Abstract 260: Restructuring a Failed Cardiac Surgery Program in an Under Served Minority Population County

Objectives: Fifty years ago, Donabedian described the conceptual framework for quality in healthcare as the triad of process, structure and outcome. These principals were applied to a failed urban cardiac surgery program (volume, efficiency, and quality) in an underserved county of 900,000 people in which cardiovascular death rates are up to double the neighboring county and public health studies demonstrate high rates of cardio metabolic syndrome as well as poor access to health care. Using Cardiac Surgery as a highly measured clinical service model our hypothesis was that strict attention to all details related to Donabedian’s triad would achieve acceptable quality of care in Cardiac Surgery. Methods: The 205 patients undergoing coronary artery bypass (CAB) formed the study group. We performed a preliminary 6 month planning process evaluating and improving equipment, human resources, facilities, and patient care protocols. Emphasis was placed staff education. This process was facilitated and modeled through training and oversight by a medical school/academic health center. All structure and processes and of care including preoperative, intraoperative, and postoperative protocols were recreated and rehearsed prior to program re-start. Data for all cardiac operations were recorded using the Society of Thoracic Surgeons National database (STS). Results: 205 coronary consecutive artery bypasses (CAB) were performed. Medical comorbid conditions were higher than the STS national mean. However, the risk adjusted outcome data for the first 205 CAB population yielded a mortality of 0.5% (expected 2.5%; O/E= 0.20) as well as a complication rate (Table 1) lower than expected. The first STS rating was 3-star for CAB, 2017 (top 10% of >1000 cardiac programs, p<0.05) indicating strict adherence to a quality-first standard of care. Conclusions: Strict attention to the process and structure fundamentals and details of Cardiac Surgical care in an underserved at risk population can result in acceptable outcomes and quality measures at low program volume.

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Inferior outcomes following cardiac surgery in patients with a functioning renal allograft

Interactive Cardiovascular and Thoracic Surgery ◽

10.1093/icvts/ivaa245 ◽

2020 ◽

Author(s):

Ibrahim T Fazmin ◽

Muhammad U Rafiq ◽

Samer Nashef ◽

Jason M Ali

Keyword(s):

Cardiac Surgery ◽

Renal Transplantation ◽

Renal Allograft ◽

Artery Bypass ◽

Perioperative Period ◽

Outcome Data ◽

Term Survival ◽

Logistic Euroscore ◽

Prolonged Length ◽

The Mean

Abstract OBJECTIVES Renal transplantation is an effective treatment for end-stage renal failure. The aim of this study was to evaluate outcomes for these patients undergoing cardiac surgery. METHODS A retrospective analysis identified patients with a functioning renal allograft at the time of surgery. A 2:1 propensity matching was performed. Patients were matched on: age, sex, left ventricle function, body mass index, preoperative creatinine, operation priority, operation category and logistic EuroSCORE. RESULTS Thirty-eight patients undergoing surgery with a functioning renal allograft were identified. The mean age was 62.4 years and 66% were male. A total of 44.7% underwent coronary artery bypass grafting and 26.3% underwent a single valve procedure. The mean logistic EuroSCORE was 10.65. The control population of 76 patients was well matched. Patients undergoing surgery following renal transplantation had a prolonged length of intensive care unit (3.19 vs 1.02 days, P < 0.001) and hospital stay (10.3 vs 7.17 days, P = 0.05). There was a higher in-hospital mortality (15.8% vs 1.3%, P = 0.0027). Longer-term survival on Kaplan–Meier analysis was also inferior (P < 0.001). One-year survival was 78.9% vs 96.1% and 5-year survival was 63.2% vs 90.8%. A further subpopulation of 11 patients with a failed renal allograft was identified and excluded from the main analysis; we report demographic and outcome data for them. CONCLUSIONS Patients with a functioning renal allograft are at higher risk of perioperative mortality and inferior long-term survival following cardiac surgery. Patients in this population should be appropriately informed at the time of consent and should be managed cautiously in the perioperative period with the aim of reducing morbidity and mortality.

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Post cardiac surgery Mediastinitis : Risk factors and therapeutic management

European Journal of Preventive Cardiology ◽

10.1093/eurjpc/zwab061.416 ◽

2021 ◽

Vol 28 (Supplement_1) ◽

Author(s):

S Mleyhi ◽

M Messai ◽

R Miri ◽

M Ben Mrad ◽

J Ziadi ◽

...

Keyword(s):

Risk Factors ◽

Cardiac Surgery ◽

Heart Surgery ◽

Artery Bypass ◽

Clinical Signs ◽

Surgical Care ◽

Coronary Bypass ◽

Funding Sources ◽

Biological Tests ◽

Definition Of

Abstract Funding Acknowledgements Type of funding sources: None. Background : Despite the progress in therapy and patient management in cardiac surgery, postoperative mediastinitis remains serious complication. Our study aims to study the incidence of mediastinitis after cardiac surgery and to identify the risk factors. Methods We conducted a retrospective, descriptive study including patients who had undergone cardiac surgery by sternotomy during a period of 5 years ( 2015 – 2019)and who meet the definition of mediastinitis proposed by the "Centers of disease control and disease". We collected the demographic characteristics of the patients and operative operative data of the first intervention as well as those relating to mediastinitis. Results 25 patients ( 2.93%) among 1042 patients operated for cardiac surgery during the cited period presented mediastinitis. The main clinical signs were : surgical wound infection (80%), fever (40%) and sternal instability (30%). Biological tests showed : hyperleukocytosis and high C-Reactive Protein in 22.7 % and 58.1 % of cases respectively. Gram-positive cocci are largely predominant and one case of Candida mediastinitis was found. type 1 diabetes and coronary artery bypass grafting were significantly associated with the occurrence of mediastinitis with P <0.01. The mean duration of intra venous antibiotic therapy was 21 days. 92 % of patients operated on for mediastinitis are cured, 4 % had a recurrence of infection and 4 % died. CONCLUSION Mediastinitis after heart surgery is rare but serious. The main risk factors are insulin-dependent diabetes and coronary bypass surgery. The curative treatment is heavy and it is based on a rigorous and long medico-surgical care.

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A Failed Cardiac Surgery Program in an Underserved Minority Population County Reimagined: The Power of Partnership

Journal of the American Heart Association ◽

10.1161/jaha.120.018230 ◽

2020 ◽

Vol 9 (23) ◽

Cited By ~ 1

Author(s):

James M. Brown ◽

M. J. Hajjar‐Nejad ◽

Guerda Dominique ◽

Malinda Gillespie ◽

Imran Siddiqi ◽

...

Keyword(s):

Cardiac Surgery ◽

Coronary Artery ◽

Coronary Artery Bypass Grafting ◽

Coronary Artery Bypass ◽

Artery Bypass ◽

Performance Outcomes ◽

Minority Population ◽

Bypass Grafting ◽

Hospital System ◽

Artery Bypass Grafting

Background Prince George's County Maryland, historically a medically underserved region, has a population of 909 327 and a high incidence of cardiometabolic syndrome and hypertension. Application of level I evidence practices in such areas requires the availability of highly advanced cardiovascular interventions. Donabedian principles of quality of care were applied to a failing cardiac surgery program. We hypothesized that a multidisciplinary application of this model supported by partnership with a university hospital system could result in improved quality care outcomes. Methods and Results A 6‐month assessment and planning process commenced in July 2014. Preoperative, intraoperative, and postoperative protocols were developed before program restart. Staff education and training was conducted via team simulation and rehearsal sessions. A total of 425 patients underwent cardiac surgical procedures. Quality tracking of key performance measures was conducted, and 323 isolated coronary artery bypass grafting procedures were performed from July 2014 to December 2019. Key risk factors in our patient demographic were higher than the Society of Thoracic Surgeons national mean. Risk‐adjusted outcome data yielded a mortality rate of 0.3% versus 2.2% nationally. The overall major complication rate was lower than expected at 7.1% compared with 11.5% nationally. Readmission rate was less than the Society of Thoracic Surgeons mean for isolated coronary artery bypass grafting (4.0% versus 10.1%, P <0.0001). Significant differences in 6 key performance outcomes were noted, leading to a 3‐star Society of Thoracic Surgeons designation in 7 of 8 tracking periods. Conclusions Excellent outcomes in cardiac surgery are attainable following program renovation in an underserved region in the setting of low volume. The principles and processes applied have potential broad application for any quality improvement effort.

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Post cardiac surgery Mediastinitis : Risk factors and therapeutic management

European Journal of Cardiovascular Nursing ◽

10.1093/eurjcn/zvab060.048 ◽

2021 ◽

Vol 20 (Supplement_1) ◽

Author(s):

S Mleyhi ◽

R Miri ◽

M Messai ◽

H Ellouze ◽

B Tesnim ◽

...

Keyword(s):

Risk Factors ◽

Cardiac Surgery ◽

Heart Surgery ◽

Artery Bypass ◽

Clinical Signs ◽

Surgical Care ◽

Coronary Bypass ◽

Funding Sources ◽

Biological Tests ◽

Definition Of

Abstract Funding Acknowledgements Type of funding sources: None. Background : Despite the progress in therapy and patient management in cardiac surgery, postoperative mediastinitis remains an serious complication. Our study aims to study the incidence of mediastinitis after cardiac surgery and to identify the risk factors. Methods We conducted a retrospective, descriptive study including patients who had undergone cardiac surgery by sternotomy during a period of 5 years ( 2015 – 2019)and who meet the definition of mediastinitis proposed by the "Centers of disease control and disease". We collected the demographic characteristics of the patients and operative operative data of the first intervention as well as those relating to mediastinitis. Results 25 patients ( 2.93%) among 1042 patients operated for cardiac surgery during the cited period presented mediastinitis. The main clinical signs were : surgical wound infection (80%), fever (40%) and sternal instability (30%). Biological tests showed : hyperleukocytosis and high C-Reactive Protein in 22.7 % and 58.1 % of cases respectively. Gram-positive cocci are largely predominant and one case of Candida mediastinitis was found. type 1 diabetes and coronary artery bypass grafting were significantly associated with the occurrence of mediastinitis with P <0.01. The mean duration of intra venous antibiotic therapy was 21 days. 92 % of patients operated on for mediastinitis are cured, 4 % had a recurrence of infection and 4 % died. CONCLUSION Mediastinitis after heart surgery is rare but serious. The main risk factors are insulin-dependent diabetes and coronary bypass surgery. The curative treatment is heavy and it is based on a rigorous and long medico-surgical care.

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Technical factors affecting cardiac surgical mortality in Australia

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492319854888 ◽

2019 ◽

Vol 27 (6) ◽

pp. 443-451 ◽

Cited By ~ 1

Author(s):

Justin CY Chan ◽

Aashray K Gupta ◽

Wendy J Babidge ◽

Michael G Worthington ◽

Guy J Maddern

Keyword(s):

Cardiac Surgery ◽

Clinical Management ◽

Coronary Revascularization ◽

Artery Bypass ◽

Bypass Graft ◽

Surgical Care ◽

Surgical Pathology ◽

Surgical Mortality ◽

Technical Factors ◽

Management Issues

Aim Examination of potentially avoidable issues in surgical deaths can provide a basis for quality improvement. Perioperative technical factors in cardiac surgery may lead or contribute to patient mortality. Using data from a well-established and comprehensive national surgical mortality audit, we aimed to identify and describe clinical management issues leading to mortality in Australian cardiac surgical patients. Methods Retrospective analysis of a cardiac surgical dataset from the Australian and New Zealand Audit of Surgical Mortality (February 2009 to December 2015) was undertaken. Clinical management issues related to technical factors were analyzed using a thematic analysis approach. Technical clinical management issues were categorized based on the most common themes, followed by qualitative analysis of each theme. Results We identified 256 patients with least one technical management issues (total 270). Injury to structures was the most common theme ( n = 115, 44.9%), followed by unaddressed surgical pathology ( n = 39, 15.2%) and inadequate myocardial protection ( n = 34, 13.2%). More specifically, the most common structural injury involved the right ventricle, with the aorta and femoral vessels also commonly injured. The most common unaddressed surgical pathology was incomplete coronary revascularization, followed by systolic anterior motion of the mitral valve during mitral repair. Graft failure occurred during coronary artery bypass graft surgery, with a poor target vessel being a common issue. Conclusion Technical factors in cardiac surgery resulting in potentially avoidable mortality constitute an important subset of deaths. These findings can inform various stakeholders to improve the quality and safety of surgical care.

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Examination of psychological risk factors for chronic pain following cardiac surgery: protocol for a prospective observational study

BMJ Open ◽

10.1136/bmjopen-2018-022995 ◽

2019 ◽

Vol 9 (2) ◽

pp. e022995

Author(s):

Michael H McGillion ◽

Shaunattonie Henry ◽

Jason W Busse ◽

Carley Ouellette ◽

Joel Katz ◽

...

Keyword(s):

Risk Factors ◽

Cardiac Surgery ◽

Short Form ◽

Artery Bypass ◽

Outcome Data ◽

Life Years ◽

Chronic Postsurgical Pain ◽

Gender Based ◽

And Gender ◽

The Impact

IntroductionApproximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not.Methods and analysesIn this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score.Ethics and disseminationThis protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals.Trial registration numberNCT01842568.

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Pregnancy-Related Cardiovascular Complications: Case Presentation and Review of Literature

The Heart Surgery Forum ◽

10.1532/hsf.1654 ◽

2016 ◽

Vol 19 (5) ◽

pp. E248-E254 ◽

Cited By ~ 3

Author(s):

Hasan Baki Altinsoy ◽

Ozkan Alatas ◽

Salih Colak ◽

Hakan Atalay ◽

Omer Faruk Dogan

Keyword(s):

Cardiac Surgery ◽

Cesarean Section ◽

Pregnant Women ◽

Median Time ◽

Artery Bypass ◽

Prosthetic Heart Valve ◽

Cardiovascular Complications ◽

Time To Diagnosis ◽

Valve Thrombosis ◽

Placental Blood

Background: Cardiovascular complications that can cause severe catastrophic outcomes for both the mother and the fetus are rarely seen during pregnancy. Time to diagnosis is often delayed by a low degree of suspicion and atypical presentation. We report surgical strategies in three pregnant women with cardiovascular complications. Methods: A retrospective search from 2009 to 2016 identified three pregnant women who underwent urgent cardiac surgery. We used extracorporeal circulation (ECC) without cesarean section with careful follow-up of the fetuses during the perioperative and postoperative period. We used levosimendan as a potent inodilator in all patients to increase feto-placental blood flow and fetal heart rhythm.Results: Median time to diagnosis was 23.8 h (range 11.7-120 h) and median time from diagnosis to arrival in the operating theater was 9.8 h (range 7.4-19.8 h). One patient with prosthetic heart valve thrombosis underwent concomitant cesarean section prior to cardiac surgery. In a young pregnant woman who had spontaneous dissection of the left anterior descending artery, on-pump beating heart coronary artery bypass grafting was performed without cross clamping. Two and three months after surgery, cesarean sections were performed without any complication in two pregnant women.Conclusion: Because unusual cardiovascular complications are the main cause of maternal and/or fetus death during pregnancy, prompt and exact diagnosis is very important. Life-saving surgical strategy with the help of appropriate teams are necessary to optimize outcome for both mother and baby.

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The Use of Posterior Pericardiotomy Technique to Prevent Postoperative Pericardial Effusion in Cardiac Surgery

The Heart Surgery Forum ◽

10.1532/hsf98.20111128 ◽

2012 ◽

Vol 15 (2) ◽

pp. 84 ◽

Cited By ~ 4

Author(s):

Canturk Cakalagaoglu ◽

Cengiz Koksal ◽

Ayse Baysal ◽

Gokhan Alici ◽

Birol Ozkan ◽

...

Keyword(s):

Cardiac Surgery ◽

Heart Surgery ◽

Artery Bypass ◽

Pericardial Tamponade ◽

Anxiety Level ◽

Control Group ◽

Echocardiographic Study ◽

Number Of Patients ◽

Hospital Stays

Aim: The goal was to determine the effectiveness of the posterior pericardiotomy technique in preventing the development of early and late pericardial effusions (PEs) and to determine the role of anxiety level for the detection of late pericardial tamponade (PT).Materials and Methods: We divided 100 patients randomly into 2 groups, the posterior pericardiotomy group (n = 50) and the control group (n = 50). All patients undergoing coronary artery bypass grafting surgery (CABG), valvular heart surgery, or combined valvular and CABG surgeries were included. The posterior pericardiotomy technique was performed in the first group of 50 patients. Evaluations completed preoperatively, postoperatively on day 1, before discharge, and on postoperative days 5 and 30 included electrocardiographic study, chest radiography, echocardiographic study, and evaluation of the patient's anxiety level. Postoperative causes of morbidity and durations of intensive care unit and hospital stays were recorded.Results: The 2 groups were not significantly different with respect to demographic and operative data (P > .05). Echocardiography evaluations revealed no significant differences between the groups preoperatively; however, before discharge the control group had a significantly higher number of patients with moderate, large, and very large PEs compared with the pericardiotomy group (P < .01). There were 6 cases of late PT in the control group, whereas there were none in the pericardiotomy group (P < .05). Before discharge and on postoperative day 15, the patients in the pericardiotomy group showed significant improvement in anxiety levels (P = .03 and .004, respectively). No differences in postoperative complications were observed between the 2 groups.Conclusion: Pericardiotomy is a simple, safe, and effective method for reducing the incidence of PE and late PT after cardiac surgery. It also has the potential to provide a better quality of life.

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