Background The development of a ventricular septal defect(VSD) after myocardial infarction(MI) is an uncommon but highly lethal complication. We examined the Society of Thoracic Surgeons(STS) database to characterize patients undergoing surgical repair of post-MI VSD and to identify risk factors for poor outcomes. Methods This was a retrospective review of the STS database to identify adult(≥18 years) patients who underwent post-MI VSD repair between 1999–2010. Patients with congenital heart disease were excluded. The primary outcome was operative mortality. The covariates in the current STS model for predicted coronary artery bypass(CABG) operative mortality were incorporated in a logistic regression model in this cohort. Results There were 2,876 patients included. Mean age was 68±11 years, and 1,624(56.5%) were men. 215(7.5%) patients had prior CABG surgery, 950(33%) had prior percutaneous intervention, and 1,869(65.0%) were supported preoperatively with an intra-aortic balloon pump. Surgical status was urgent in 1,007(35.0%) and emergent in 1,430(49.7%). Concomitant CABG was performed in 1,837(63.9%). Operative mortality was 54.1%(1,077/1,990) if repair was ≤7 days from MI, and 18.4%(158/856) if >7 days from MI. Multivariable analysis identified several factors associated with increased odds of operative mortality. Conclusions In the largest study to date to examine post-MI VSD repair, ventricular septal rupture remains a devastating complication. As alternative therapies emerge to treat this condition, these results will serve as a benchmark for future comparisons.

ATIENTS WHO UNDERGO CARdiac surgery receive a significant proportion of the 14 million units of allogeneic red blood cells (RBCs) transfused annually in the United States. 1 Numerous observational studies in patients who underwent cardiac surgery have shown an association between RBC transfusion and adverse outcome, including morbidity, mortality, resource utilization, and quality of life. [2][3][4][5][6][7][8][9] To date, no large randomized trials of transfusion thresholds have been conducted in cardiac surgery to our knowledge to address this issue.Almost 20 years ago, the study by Goodnough et al 10 demonstrated that there was significant practice variability in transfusion practices at 18 US centers. However, this study and subsequent studies [11][12][13][14] were limited in size and did not adjust for hospital or patient factors. Since these earlier studies, the Society of Thoracic Surgeons (STS) and Society of Cardiovascular Anesthesiologists published transfusion recommendations in 2007. 15 However, the degree to which guidelines have resulted in consensus in community transfusion practice is unknown. Therefore, the primary goal of our study was to assess use of RBC, fresh-frozen plasma, and platelet transfusions in coronary artery bypass graft (CABG) surgery in contemporary practice. Our analyses specifically addressed the degree to which transfusion practices varied among US hospitals, after adjusting for patient characteristics. METHODS Data SourceThe STS Adult Cardiac Surgery Database (ACSD) was established in 1989 to report outcomes following cardiothoracic surgical procedures. [16][17][18][19][20] The database captures clinical information from the majority of US cardiac surgical procedures. A recent analysis demon-strated that more than 80% of patients undergoing CABG operations in the United States in 2007 were represented in the STS database. 21 Sites enter patient data using uniform definitions

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Objectives To characterize operative outcomes for ascending aorta and arch replacement on a national scale and develop risk models for mortality and major morbidity. Background Contemporary outcomes for ascending aorta and arch replacement in North America are unknown. Methods We queried the Society of Thoracic Surgeons Database for patients undergoing ascending aorta (+/− root) +/− arch replacement from 2004 to 2009. The database captured 45,894 cases, including 12,702 root, 22,048 supracoronary ascending alone, 6,786 ascending+arch, and 4,358 root+arch. Baseline characteristics and clinical outcomes were analyzed. A parsimonious multivariable logistic regression model was constructed to predict risks of mortality and major morbidity. Results Operative mortality was 3.4% for elective and 15.4% for non-elective cases. A risk model for operative mortality [c-index 0.81] revealed a risk-adjusted odds ratio (OR) for death following emergent vs. elective operation of 5.9 [95% confidence interval (CI) 5.3, 6.6]. Among elective patients, end stage renal disease and re-operative status were the strongest predictors of mortality (adjusted OR 4.0 [95% CI 2.6, 6.4] and 2.3 [95% CI 1.9, 2.7] respectively, p<0.0001). Conclusions Current outcomes for ascending aorta and arch replacement in North America are excellent for elective repair; however, results deteriorate for non-elective status, suggesting that increased screening and/or lowering thresholds for elective intervention could potentially improve outcomes. The predictive models presented may serve clinicians in counseling patients.

Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD). Using this cohort, we sought to (1) evaluateBackground-There is a paucity of long-term data comparing biological versus mechanical aortic valve prostheses in older individuals. Methods and Results-We performed follow-up of patients aged 65 to 80 years undergoing aortic valve replacement with a biological (n=24 410) or mechanical (n=14 789) prosthesis from 1991 to 1999 at 605 centers within the Society of Thoracic Surgeons Adult Cardiac Surgery Database using Medicare inpatient claims (mean, 12.6 years; maximum, 17 years; minimum, 8 years), and outcomes were compared by propensity methods. Among Medicare-linked patients undergoing aortic valve replacement (mean age, 73 years), both reoperation (4.0%) and endocarditis (1.9%) were uncommon to 12 years; however, the risk for other adverse outcomes was high, including death (66.5%), stroke (14.1%), and bleeding (17.9%). Compared with those receiving a mechanical valve, patients given a bioprosthesis had a similar adjusted risk for death (hazard ratio, 1.04; 95% confidence interval, 1.01-1.07), higher risks for reoperation (hazard ratio, 2.55; 95% confidence interval, 2.14-3.03) and endocarditis (hazard ratio, 1.60; 95% confidence interval, 1.31-1.94), and lower risks for stroke (hazard ratio, 0.87; 95% confidence interval, 0.82-0.93) and bleeding (hazard ratio, 0.66; 95% confidence interval, 0.62-0.70). Although these results were generally consistent among patient subgroups, bioprosthesis patients aged 65 to 69 years had a substantially elevated 12-year absolute risk of reoperation (10.5%). Conclusions-Among patients undergoing aortic valve replacement, long-term mortality rates were similar for those who received bioprosthetic versus mechanical valves. Bioprostheses were associated with a higher long-term risk of reoperation and endocarditis but a lower risk of stroke and hemorrhage. These risks varied as a function of a patient's age and comorbidities.

Patients undergoing elective aortic root or combined aortic valve-ascending aortic surgery at North American hospitals that performed fewer than 30 to 40 of such procedures annually have greater risk-adjusted mortality than those undergoing surgery in higher volume hospitals. Causative factors for this inverse association between hospital volume and mortality deserve additional analysis.

Background Post-operative atrial fibrillation (POAF) is a well-recognized complication of cardiac surgery, however, its management remains a challenge and the implementation and outcomes of various strategies in clinical practice remain unclear. Methods We compared patient characteristics, operative procedures, post-operative management, and outcomes between patients with and without POAF following coronary artery bypass grafting (CABG) in the Society for Thoracic Surgery multicenter CAPS-Care registry (2004–2005). Results Of 2,390 patients who underwent CABG, 676 (28%) had POAF. Compared with patients without POAF, those with POAF were older (median age 74 vs. 71, p<0.0001), more likely to have hypertension (86% vs. 83%, p=0.04), and impaired renal function (median estimated glomerular filtration rate, 56.9 vs. 58.6 mL/min/1.73m2, p=0.0001). A majority of patients with POAF were treated with amiodarone (77%) and beta-blockers (68%); few underwent cardioversion (9.9%). Patients with POAF were more likely to experience complications (57% vs.41%, p<0.0001), including acute limb ischemia (1.0% vs. 0.4%, p=0.03), stroke (4% vs. 1.9%, p=0.002), and reoperation (13% vs. 7.9%, p<0.0001). Length of stay (median 8 days vs. 6 days, p<0.0001), in-hospital mortality (6.8% vs. 3.7%, p=0.001), and 30-day mortality (7.8 vs. 3.9, p<0.0001) were all worse for patients with POAF. In adjusted analyses, POAF remained associated with increased length of stay following surgery (adjusted ratio of the mean 1.27, 95% CI 1.2–1.34, p<0.0001). Conclusions In conclusion, post-operative AF is common following CABG, and such patients continue to have higher rates of post-operative complications. Post-operative AF is significantly associated with increased length of stay following surgery.