.9 days. CONCLUSIONS: Robot-assisted coronary artery bypass grafting is safe, feasible and it seems to represent an effective alternative to traditional coronary artery bypass grafting in selected patients.

Survival and Long-Term Outcomes of Aortic Valve Replacement in Patients Aged 55 to 65 Years.

BACKGROUND: This study aims to compare the outcomes after aortic valve replacement (AVR) with mechanical and biological valves in middle-aged patients (55-65 years) to determine the impact on long-term mortality and morbidity. METHODS: A retrospective analysis of 373 patients between 55 and 65 years of age who received a primary AVR with or without concomitant coronary artery bypass graft between April 1995 and March 2014. Propensity matching yielded 118 patient pairs in the mechanical and biological valve cohorts. RESULTS: Median follow-up time was 6.9 years. No differences in long-term survival or a composite outcome of stroke, bleeding, and endocarditis (major adverse prosthesis-related event; MAPE) were observed in patients receiving biological versus mechanical valves. Actuarial 15-year survival was 46.4% (95% confidence interval [CI], 28.8-62.3%) in the biological valve group versus 60.6% (95% CI, 47.5-71.4%) in the mechanical valve group (hazard ratio, 1.16 [95%CI, 0.69-1.94], p = 0.58). The 15-year cumulative incidence of MAPE was 53.3% (95% CI, 33.7-69.4%) for biological valves versus 24.5% (95% CI, 16.2-33.8%) for mechanical valves (hazard ratio, 0.65 [95% CI, 0.37-1.14], p = 0.12). The 15-year cumulative incidence of reoperation was higher in the bioprosthetic group (26.0% [95% CI, 14.0-39.8%] vs. 5.4% [95% CI, 2.0-11.4%]; hazard ratio 0.24 [95% CI, 0.09-0.68] p < 0.01). CONCLUSION: There is no difference in survival and MAPE at 15 years between biological and mechanical valves. The risk of reoperation was significantly higher in the biological valve group and may affect valve choice in middle-aged patients.

Analysis of Short- and Long-term Outcomes of Patients With Surgically Treated Left-sided Infective Endocarditis: A 5-Year Longitudinal Follow-up Study.

This study aims to analyze survival, repeat hospitalization, and risk factors for surgically treated left-sided endocarditis. Retrospective review of all 166 (114 native and 52 prosthetic) patients operated between January 2004 and March 2015 was performed. Long-term survival and repeat hospitalization data for 134 of 166 patients were obtained via linked clinical databases with the Manitoba Centre for Health Policy. Kaplan-Meier estimates of survival and hospital readmission and Cox multivariable regression analysis of factors influencing outcomes were performed. Survival at 1 and 5 years was 91% and 80%, respectively, and major adverse prosthesis-related event repeat hospitalization rates were 12% and 21%, respectively. Repeat hospitalization because of endocarditis was 7% and 11% at 1 and 5 years, respectively. Survival and repeat hospitalization were similar for aortic and mitral valves. Survival after surgically treated endocarditis was similar to survival for age-, sex-, and valve-matched surgical valve replacements for noninfectious indications (P = 0.53). Viridans Streptococci was the most common organism in native valve endocarditis, and culture negative endocarditis was most common in prosthetic valves. Prosthetic valve endocarditis (P < 0.01) and preoperative renal dysfunction (P < 0.01) were risk factors for in-hospital mortality and major postoperative adverse events. Diabetes and renal dysfunction were associated with poor long-term survival, functional survival, and repeat hospitalization. This analysis suggests that surgery remains a very effective tool in management of these complex patients in terms of survival and major adverse prosthesis-related event repeat hospitalization.

Outcomes of octogenarians discharged from the hospital after prolonged intensive care unit length of stay after cardiac surgery.

OBJECTIVE: Octogenarians offered complex cardiac surgery frequently experience a prolonged intensive care unit length of stay; however, minimal data exist on the outcomes of these patients. We sought to determine the rates and predictors of 1-year noninstitutionalized survival ("functional survival") and rehospitalization for octogenarian patients with prolonged intensive care unit length of stay after cardiac surgery and who were discharged from hospital. METHODS: The outcomes of discharged patients aged 80 years or more who underwent cardiac surgery with prolonged intensive care unit length of stay (≥5 consecutive days) from January 1, 2000, to December 31, 2011, were examined retrospectively from linked clinical and administrative provincial databases. Regression analysis was used to determine predictors of 1-year functional survival and rehospitalization after discharge from the hospital. RESULTS: A total of 80 of 683 (11.7%) discharged octogenarian patients had prolonged intensive care unit length of stay. Functional survival at 1 year was 92% and 81% for those with nonprolonged and prolonged intensive care unit lengths of stay, respectively (P < .01). Lack of outpatient physician visits within 30 days of discharge (hazard ratio, 5.18; P < .01) was a significant predictor of poor 1-year functional survival. The 1-year rehospitalization rates were 38% and 48% for those with nonprolonged and prolonged intensive care unit lengths of stay, respectively, with 41% of all rehospitalizations occurring within 30 days of initial discharge. A rural residence (hazard ratio, 1.82; P < .01) and nosocomial pneumonia during patients' operative admissions (hazard ratio, 2.74; P < .01) were associated with rehospitalization within 30 days of discharge. CONCLUSIONS: Octogenarians with prolonged intensive care unit length of stay have acceptable functional survival at 1 year but have high rates of early rehospitalization. Access to health services may influence functional survival and early rehospitalizations. These data suggest that close follow-up of these vulnerable patients after hospital discharge is warranted.

Predictors of survival, functional survival, and hospital readmission in octogenarians after surgical aortic valve replacement.

OBJECTIVE: To analyze outcomes and predictors of functional survival (personal care home admission and mortality) and hospital readmission in patients aged ≥80 years who underwent surgical aortic valve replacement (SAVR) in a Manitoba hospital. METHODS: This was a retrospective cohort study of patients aged ≥80 years who underwent SAVR with or without coronary artery bypass grafting in Manitoba between 1995 and 2014. Data from the Manitoba Adult Cardiac Surgery database and the Manitoba Centre for Health Policy were used. Kaplan-Meier estimates of outcomes and Cox multivariate regression analysis of risk factors were performed. Survival was compared with that of age- and sex-matched life expectancy. RESULTS: A total of 1872 patients were aged ≥50 years and 378 were aged ≥80 years, 55% of whom (n = 208) underwent concurrent coronary artery bypass grafting. Compared with younger patients, octogenarians had higher in-hospital mortality (8.5%; P <.001), longer median intensive care unit stay (47.2 hours; P <.001), and longer median in-hospital stay (13 days; P <.001). The median follow-up was 5.2 years. Functional survival was 82.4% at 1 year and 56.5% at 5 years, and freedom from hospital readmission was 61.5% at 1 year and 28.4% at 5 years. Survival approximated the age- and sex-matched life expectancy at 1 year (83.8%) and 5 years (60.8%). Preoperative atrial fibrillation, peripheral vascular disease, female sex, postoperative acute kidney injury, and blood transfusion were associated with adverse outcomes. CONCLUSIONS: In eligible octogenarians, SAVR has acceptable 1- and 5-year functional survival and hospital readmission rates, but significant perioperative mortality and morbidity.

A novel system for the treatment of aortic annular dilation: an ex vivo investigation.

OBJECTIVES: The main reason for aortic repair failures is recurrent annular dilatation. The fibrous portion of left ventricular outflow tract dilates. A novel device was designed to tackle this problem. METHODS: The device consists of an internal ring applied at the aortic annulus plus an external flexible band at the level of the aortic root. The internal ring has a semi-rigid portion (40%, placed at ventriculo-arterial junction) and a flexible portion to allow it to conform along the curves of the non-coronary/right coronary leaflet and right coronary/left coronary leaflet commissures. The external band acts as a reinforcement to the internal ring. A pulsatile mock loop capable of housing porcine aortic valve was used. Working conditions were 60 bpm of heart rate, 75 of stroke volumes and 120-80 mmHg of simulated pressure. Mean gradient, effective orifice area, annular diameter, coaptation height and length were recorded on 11 aortic root units (ARUs). High-speed video and standard echocardiographic images were also recorded. All data were acquired in the following conditions: (i) basal (untreated ARU); (ii) pathological condition (left coronary/non-coronary triangle was dilated by suturing an aortic patch); and (iii) ARU treated with the device. RESULTS: Gradients and effective orifice area were respectively 0.9 ± 0.64 mmHg and 3.1 ± 0.7cm2 (pathological) and 3.7 ± 1.1 mmHg and 1.5 ± 0.2cm2 (treated, P < 0.05). Left coronary/non-coronary diameter decreased from 2.4 ± 0.2 cm (pathological) to 2.0 ± 0.2 (treated, P < 0.05). Coaptation length and height were fully restored to basal values following treatment. Visual inspection showed proper dynamics of the leaflet, confirmed by high-speed video and echocardiography. CONCLUSIONS: The device allowed for restoring physiologic-like coaptation in the experimental model, without inducing clinically relevant worsening of the haemodynamics of the treated ARU.

Transcatheter Aortic Valve Implantation in an Extremely Tortuous S-Shaped Aorta.

Transcatheter aortic valve implantation (TAVI) has emerged as an alternative technique to treating aortic stenosis in patients with high surgical risk. We present a case of a successful transfemoral TAVI in a high-risk patient with an extremely tortuous iliofemoral system and a significant S-type bend in the descending aorta. With careful preprocedure planning and using all the techniques available, TAVI can be performed in the most challenging patients.

Early Rehospitalization After Prolonged Intensive Care Unit Stay Post Cardiac Surgery: Outcomes and Modifiable Risk Factors.

BACKGROUND: Prolonged intensive care unit length of stay (prICULOS) following cardiac surgery (CS) in older adults is increasingly common but rehospitalization characteristics and outcomes are understudied. We sought to describe the rehospitalization characteristics and subsequent non-institutionalized survival of prICULOS (ICULOS ≥5 days) patients and identify modifiable risk factors to decrease 30-day rehospitalization. METHODS AND RESULTS: Consecutive patients from January 1, 2000 to December 31, 2011 were analyzed utilizing linked clinical and administrative databases. Logistic regression was used to identify risk factors associated with 30-day rehospitalization. Out of 9210 consecutive patients discharged from the hospital alive, 596 (6.5%) experienced prICULOS. Cumulative incidence of rehospitalization for the prICULOS cohort at 30 and 365 days was 17.5% and 45.6% versus 11.4% and 28.1% for non-prICULOS (P<0.01). Over 40% of rehospitalizations for the entire cohort occurred within 30 days of discharge costing over $12 million. The most common reasons for rehospitalization were heart failure (in prICULOS) and infection (in non-prICULOS). Rehospitalization within 30 days was associated with a 2.29-fold risk of poor 1-year noninstitutionalized survival for the entire cohort. Potentially modifiable factors affecting 30-day rehospitalization included lack of physician visits within 30 days of discharge (odds ratio 2.11; P=0.01), and preoperative anxiety diagnosis (odds ratio 2.20; P=0.01). CONCLUSIONS: PrICULOS patients have high rates of rehospitalization that is associated with an increased rate of poor noninstitutionalized survival. Addressing modifiable risk factors including early postdischarge access to physician services, as well as access to mental health services may improve patient outcomes.

Association of Pre-hospital ECG Administration With Clinical Outcomes in ST-Segment Myocardial Infarction: A Systematic Review and Meta-analysis.

BACKGROUND: Delays in reperfusion for patients with myocardial ischemia leads to increased morbidity and mortality. The objective of this review was to identify, evaluate, and critically appraise the evidence on whether pre-hospital electrocardiography (ECG) reduces patient mortality and improves post-ST-segment myocardial infarction patient-oriented outcomes. METHODS: We searched PubMed/MEDLINE, EMBASE, and Cochrane Library (1990-2015) for controlled clinical studies. We also searched conference proceedings, trial registries, and reference lists of narrative and systematic reviews. Two reviewers independently identified and extracted data from studies that compared pre-hospital ECG with standard of care in patients with suspected myocardial infarction who underwent primary percutaneous coronary intervention. Internal validity was assessed using the Newcastle-Ottawa scale. RESULTS: We screened 21,197 citations and included 63 unique studies (plus 22 companion publications). Most studies were of moderate quality. Pre-hospital ECG was associated with significantly fewer deaths (relative risk, 0.68; 95% confidence interval [CI], 0.63-0.74; 45 studies; 71,315 patients; I2, 0%), reduced time to reperfusion (mean difference, -35.32 minutes; 95% CI, -44.02 to -26.61; 26 studies; 27,524 patients; I2, 97%), shorter hospital stays (mean difference, -0.63 days; 95% CI, -1.05 to -0.20; 10 studies; 39,275 patients; I2, 39%), and more patients had first medical contact to device time < 90 minutes than standard of care (relative risk, 1.77; 95% CI, 1.52-2.07; 11 studies; 20,991patients; I2, 93%). CONCLUSIONS: Use of pre-hospital ECG is associated with decreased mortality and overall better patient outcomes.

Long-Term Outcome and Predictors of Noninstitutionalized Survival Subsequent to Prolonged Intensive Care Unit Stay After Cardiac Surgical Procedures.

BACKGROUND: There are minimal data on long-term functional survival (alive and not institutionalized) in patients undergoing cardiac operations who require a prolonged intensive care unit length of stay (prICULOS). We sought to describe 1- and 5-year functional survival in patients who had a prICULOS (ICULOS ≥ 5 days) and determine predictors of functional survival at 1 year. METHODS: Data were obtained from linked clinical and administrative databases from January 1, 2000 to December 31, 2011 to conduct this retrospective single-region analysis. Logistic regression was used to develop a model predicting functional survival at 1 year for patients who had a prICULOS after cardiac operations. RESULTS: There were 9,545 admissions to the ICU after cardiac operations; of these patients, 728 (7.6%) experienced a prICULOS. There was an increasing trend in patients who had a prICULOS over this study period. The functional survival at 1 and 5 years from the surgical procedure for the non-prICULOS versus the prICULOS cohort was 1 year (94.9% versus 73.9%) and 5 years (84.9% versus 53.8%) (p < 0.001). Factors associated with lower rates of functional survival at 1 year were age 80 years or older, female sex, peripheral vascular disease, preoperative renal dysfunction, cerebrovascular disease, preoperative infection, need for extracorporeal membrane oxygenation/ventricular assist device (ECMO/VAD) after cardiotomy, number of days on mechanical ventilation, and number of days in the ICU beyond 5 days (area under the receiver operating characteristic [ROC] curve = 0.766). CONCLUSIONS: The majority of patients who had a prICULOS experienced successful functional survival up to 5 years after cardiac operations. Identification of risk factors for poor functional survival may be of assistance to clinicians, patients, and families for prognostication and decision making.

Recurrent Seizures Following Cardiac Surgery: Risk Factors and Outcomes in a Historical Cohort Study.

OBJECTIVES: To determine the risk factors for and outcomes after recurrent seizures (RS) in patients following cardiac surgery. DESIGN: A historical cohort study. SETTING: A single-center university teaching hospital. PARTICIPANTS: Cardiac surgery patients from April 2003 to September 2010 experiencing postoperative seizures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were divided into an isolated seizure group and an RS group. Risk factors for RS were determined using logistic regression. Intermediate-term follow-up was conducted by phone. Of 7,280 consecutive patients undergoing cardiac surgery, 61 (0.8%) experienced postoperative seizure and 36 (59%) of those experienced at least 1 recurrence. Of these, 32 (89%) experienced RS within 24 hours of the first seizure, and 29 (81%) had grand mal seizures. Preoperative creatinine ≥120 µmol/L (p = 0.02), time until first seizure occurred (≤4 hours; p = 0.01), and procedures involving the thoracic aorta were associated with RS (R(2) = 0.53, p<0.05). Patients with RS had longer intensive care unit stays (5.3 v 2.9 days, p = 0.03) and longer mechanical ventilation duration (53.3 v 15.0 hours, p = 0.01). At a median follow-up of 21 months for the RS group and 16 months for the isolated seizure group, restrictions, anticonvulsant use, morbidity, and mortality were similar between patients with isolated versus recurrent seizures. CONCLUSIONS: Higher preoperative creatinine, thoracic aortic surgery, and early seizure onset were associated with RS after cardiac surgery. When compared to isolated seizures, recurrence per se was not associated with significantly increased long-term morbidity or mortality.

Clinical outcomes of minimally invasive endoscopic and conventional sternotomy approaches for atrial septal defect repair.

BACKGROUND: Concerns remain that minimally invasive atrial septal defect (ASD) repair may compromise patient outcomes. We compared clinical outcomes of adult patients undergoing ASD repair via a minimally invasive endoscopic approach versus a "gold standard" sternotomy. METHODS: We retrospectively reviewed the clinical outcomes of consecutive patients who underwent ASD patch repair at our institution between 2002 and 2012. We compared in-hospital/30-day mortality, postoperative complications, length of stay in hospital and in the intensive care unit and blood product requirements between patients who underwent right mini-thoracotomy (MT) and those who underwent conventional sternotomy. RESULTS: During the study period, 73 consecutive patients underwent ASD patch repair at our institution: 51 (age 47 ± 16 yr, 66.7% women) in the MT group and 22 (age 46 ± 21 yr, 59.1% women) in the sternotomy group. In-hospital mortality was similar between the 2 groups (MT 0% v. sternotomy 4.5%, p = 0.30). There were no significant differences in any postoperative complications or blood product requirements. No patients in the MT group suffered stroke, retrograde aortic dissection or leg ischemia. Mean intensive care unit (MT 1.2 ± 1.2 d v. sternotomy 1.7 ± 2.2 d, p = 0.26) and hospital length of stays (MT 5.1 ± 2.2 d v. sternotomy 6.3 ± 3.6 d, p = 0.17) were similar between the groups; however, there was a trend toward fewer patients requiring prolonged hospital stays (> 10 d) in the MT group (3.9% v. 18.2%, p = 0.06). CONCLUSION: Repair of ostium secundum and sinus venosus ASD can be performed safely via MT endoscopic approach with similar outcomes as sternotomy. Patient preference for a more cosmetically appealing incision may be considered without concern of compromised outcomes.

CONTEXTE: Des inquiétudes persistent au sujet des résultats potentiellement négatifs chez les patients soumis à une intervention de réparation de communication interauriculaire (CIA) minimalement effractive. Nous avons comparé les résultats cliniques chez des patients adultes soumis à une réparation de CIA par approche endoscopique minimalement effractive ou par sternotomie classique ­ « l'étalon-or ¼. MÉTHODES: Nous avons passé en revue de manière rétrospective les résultats cliniques chez des patients consécutifs qui ont subi un traitement d'occlusion de leur CIA dans notre établissement, entre 2002 et 2012. Nous avons comparé la mortalité en cours d'hospitalisation et à 30 jours, les complications postopératoires, la durée des séjours à l'hôpital et aux soins intensifs et le recours aux produits sanguins chez les patients selon qu'ils avaient subi une mini-thoracotomie (MT) ou une sternotomie classique. RÉSULTATS: Durant la période de l'étude, 73 patients consécutifs ont subi un traitement d'occlusion de leur CIA dans notre établissement : 51 (âge 47 ± 16 ans, 66,7 % femmes) dans le groupe MT et 22 (âge 46 ± 21 ans, 59,1 % femmes) dans le groupe sternotomie. La mortalité perhospitalière a été similaire entre les 2 groupes (MT 0 % c. sternotomie 4,5 %, p = 0,30). On n'a noté aucune différence significative quant aux complications postopératoires et aux besoins en produits sanguins. Aucun patient du groupe MT n'a subi d'AVC, de dissection aortique rétrograde ou d'ischémie à la jambe. La durée moyenne des séjours aux soins intensifs (MT 1,2 ± 1,2 j c. sternotomie 1,7 ± 2,2 j, p = 0,26) et à l'hôpital (MT 5,1 ± 2.2 j c. sternotomie 6,3 ± 3,6 j, p = 0,17) a été similaire entre les groupes; toutefois, on a noté une tendance à un nombre moindre de patients nécessitant une hospitalisation prolongée (> 10 j) dans le groupe MT (3,9 % c. 18,2 %, p = 0,06). CONCLUSION: La réparation de la CIA au niveau de l'ostium secundum et du sinus veineux peut se faire de manière sécuritaire par approche endoscopique MT, avec des résultats similaires à ceux de la sternotomie. On peut tenir compte de la préférence des patients pour une incision plus acceptable au plan esthétique sans crainte de compromettre les résultats.

Bioprosthetic heart valves of the future.

Glutaraldehyde-fixed bioprosthetic heart valves (GBHVs), derived from pigs or cows, undergo structural valve deterioration (SVD) over time, with calcification and eventual failure. It is generally accepted that SVD is due to chemical processes between glutaraldehyde and free calcium ions in the blood. Valve companies have made significant progress in decreasing SVD from calcification through various valve chemical treatments. However, there are still groups of patients (e.g., children and young adults) that have accelerated SVD of GBHV. Unfortunately, these patients are not ideal patients for valve replacement with mechanical heart valve prostheses as they are at high long-term risk from complications of the mandatory anticoagulation that is required. Thus, there is no "ideal" heart valve replacement for children and young adults. GBHVs represent a form of xenotransplantation, and there is increasing evidence that SVD seen in these valves is at least in part associated with xenograft rejection. We review the evidence that suggests that xenograft rejection of GBHVs is occurring, and that calcification of the valve may be related to this rejection. Furthermore, we review recent research into the transplantation of live porcine organs in non-human primates that may be applicable to GBHVs and consider the potential use of genetically modified pigs as sources of bioprosthetic heart valves.

Cost-effectiveness analysis of rheumatic heart disease prevention strategies.

Rheumatic heart disease (RHD), secondary to group A streptococcal infection is endemic in the developing as well as parts of the developed world with significant costs to the patient, and to the healthcare system. We briefly review the prevalence and cost of RHD in developed and developing nations. We subsequently develop a Markov model to evaluate the cost-effectiveness of three strategies (vs standard no prevention) for preventing RHD in a developing world country: primary prophylaxis (throat swab to detect and subsequently treat group A streptococci as needed); primary prophylaxis (antibiotic prophylaxis for all) with benzathine penicillin G once monthly to all patients (ages 5-21 years) regardless of evidence of infection; and secondary prophylaxis with monthly only to those with echocardiographic evidence of early RHD. Our model suggests that echocardiographic screening and secondary prophylaxis is the best strategy although the strategies change depending on parameters used.

Incidence, secular trends, and outcomes of cardiac surgery in Aboriginal peoples.

BACKGROUND: Canada's Aboriginal people experience a disproportionate burden of comorbid illnesses predisposing them to higher rates of atherosclerotic disease. We set out to investigate secular rates of cardiovascular surgery (CVSx) and postsurgical outcomes in Aboriginals compared with non-Aboriginals. METHODS: All patients undergoing CVSx in Manitoba, Canada from 1995-2007 (N =12,170 [Aboriginal, 574, 4.7%; non-Aboriginal, 11,596, 95.3%]) were included in our study cohort. Race was self-identified. Age- and sex-adjusted incidence were determined using 2001 and 2006 census data. Multivariable logistic regression models were constructed to determine the association between race and the outcomes of death, infections, and a composite of adverse events. RESULTS: CVSx rates were significantly lower in Aboriginals compared with non-Aboriginals (all CVSx, 63.6 vs 97.7 per 10,000 population; coronary artery bypass grafting only, 46.2 vs 71.9 per 10,000 population, respectively). The lower CVSx rates were most pronounced among Aboriginals residing in urban areas (21.0 vs 78.0 per 10,000). Postoperatively, Aboriginals experienced significantly higher odds of infections (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.13-2.34; P = 0.008), in particular pneumonia (OR, 2.24; 95% CI, 1.58-3.19; P < 0.0001). There was no increase in risk of death after surgery (OR, 1.15; 95% CI, 0.63-2.08; P = 0.6) or the composite outcome (OR, 1.0; 95% CI, 0.66-1.52; P = 1.0) compared with non-Aboriginals. CONCLUSIONS: Aboriginal peoples, particularly in the urban setting, are considerably less likely to undergo CVSx. When they do, they have postoperative mortality similar to that of non-Aboriginals. Our findings suggest an urban racial disparity in access to CVSx.

Longer in-hospital wait times do not result in worse outcomes for patients requiring urgent coronary artery bypass graft surgery.

BACKGROUND: In certain health care systems, patients wait for non-emergency services. Although waiting may not be considered acceptable, the delay may allow for patient optimization, such as giving time for "toxic" agents to be cleared, that could improve outcomes. We sought to determine the relationship between wait times and outcomes in in-hospital patients undergoing urgent coronary artery bypass graft (CABG) surgery. METHODS AND RESULTS: A prospectively collected database of consecutive, medically urgent, but clinically stable patients undergoing CABG surgery from 1995 to 2007, was analyzed. A total of 3067 patients with need for urgent CABG surgery with various in-hospital wait times (n = 440, 0-2 days; n = 799, 3-5 days; n = 1317, 6-10 days; n = 511, 11-15 days) were included. There were no differences in mortality, intensive care unit (ICU) or post-surgery hospital length of stay (LOS) among the patient groups. Multivariate logistic regression analysis revealed that wait time was not associated with mortality (P = 0.625). Due to changes in the nonsurgical management of coronary artery disease, a separate analysis of patients, from 2002 to 2007, was also performed to explore contemporary results. In the latter subset, 1495 patients (n = 175, 341, 720, 259, in the same 4 respective wait-time groups) were included; the 0-2 days patient group underwent more blood transfusions (50% vs 38%; P = 0.01), prolonged ventilation (6% vs 2%; P = 0.05), post-operative dialysis (2% vs 0%; P = 0.08), and longer ICU LOS (26 vs 23 hours; P = 0.02) compared with the 3-5 days patient group. The Society of Thoracic Surgeons mortality risk scores of the 0-2 days and 3-5 days groups were the same (1.5%). Multivariate regression analysis revealed that increased wait time was associated with fewer patients requiring blood transfusion (P < 0.05) for CABG surgery. CONCLUSION: Waiting for in-hospital urgent CABG surgery does not lead to worse patient outcomes and may, in fact, reduce the procedural and medical risks of postoperative blood transfusions, prolonged ventilation, dialysis, and shorten ICU LOS.

Can long-term ventricular assist devices be safely implanted in low-volume, non-heart transplant centres?

BACKGROUND: Mechanical circulatory support (MCS) using long-term ventricular assist devices (VADs) is an established therapy in select patients with advanced heart failure. Studies have suggested that outcomes after VAD implantation may be dependent on institutional procedural volume, and outcome data from non-transplant centres are lacking. This study reviews the outcomes of patients who received a long-term VAD at our centre to determine if these devices can be safely implanted at tertiary care, low-volume, non-transplant centres. METHODS: We conducted a single-centre retrospective cohort study, examining the clinical outcomes of consecutive patients who received a long-term VAD over a 42-month period. RESULTS: During the study period 73 patients required MCS, of whom 16 received a long-term VAD. This select group had a mean Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile of 1.6 (0.9) and before implantation 94% required at least 1 inotropic medication, 69% had suffered a cardiac arrest, 63% required an intra-aortic balloon pump, 69% required mechanical ventilation, and 44% required short-term MCS. The primary outcome of survival to transplant or ongoing MCS at 1 year was achieved in 75% of patients. Operating room, intensive care unit, and hospital survival were 100%, 88%, and 81%, respectively. CONCLUSIONS: Long-term VADs can be implanted at low-volume, nontransplant centres with survival rates comparable with contemporary clinical trials. Availability of a specialty trained multidisciplinary team with expertise in short-term and long-term MCS options facilitates appropriate patient selection and might be more important than institutional volume in determining outcomes after implantation.