Peer review and quality assurance in cardiac surgery in Australia.

There is increasing community and government interest in determining the quality of medical performance in Australia. This means that any lead taken by the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) in defining and adopting performance indicators for the profession is appropriate and timely. The ASCTS Peer Review Committee has examined the issue of quality management, and presents here several key indicators and a draft program of remediation which, if adopted, will facilitate the achievement of the highest and most uniform surgical standards for Australia. The Committee recommends the monitoring of just one procedure initially: coronary artery surgery. The Committee sees the quality management program as involving both surgeons and hospital-based quality assurance teams. Ultimately, the profession will gain from performance measurement by being able to minimise inappropriate variations in practice. The community will benefit by having national and international best practice in cardiothoracic surgery, with surgeons being able to identify more easily those procedural changes that result in superior as well as inferior outcomes.

Fontan procedure for tricuspid atresia.

A Fontan procedure has been performed on 29 patients for tricuspid valvular atresia. The age range was 8 months to 33 years (median 10 years), the pulmonary vascular resistance ranged from 1.8-6.1 units . m2 (mean 3.3 units . m2), and the mean pulmonary arterial pressure ranged from 13-45 mm Hg (mean 21 mm Hg). Twenty-nine previous operations had been performed in 23 patients. Fourteen other associated cardiopulmonary anomalies were present in 12 patients. There were four hospital deaths (13.8%), all in patients with complicating features. Among the last 22 consecutive patients who have undergone operation, one died (4.5%). Complete atrioventricular block necessitated pacemaker implantation in one patient. No late deaths occurred. Of the 19 patients followed 3 months or more from the time of operation, eight have no restriction of exercise capacity, nine have only mild restriction, and two have a poor result. The Fontan approach to tricuspid atresia has several theoretical advantages over previously used shunts or pulmonary artery banding, the operative mortality in patients who have suitable anatomy and hemodynamics is low, and the results have been good.

Right coronary endarterectomy: a procedure with increased risk of perioperative infarction.

Although right coronary endarterectomy extends operability on this vessel, the procedure is associated with increased risk of perioperative infarction. Forty-nine patients at St Vincent's Hospital underwent endarterectomy and saphenous vein grafting to the distal right coronary artery, with a hospital mortality of 6.1% and a perioperative infarction rate of 20.4%, compared with rates of 4.2% and 10.9% respectively in a group of patients who did not require endarterectomy. These figures show a trend toward statistical significance which suggests that careful patient selection for endarterectomy is required to obviate an increased risk of complications with this procedure.

Left main coronary artery obstruction: early surgical experience with forty-two patients.

Direct coronary artery surgery was performed on 42 patients with high grade obstruction of the left main coronary artery (LMCA), with a perioperative infarction rate of 7% and a hospital mortality of 9-6%. There was no significant difference in presentation of patients with LMCA lesions and no prediction of this lesion could be made by preangiographic assessment. Significant obstructive lesions in other coronary vessels were noted in most patients, triple vessel disease occurring in 27 patients (64-3%), double vessel in 14 patients (33-3%) and the LMCA lesion was an isolated lesion in only one patient (2-4%). Right coronary lesions occurred in 35 patients (83%), left anterior descending artery artery lesions in 38 patients (90%) and left circumflex system lesions in 34 patients (81%). The surgical procedures are discussed.

Coronary artery surgery.

This paper assesses the results in 543 patients undergoing coronary artery surgery between 1969 and March, 1976. Indications included angina, acute infarction and ventricular arrhythmia, and there were some angina-free patients. Surgical techniques were constantly reviewed and frequently changed. The mortality in all groups was 4.2%. The mortality in chronic stable angina (424 cases) was 3%, but as from January, 1975, it has been 2%. The perioperative infarction rate in all groups was 10.7%, and this condition was the most significant cause of perioperative mortality. Modern principles of myocardial protection during surgery have helped to lower mortality and morbidity rates.

Perioperative myocardial infarction with aortocoronary bypass graft surgery.

In 1975, 160 patients underwent aortocoronary bypass graft surgery at St. Vincent's Hospital, Sydney. The incidence of perioperative myocardial infarction varied between 2-5% and 5-6% depending on the criteria used to diagnose pathological Q waves, and thus compared favourably with other reported series. The low incidence suggested that perioperative infarction should be considered as neither a deterrent to coronary bypass surgery nor a significant cause of postoperative relief of angina.