Achieving and Sustaining Zero: Preventing Surgical Site Infections After Isolated Coronary Artery Bypass With Saphenous Vein Harvest Site Through Implementation of a Staff-Driven Quality Improvement Process.

Background: Surgical site infections (SSI) increase morbidity and mortality, hospital costs, length of stay, readmissions, and risk of litigation and may impact a facility's reputation.

Methods: Through implementation of a Six Sigma, interdisciplinary team process and the Contextual Model for change engaged all stakeholders. A total of 44 perioperative processes were evaluated, with 15 processes ultimately altered.

Impact of preoperative renal dysfunction on long-term survival for patients undergoing aortic valve replacement.

Background: The impact of the degrees of renal dysfunction (RD) after aortic valve replacement (AVR) has not been well described. The purpose of this study was to compare patients undergoing AVR with a range of renal function from normal to dialysis-dependence.

Methods: A retrospective review of 2,408 patients undergoing AVR with or without coronary artery bypass graft surgery (CABG) from January 1996 to March 2009 was performed.

Long-term survival for patients with preoperative renal failure undergoing bioprosthetic or mechanical valve replacement.

Background: The objective of this study was to assess short-term and long-term outcomes after valve replacement with biologic or mechanical prostheses in patients with preoperative end-stage renal disease on chronic dialysis.

Methods: A retrospective review of patients with end-stage renal disease undergoing valve replacement from January 1996 through March 2008 at Emory Healthcare Hospitals was performed. Outcomes were compared using χ(2) tests and 2-sample t tests.

Deep hypothermic circulatory arrest for repair of the brachiocephalic artery and aorta after a gunshot wound to the chest.

The incidence of penetrating trauma to the brachiocephalic artery and aortic arch is not known, because most patients die of hemorrhage before they receive adequate treatment. Furthermore, when torrential hemorrhage from penetrating trauma is present, the anatomy of the thoracic vasculature can present a challenge for gaining adequate exposure, achieving vascular control, and performing proper repair. We describe the case of a patient with a gunshot wound to the anterior chest; he was placed under cardiopulmonary bypass and deep hypothermic circulatory arrest while we performed a patch repair of the proximal brachiocephalic artery and aortic arch.

Racial disparity persists after on-pump and off-pump coronary artery bypass grafting.

Background: Race has been shown to be an independent risk factor for operative mortality after coronary artery bypass grafting (CABG). This study sought to determine the extent to which race is a risk factor for adverse events, long-term mortality, and whether off-pump surgery (OPCAB) modifies that risk.

Methods And Results: The Society of Thoracic Surgeons Adult Cardiac Database at Emory Healthcare affiliated hospitals was queried for all primary isolated CABG records from 1997 to 2007.

Off-pump coronary artery bypass disproportionately benefits high-risk patients.

Background: It is not known which patient subgroups may benefit most from off-pump coronary artery bypass grafting (OPCAB) rather than coronary artery bypass grafting on cardiopulmonary bypass (CPB).

Methods: The Society of Thoracic Surgeons database was queried for all isolated, primary coronary artery bypass graft cases between January 1, 1997, and December 31, 2007, at a US academic center. The Society of Thoracic Surgeons Predicted Risk of Mortality (PROM) was calculated by a formula based on 30 preoperative risk factors.

Aortic valve replacement for aortic stenosis in patients with left ventricular dysfunction.

Background: The purpose of this study was to assess the impact of left ventricular dysfunction and other risk factors on short- and mid-term outcomes after aortic valve replacement for aortic stenosis.

Methods: From January 1, 2002, to December 31, 2007, 773 consecutive patients underwent primary aortic valve replacement for aortic stenosis at a single institution; concomitant coronary artery bypass graft surgery (CABG) was performed in 45.4% (351 of 773).

Successful cardiac transplantation in a patient with elevated pulmonary vascular resistance: a relative contraindication to transplantation.

Elevated pulmonary vascular resistance in a transplantation candidate should be viewed as potentially reversible, and there are several options for therapy. We describe a young patient with congenital restrictive cardiomyopathy and a markedly elevated pulmonary artery pressure. The patient underwent successful orthotopic heart transplantation after pharmacologic lowering of the pulmonary artery pressure with a new drug combination of milrinone and nesiritide.

Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery.

Background: The predictive role of hemoglobin A1c (HbA1c) on long-term outcomes after coronary artery bypass surgery has not been evaluated.

Methods: Preoperative HbA1c levels were obtained in 3,201 patients undergoing primary, elective coronary artery bypass surgery at Emory Healthcare Hospitals from January 2002 to December 2006 and entered prospectively into a computerized database. Long-term survival status was determined by cross-referencing patient records with the Social Security Death Index.

Off-pump coronary bypass surgery for high-risk patients: only in expert centers?

Purpose Of Review: Off-pump coronary artery bypass (OPCAB) grafting has been increasingly adopted in an effort to prevent deleterious effects of cardiopulmonary bypass, including the associated inflammatory response, global myocardial ischemia and the risks of aortic manipulation. In many studies, the greatest benefit of OPCAB has been in high-risk patients. This review will summarize the recent literature examining outcomes of OPCAB versus on-pump coronary artery bypass in high-risk subgroups, and will examine the safety of routine application of OPCAB in these patients.

Placement of a continuous-flow ventricular assist device in the failing ventricle of an adult patient with complex cyanotic congenital heart disease.

For patients with end-stage heart failure and contraindications to transplantation, insertion of a continuous-flow left ventricular assist device (LVAD) is an effective treatment strategy. We present a case of LVAD insertion in a 46-year-old man with cyanotic complex congenital heart disease and an extensive surgical history who presented with failure of his systemic ventricle. The insertion of an LVAD in our patient restored cardiac output and improved cyanosis and native ventricular function.

Intraoperative TandemHeart implantation as an adjunct to high-risk valve surgery.

Newer generations of assist devices for postcardiotomy support in patients with ventricular failure have eliminated bearings and incorporated suspended impellers, smaller cannulae and hardware, and simplified insertion techniques. We describe the use of a surgically implanted, percutaneous, continuous-flow centrifugal pump (the TandemHeart percutaneous ventricular assist device) as part of a planned, pre-emptive approach for postcardiotomy support in a patient with severe mitral regurgitation, moderate tricuspid regurgitation, and biventricular failure. To our knowledge, this report documents the 1st use of a percutaneous ventricular assist device as an elective support device in a patient undergoing high-risk mitral or tricuspid valve surgery.

Biatrial primary cardiac paraganglioma: a rare finding.

The majority of primary cardiac tumors are benign; of these tumors, cardiac paragangliomas are among the rarest. We report a case of biatrial cardiac paraganglioma discovered during workup for palpitations and fatigue. The tumor involved the interatrial septum, with a lobulated portion protruding through the foramen ovale into the right atrium.

Outcomes after off-pump reoperative coronary artery bypass grafting.

Objective: : Application of off-pump techniques to reoperative coronary artery bypass (redo CABG) has been limited by technical difficulty and potential for embolism of atheromatous debris from diseased grafts, resulting in myocardial infarction and rapid hemodynamic deterioration. We compared outcomes after off-pump (OPCAB) and on-pump (ONCAB) in redo CABG.

Methods: : A retrospective chart review was performed for patients who underwent redo CABG at a single academic institution between January 1997 and December 2004.

Intrathoracic gastrojejunostomy for gastric outlet obstruction after Ivor Lewis esophagogastrectomy.

Gastric outlet obstruction after esophagogastrectomy with a drainage procedure is unusual, but when encountered, its management can be formidable. A Rous-en-Y intrathoracic gastrojejunostomy was created in a 74-year-old woman 2 years after Ivor Lewis esophagogastrectomy for benign disease to treat severe gastric outlet obstruction at the native pylorus.

Reduction of infarct size and preservation of endothelial function by multidose intravenous adenosine during extended reperfusion.

It has been proposed that infarct extension is developed from the early to the late phase of reperfusion (R). This study compares the protective effect of single or multidose administration of adenosine (Ado) on infarct size during early and late phases of R by attenuating neutrophil (PMN) recruitment. Forty-one dogs underwent 60-min left anterior descending artery (LAD) ischemia followed by 6, 24, and 48 h of R, respectively.

Pretreatment with phenoxybenzamine attenuates the radial artery's vasoconstrictor response to alpha-adrenergic stimuli.

Background: Although the radial artery bypass conduit has excellent intermediate-term patency, it has a proclivity to vasospasm. We tested the hypothesis that brief pretreatment of a radial artery graft with the irreversible adrenergic antagonist phenoxybenzamine attenuates the vasoconstrictor response to the vasopressors phenylephrine and norepinephrine compared with the currently used papaverine/lidocaine.

Methods: Segments of human radial artery grafts were obtained after a 30-minute intraoperative pretreatment with a solution containing 20 mL of heparinized blood, 0.

Optimal dose and mode of delivery of Na+/H+ exchange-1 inhibitor are critical for reducing postsurgical ischemia-reperfusion injury.

Background: In clinical trials, perioperative intravenous Na(+)/H(+) exchange isoform-1 (NHE1) inhibitors were only moderately effective in high-risk patients undergoing surgical reperfusion (GUARDIAN trial). However, effective myocardial concentrations of NHE1 inhibitor may not have been achieved by parenteral administration alone. We tested the hypothesis that increasing doses of NHE1 inhibitor EMD 87580 ((2-methyl-4,5-di-(methylsulfonyl)-benzoyl)-guanidine) delivered in blood cardioplegia (BCP) and by parenteral route at reperfusion reduce myocardial injury after surgical reperfusion of evolving infarction.

Inhibition of myocardial apoptosis reduces infarct size and improves regional contractile dysfunction during reperfusion.

Objective: Myocardial apoptosis is primarily triggered during reperfusion (R) through various mechanisms that may involve endonuclease to cleavage genomic DNA in the internucleosomal linker regions. However, the relative contribution of myocardial apoptosis to development of myocardial injury during R remains unknown. In the present study, we examined whether inhibition of apoptosis with aurintricarboxylic acid (ATA), an endonuclease inhibitor, during R reduces infarct size and improves regional contractile function.

Palliative management of malignant airway obstruction.

Background: Obstruction of the airway due to unresectable malignant disease is a frightening condition that portends a poor prognosis. Endobronchial treatment modalities were reviewed to determine the most effective management strategy.

Methods: A 12-year retrospective review (1988 to 1999) of 121 consecutive patients with inoperable malignant airway obstruction (MAO) was performed.

Adenosine in myocardial protection in on-pump and off-pump cardiac surgery.

Adenosine is most well known for its potent vasodilation of the vasculature. However, it also promotes glycolysis, and activates potassium-sensitive adenosine triphosphate (K(ATP)) channels. Adenosine also strongly inhibits neutrophil function such as superoxide anion production, protease release, and adherence to coronary endothelial cells.

Blood cardioplegia supplementation with the sodium-hydrogen ion exchange inhibitor cariporide to attenuate infarct size and coronary artery endothelial dysfunction after severe regional ischemia in a canine model.

Background: Activation of the sodium-hydrogen ion exchange mechanism results in accumulation of intracellular calcium through the sodium-calcium ion antiport mechanism. Administration of a sodium-hydrogen ion exchange inhibitor before or during ischemia attenuates myocardial ischemia and reperfusion injury. However, the cardioprotection exerted by sodium-hydrogen ion exchange inhibitors as adjuncts to cardioplegia without perioperative administration has not been tested in a model of surgical reperfusion of acute coronary occlusion with cardiopulmonary bypass.

Preserved myocardial blood flow and oxygen supply-demand balance with active coronary perfusion during simulated off-pump coronary artery bypass grafting.

Background: During off-pump coronary artery bypass surgery, concern remains about the possible myocardial injury associated with the transient occlusion and stabilization of the target vessels. Although intraluminal shunts are used to avoid ischemia during graft anastomosis, blood flow through the shunts can be affected by upstream pressure and inherent resistance, resulting in reduced blood flow during hypotension or severe proximal stenosis.

Methods: In anesthetized dogs regional myocardial blood flow (microspheres), oxygen consumption, lactate extraction, and systolic shortening (sonomicrometry) were measured in the myocardium served by the left anterior descending coronary artery with native perfusion after interposition of a 2.