HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lawrence J. Dacey Charles A.S. Marrin Jeremy R. Morton Bruce J. Leavitt Christopher T. Maloney Felix Hernandez Robert A. Clough William C. Nugent David C. Charlesworth Stephen K. Plume Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by O’Connor, G. T. Articles by Plume, S. K. Search for Related Content PubMed PubMed Citation Articles by O’Connor, G. T. Articles by Plume, S. K.

Ann Thorac Surg 1998;66:1323-1328
© 1998 The Society of Thoracic Surgeons

---

Original articles: cardiovascular

Results of a regional study of modes of death associated with coronary artery bypass grafting

^a Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
^b Maine Medical Center, Portland, Maine, USA
^c Fletcher Allen Health Care, Burlington, Vermont, USA
^d Optima Health Care: Catholic Medical Center, Manchester, New Hampshire, USA
^e Eastern Maine Medical Center, Bangor, Maine, USA

Accepted for publication May 9, 1998.

Address reprint requests to Dr O’Connor, Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Strasenburgh Hall, Rm 330, Hanover, NH 03755
e-mail: (gerald.t.o’connor{at}dartmouth.edu)

	Abstract

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Northern New... References

 
Background. It is well known that surgeon-specific in-hospital mortality rates for coronary artery bypass grafting vary, but this aggregate measure does not suggest specific opportunities for improvement.

Methods. We performed a regional prospective study of 8,641 consecutive patients undergoing isolated coronary artery bypass grafting by all of the 23 cardiothoracic surgeons practicing in northern New England during the study period. Mode of death was assigned by an end points committee using predetermined definitions. Surgeons were ranked according to risk-adjusted mortality rates and grouped in terciles, and cause-specific mortality rates were determined.

Results. The mortality rate was 3.3% in the lowest surgeon mortality tercile and 5.8% in the highest tercile. Fatal heart failure accounted for 80.0% of the difference in aggregate mortality rates, ranging from 1.9% in lowest surgeon mortality tercile to 4.0% in the highest tercile (p < 0.001). Rates of other causes did not differ significantly across surgeon mortality terciles. Differences in rates of fatal heart failure could not be explained by differences in preoperative left ventricular dysfunction or other patient characteristics.

Conclusions. Most of the difference in observed mortality rates across surgeons is attributable to differences in rates of heart failure.

	Introduction

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Northern New... References

 
Surgeons have different mortality rates after coronary artery bypass grafting (CABG), but knowledge of differences in mortality rates does not necessarily suggest specific opportunities for improvement [1–4]. There are several organized efforts to reduce perioperative mortality [5–7], but the understanding of an individual surgeon’s or institution’s experience may be unreliable as a guide to improvement as patient deaths are relatively rare and even the most thoughtful analysis of a few deaths may be inadequate to guide changes in surgical organization or technique [8]. Coronary artery bypass grafting is an extraordinarily complex activity involving many clinical professionals and hundreds of discrete processes.

Improving the results of CABG operations will require more detailed information on the cause of surgical outcomes. The Northern New England Cardiovascular Disease Study Group is a voluntary research consortium composed of clinicians, scientists, and hospital administrators representing six medical centers in Maine, New Hampshire, Vermont, and Massachusetts. A registry for CABG patients has been maintained since 1987, and a region-wide quality improvement process was initiated during 1990 [6]. We have developed and instituted a process for coding the mode of death. This report describes the mode of death associated with CABG operation among 8,641 consecutive patients and the association between cause-specific and surgeon-specific mortality rates.

	Material and methods

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Northern New... References

 
Data collection
All 23 cardiothoracic surgeons practicing in northern New England during the study period participated in this prospective study of 8,641 consecutive patients undergoing isolated CABG. In-hospital deaths during the index admission were used to calculate the mortality rates. These were reported by surgeons and validated by participating hospitals. There were 387 deaths yielding a mortality rate of 4.48%. Data elements collected were patient age and sex; body surface area; presence of comorbidities (diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, preoperative renal failure requiring dialysis); cardiac catheterization results (ejection fraction [9], left ventricular end-diastolic pressure, number of diseased coronary arteries [10], stenosis of the left main coronary artery [>90%]), and prior CABG operation. The priority of the operation (emergent, urgent, elective) was assessed by the cardiothoracic surgeons using definitions previously described [11]. The variables used in this study were similar to those used by other investigators [12–15].

Creating and analyzing mortality groups
We sought to understand the association between cause-specific rates and surgeon-specific mortality rates. Risk-adjusted mortality rates were calculated for each surgeon using logistic regression analysis [11, 16, 17]. The risk model included all data elements listed above and in Table 1. Because surgeon-specific mortality rates are statistically unstable, the adjusted mortality rates were rank ordered and divided into terciles, yielding three groups with observed mortality rates of 3.26%, 4.47%, and 5.82%.

Assigning mode of death
Assigning the mode of death is challenging because there is often a cascade of adverse clinical events that precedes a patient’s death. The intent of our process was to identify the seminal clinical event leading to each patient’s death. This seminal event frequently differed from the terminal condition leading directly to death. For example, one patient, despite doing well initially, experienced a severe cerebrovascular accident on the second postoperative day. Although the patient ultimately died 2 weeks later of aspiration pneumonia, the neurologic event, not respiratory failure, was identified as the mode of death. Had the same patient required significant inotropic support and an intraaortic balloon pump for hypotension before the stroke, heart failure would have been assigned as the mode of death.

The primary data for assigning the mode of death were obtained by trained medical record abstractors, most of whom were experienced critical care nurses. The data abstracted included the chronologic sequence of postoperative clinical events leading to each patient’s death, intraoperative and postoperative data (including the insertion of an intraaortic balloon pump, return to cardiopulmonary bypass, continued use of inotropic support, return to the operating room), the surgeon’s assessment of mode of death, and autopsy data if available.

Initial coding of mode of death was accomplished with predefined rules. These rules coded some cases of bleeding and low output failure including cases in which bleeding or significant cardiac failure were the only events recorded by the record reviewer. If the mode of death could not be coded easily and unambiguously by these rules, the case was referred to the clinical endpoints committee, which consisted of 2 cardiac surgeons, a cardiac surgery fellow, and the study epidemiologist. This group reviewed the detailed data extraction forms, considered the sequence of postoperative clinical events, autopsy findings when available, and the responsible clinician’s assessment in the medical record. Although some intraoperative information was used to assign mode of death (insertion of intraaortic balloon pump, return to cardiopulmonary bypass), the committee was blinded to most other intraoperative variables and all preoperative patient data. If these data led to a unanimous vote of the committee the mode of death was coded. If not, the case was referred to the regional review group, composed of representatives from each of the participating medical centers.

Of 387 deaths, medical records were not available for 3 cases. Of the remaining 384 deaths, 154 (40.1%) were assigned using predefined coding rules, 189 (49.2%) were assigned by the clinical end points committee, and 41 (10.7%) were assigned by the regional review group. Deaths were classified as resulting from clinical sequences beginning with hemorrhage, dysrhythmia, heart failure, respiratory failure, neurologic causes, or other causes. In all phases of the review process, the mode of death was assigned without knowledge of medical center or surgeon identity, or of the mortality tercile to which the patient had been assigned.

One hundred data abstraction forms were selected randomly for retesting. The review groups were unaware of the reevaluation process. Ninety-three deaths were in agreement with the initial classification. Of the 7 discordant assignments, 5 changed from dysrhythmia to heart failure, 1 changed from "other causes" to respiratory failure, and 1 changed from hemorrhage to respiratory failure. The kappa statistic, used to assess the concordance between repeat classifications, was 0.88 (p < 0.0001), indicating excellent agreement [20, 21].

	Results

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Northern New... References

 
Patient and disease characteristics of the risk-adjusted mortality terciles are summarized in Table 1. The patients were similar in age, sex, body surface area, peripheral vascular disease, preoperative renal failure, ejection fraction, left ventricular end-diastolic pressure, presence of left main coronary artery stenosis, and percent undergoing urgent or emergent operation. The proportion of patients having a prior CABG operation ranged from 5.9% to 8.4%, with the highest percentage in the highest mortality group. The proportion of patients with chronic obstructive pulmonary disease ranged from 7.8% to 13.9%, with the lowest percentage in the highest mortality tercile. There was a very similar distribution of ejection fraction categories by mortality terciles (Fig 1).

View larger version (18K): [in this window] [in a new window]   Fig 1. Preoperative ejection fraction by surgeon mortality tercile.

View larger version (21K): [in this window] [in a new window]   Fig 2. Rates of assigned mode of death by surgeon mortality terciles. (Resp = respiratory.)

	Comment

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Northern New... References

The 27 deaths attributed to fatal hemorrhage and 21 each to dysrhythmia and respiratory failure were too few to study specific risk factors associated with these modes of death. Even in the 249 deaths attributable to heart failure, we would be unable to study risk factors for some subgroups.

Our findings are dependent on our method for classifying modes of death. The clinical setting is exceedingly complex, and the mode of death for some patients defied simple description. The difficulty of classifying deaths in cardiac patients has been described by Pratt and associates [22]. Our intent was to attribute the mode of death to the most likely responsible upstream event rather than to its consequences. Coding of mode of death was done without knowledge of the identity of the patient, physician, or medical center. Preoperative data were not known by the staff doing the initial coding or by the members of the end points committee. Some deaths were probably misclassified. However, because the attribution of mode of death was done without knowledge of the mortality tercile into which that patient would be placed, random misclassification would tend to make the mortality terciles to look more like each other, obscuring rather than emphasizing real differences.

Early descriptions of heart failure after cardiac operations came from observations of Lillehei and Dietzman and associates [23] and colleagues [24]. In a 25-patient case series these investigators described and defined the low cardiac output syndrome and suggested its mechanisms and effects on both myocardial function and on the peripheral vasculature. These observations were expanded by Kouchoukos and colleagues [25], who also recognized the significance of this syndrome in subsequent cardiovascular morbidity and mortality. In a series of 54 deaths, these authors attributed 30 (55.6%) to heart failure. Sergeant and coworkers [26] described the mode of death after cardiac surgery among 545 deaths at a single institution. Heart failure was the mode of death for 216 (40%). Although the data described by Kouchoukos and colleagues [25] and Sergeant and associates [26] differed in follow-up period and in method of classifying deaths, heart failure was the predominant mode of death in both reports.

Because the mortality terciles in the present study were virtually identical with respect to preoperative left ventricular function, these findings suggest that variable results in the outcomes of cardiac operations may arise from different processes of clinical care. Subtle differences in clinical condition of patients may also explain some of these differences. In this study, the primary surgeon was used as a proxy for a system of care. It is important to remember that this method of assigning responsibility for clinical care is somewhat arbitrary and does not imply causality. There are many discrete processes of care involved in cardiac surgery and many individual professional responsibilities. Tobler and colleagues [7] studied processes of care provided for 770 patients at six Veterans Affairs Medical Centers. They described perfusion, anesthesia, operative technique, the measurement and management of hemodynamics, and the timing and conduct of extubation. They found wide variation in virtually all of these processes. For example, use of retrograde cardioplegia varied from 2% to 89% among hospitals and use of blood cardioplegia varied from 0% to 100%. The most likely explanation for the differences in rates of fatal heart failure in the current study is that different processes and systems of clinical care yield different results. Because benchmarking is relatively infrequent in clinical practice, these differences in processes of care and their effect on clinical outcomes may go unnoticed.

The primary finding of this study is the extent to which the incidence of heart failure explains observed differences in overall mortality rates. Processes of care possibly related to heart failure include preoperative treatment of ischemia, myocardial protection, surgical techniques, perfusion and anesthesia techniques, and the recognition and treatment of perioperative heart failure. Optimal processes include adequate communication between clinicians, and clarity of roles and responsibilities. We need a better understanding of these processes of care and of their relationship to the development of perioperative heart failure. If we can organize and document surgical care so that we can learn cumulatively from daily experience, a focus on preventing and treating heart failure is a simplifying assumption that may allow more rapid progress toward improving clinical outcomes in CABG operations.

	Acknowledgments

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Northern New... References

 
This study was supported in part by the Merck/Society for Epidemiologic Research Clinical Epidemiology Fellowship to Dr O’Connor and by grants (HS 06503, HS 06813) from the Agency for Health Care Policy and Research.

	Footnotes

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Northern New... References

 
^* The members of the study group are listed in Appendix 1.

	Appendix 1. Northern New England Cardiovascular Disease Study Group

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Northern New... References

 
Beth Israel-Deaconess Medical Center, Boston, MA
David Brackett, RN, Mary Bogosian, CCP, Christian T. Campos, MD, Jeannie Fischer, PA, Philip J. Fitzpatrick, MD, Beth Jennings, Robert G. Johnson, MD, Wendy Kowalker, Patricia Lahey, RN, Stephen J. Lahey, MD, David Leeman, MD, Keith P. Lewis, MD, Stanley Lewis, MD, David Leeman, MD, Maria Lustenberger, RN, Peter R. Maggs, MD, Richard W. Nesto, MD, Brian O’Connor, CCP, Patty Pawlow, RN, Kathy Peterson, RN, Patricia Rabett, RN, Cheryl Sirois, RN, Samuel Shubrooks, MD, Terri Stokes, RN, Susan Sumner, RN, Paul G. Vivino, MD, Albert Washko, MD, and Ronald M. Weintraub, MD

Dartmouth Hitchcock Medical Center, Hanover, NM
Virginia Beggs, MS, John D. Birkmeyer, MD, Nancy J. O. Birkmeyer, PhD, William Burke RCVT, Edward Catherwood, MD, Mike Chamberlain, RN, Lawrence J. Dacey, MD, Gordon DeFoe, CCP, Kenneth Dixon-Vestal, RN, Thomas Dodds, MD, Mary Fillinger, MD, Bruce Friedman, MD, Christine Heins, RN, Bruce Hettleman, MD, Karen A. Jean, RN, Pamela Jenkins, MD, Joseph Kasper, ScD, Lori Key, RN, Terry Kneeland, MPH, Judith Kobe, RN, Michael Losos, RN, Elizabeth Maislen, ARNP, David Malenka, MD, Charles A. S. Marrin, MB,BS, Mary Menduni, RN, Nathaniel Niles, MD, William C. Nugent, MD, Gerald T. O’Connor, PhD, Elaine M. Olmstead, Daniel O’Rourke, MD, Stephen K. Plume, MD, Hebe B. Quinton, MS, John Robb, MD, Cathy S. Ross, John Sanders, MD, William Schults, MS, Jon Wahrenberger, MD, and Beth Wolf.

Eastern Maine Medical Center, Bangor, ME
Robert Allen, MD, Jim Blum, MS, Chae C. Choi, MD, Deborah Carey-Johnson, RN, Tina Closson, RN, Robert Clough, MD, Cynthia M. Downs, MSN, Glen D. Garson, MD, Felix Hernandez, Jr, MD, Rebecca Henry, RN, Joseph J. Hessel, MD, Robert M. Hoffman, MD, John H. Jentzer, MD, Edward R. Johnson, MD, Peter Marshall, MD, Helen McKinnon, RN, Cathy Mingo, RN, Craig Pedersen, PA, Wendy Perkins, LPN, Robert Rosenthal, MD, Matthew L. Rowe, MD, Katrina Sargent, M. Theodore Silver, MD, Sherry Spraque, Wolfgang J. T. Spyra, MD, Laurie True, RN, Peter Ver Lee, MD, Paul vom Eigen, MD, Craig Warren, CCP, and William Witmer, MD.

Fletcher Allen Health Care, Burlington, VT
Richard G. Brandenburg, PhD, Pamela Brown, Betsy Burns, RN, Mark Capeless, MD, Kevin Carey, MD, Steve Colmanaro, PA, Steve Crumb, RN, Betty Diette, RN, Maureen Dwyer, ARNP, Karen Farrell, ANP, Jan Faucett, RN, Sally Gagnon, RN, Susan Geoffrey, RN, Larry Goetschius, Walter D. Gundel, MD, Richard S. Jackson, MD, David Johnson, MD, Charlie Krumholz, CCP, Ann Laramee, RN, Bruce J. Leavitt, MD, Martin Lewinter, MD, Steve Marcus, PA, Karen McKenny, RN, Mitchell Norotsky, MD, Madeline Norse, RN, William C. Paganelli, MD, PhD, Diane Pappalardo, MHSA, Daniel S. Raabe, MD, Melinda Rabideau, RN, Martha Root, RN, Janice Smith, RN, Christopher M. Terrien, Jr, MD, Edward Terrien, MD, Matthew Watkins, MD, and Jane Wilde, MSN.

Maine Medical Assessment Foundation
Robert B. Keller, MD, David C. Soule, and David Wennberg, MD, MPH.

Maine Medical Center, Portland, ME
Lawrence Adrian, PA, Warren D. Alpern, MD, Eric Anderson, Richard A. Anderson, MD, Linda Banister, RN, Claire Berg, RN, Seth Blank, MD, John Braxton, MD, Carl E. Bredenberg, MD, Michael Brennan, PA, David Burkey, MD, Cantwell Clark, MD, Jane Cleaves, RN, Vincent Conti, Deborah Courtney, RN, Joshua Cutler, MD, Desmond Donegan, MD, Pat Fallo, RN, Rick Forest, CCP, Robert Groom, CCP, Daniel Hanley, MD, Mary Beth Hourihan, MD, Jane Kane, RN, Saul Katz, MD, Mirle A. Kellett, Jr, MD, Robert Kramer, MD, Costas T. Lambrew, MD, F. Stephen Larned, MD, Lee Lucas, Paul D. McGrath, MD, Jeremy R. Morton, MD, Edward R. Nowicki, MD, John R. O’Meara, MD, Sheilia Parker, RN, Patricia Peasley, RN, Cathy Prouty, RN, Reed D. Quinn, MD, Dennis Redfield, RN, Karen Reynolds, MPH, Jean Saunders, MSN, MPH, Alyce Schultz, PhD, Susan Seekins, RN, Karen Tolan, RN, Nancy Tooker, RN, Joan F. Tryzelaar, MD, Kathy Viger, RN, Paul T. Vaitkus, MD, Cynthia Westlund, RN, and Wanda Whittet, RN.

Optima Health Care: Catholic Medical Center, Manchester, NH
Yvon Baribeau, MD, Ann Becker, RN, Craig C. Berry, MD, Kevin Berry, MD, William A. Bradley, MD, David C. Charlesworth, MD, Susan Cuddy, RN, Robert C. Dewey, MD, Frank Fedele, MD, Louis I. Fink, MD, Erik J. Funk, MD, Alan E. Garstka, MD, Karen Grafton, RN, Dan Halstead, CCP, Michael J. Hearne, MD, J. Beatty Hunter, MD, Alan D. Kaplan, MD, Dennis Kelly, MD, Mark A. Klinker, MD, Peggy Lambert, RN, Patrick M. Lawrence, MD, Jeffery Lockhart, MD, Christopher T. Maloney, MD, Kathy McNeil, RN, Venkatram Nethala, MD, Edward Palank, MD, John Pieroni, CCP, M. Judith Porelle, RN, Joanne Robichaud, RN, Mary Sanford, RN, James Schnitz, MD, Benjamin M. Westbrook, MD, Thomas P. Wharton, MD, Kirke W. Wheeler, MD, and Diane White, RN.

	References

Top Footnotes Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1. Northern New... References

 

1. O’Connor G.T., Plume S.K., Olmstead E.M., et al. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting. JAMA 1991;266:803-809.[Abstract]
2. New York State Department of Health. Coronary artery bypass graft surgery in New York State 1989–1991. Albany: New York State Department of Health, 1992.
3. Pennsylvania Health Care Cost Containment Council. A consumer guide to coronary artery bypass graft surgery. Harrisburg: Pennsylvania Health Care Cost Containment Council, November 1992.
4. Medicare Hospital Mortality Information, 1986. Washington, DC: US Dept of Health and Human Services, 1987. (DHHS publication no. 01-002.)
5. Hannan E.L., Kilburn H., Jr, Racz M., Shields E., Chassin M.R. Improving the outcomes of coronary artery bypass surgery in New York State. JAMA 1994;271:761-766.[Abstract]
6. O’Connor G.T., Plume S.K., Olmstead E.M., et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. JAMA 1996;275:841-846.[Abstract]
7. Tobler H.G., Sethi G.K., Grover F.L., et al. Variations in processes and structures of cardiac surgery practice. Med Care 1995;33(Suppl):OS43-OS58.[Medline]
8. Silber J.H., Rosenbaum P.R., Schwartz J.S., Ross R.N., Williams S.V. Evaluation of the complication rate as a measure of quality of care in coronary artery bypass graft surgery. JAMA 1995;247:317-323.
9. Pierpont G.L., Kruse M., Ewald S., Weir E.K. Practical problems in assessing risk for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1985;89:673-682.[Abstract]
10. The Principal Investigators of CASS and theirassociates. The National Heart, Lung, and Blood Institute Coronary Artery Surgery Study (CASS) Circulation 1981;63(Suppl 1):71-181.
11. O’Connor G.T., Plume S.K., Olmstead E.M., et al. Multivariate prediction of in-hospital mortality associated with coronary artery bypass grafting. Circulation 1992;85:2110-2118.[Abstract/Free Full Text]
12. Kennedy J.W., Kaiser G.C., Fisher L.D., et al. Multivariate discriminant analysis of the clinical and angiographic predictors of operative mortality from the Collaborative Study in Coronary Artery Surgery. J Thorac Cardiovasc Surg 1980;80:876-887.[Abstract]
13. Hannan E.L., Kilburn H., O’Donnell J.F., Lukacik G., Shields E.P. Adult open heart surgery in New York State: An analysis of risk factors and hospital mortality rates. JAMA 1990;264:2768-2774.[Abstract]
14. Parsonnet V., Dean D., Bernstein A.D. A method for uniform stratification of risk for evaluating the results of surgery in acquired adult heart disease. Circulation 1989;79(Suppl 1):3-12.
15. Kouchoukos N.T., Ebert P.A., Grover F.L., Lindesmith G.G. Report of the Ad Hoc Committee on Risk Factors for Coronary Artery Bypass Surgery. Ann Thorac Surg 1988;46:348-349.
16. Cornfield J., Gordon T., Smith W.W. Quantal response curves for experimentally uncontrolled variables. Bull Int Stat Inst 1961;38:97-115.
17. SAS Institute Inc. Statistical Analysis System (SAS). Cary, NC, 1986.
18. Hennekens C.H., Buring J.E. Epidemiology in medicine. Boston: Little, Brown and Company, 1988.
19. Armitage P., Berry G. Statistical methods in medical research, 2nd ed. London: Blackwell Scientific Publications, 1987.
20. Cohen J. A coefficient of agreement for nominal scales. Educ Psychol Meas 1960;20:37-46.
21. Landis J.R., Koch G.G. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-174.[Medline]
22. Pratt C.M., Greenway P.S., Schoenfeld M.H., Hibben M.L., Reiffel J.A. Exploration of the precision of classifying sudden cardiac death: Implications for the interpretation of clinical trials. Circulation 1996;93:519-524.[Abstract/Free Full Text]
23. Lillehei R.C., Dietzman R.H., Bloch J.H. Hypotension and low output syndrome following cardiopulmonary bypass. In: Norman J.C., ed. Cardiac surgery. New York: Appleton-Century-Crofts, 1967:437-456.
24. Dietzman R.H., Ersek R.A., Lillehei C.W., Castañeda A.R., Lillehei R.C. Low output syndrome: Recognition and treatment. J Thorac Cardiovasc Surg 1969;57:138-150.[Medline]
25. Kouchoukos N.T., Sheppard L.C., Kirklin J.W., et al. Detection and treatment of impaired cardiac performance following cardiac surgery. In: Davila J.C., ed. Henry Ford Hospital International Symposium on Cardiac Surgery, 2nd ed. New York: Appleton-Century-Crofts, 1975:232-241.
26. Sergeant PT, Blackstone EH, Lesaffre E, Flameng W, Kirklin JW (unpublished study, 1990). Cited in: Kirklin JW, Barratt-Boyes BG, eds. Cardiac surgery, 2nd ed. New York: Churchill Livingstone, 1993;1:315.

This article has been cited by other articles:

				V. Guru, J. V. Tu, E. Etchells, G. M. Anderson, C. D. Naylor, R. J. Novick, C. M. Feindel, F. D. Rubens, K. Teoh, A. Mathur, et al. Relationship Between Preventability of Death After Coronary Artery Bypass Graft Surgery and All-Cause Risk-Adjusted Mortality Rates Circulation, June 10, 2008; 117(23): 2969 - 2976. [Abstract] [Full Text] [PDF]

				E. Gongora and T. M. Sundt III Myocardial Revascularization with Cardiopulmonary Bypass Card. Surg. Adult, January 1, 2008; 3(2008): 599 - 632. [Full Text]

				F. B. Vanky, E. Hakanson, and R. Svedjeholm Long-Term Consequences of Postoperative Heart Failure After Surgery for Aortic Stenosis Compared With Coronary Surgery Ann. Thorac. Surg., June 1, 2007; 83(6): 2036 - 2043. [Abstract] [Full Text] [PDF]

				M. Ma, K. Gauvreau, C. K. Allan, J. E. Mayer Jr, and K. J. Jenkins Causes of Death After Congenital Heart Surgery Ann. Thorac. Surg., April 1, 2007; 83(4): 1438 - 1445. [Abstract] [Full Text] [PDF]

				J. F. Waljee, S. Windisch, J. F. Finks, S. L. Wong, and J. D. Birkmeyer Classifying Cause of Death After Cancer Surgery Surgical Innovation, December 1, 2006; 13(4): 274 - 279. [Abstract] [PDF]

				S. D. Surgenor, G. R. DeFoe, M. P. Fillinger, D. S. Likosky, R. C. Groom, C. Clark, R. E. Helm, R. S. Kramer, B. J. Leavitt, J. D. Klemperer, et al. Intraoperative Red Blood Cell Transfusion During Coronary Artery Bypass Graft Surgery Increases the Risk of Postoperative Low-Output Heart Failure Circulation, July 4, 2006; 114(1_suppl): I-43 - I-48. [Abstract] [Full Text] [PDF]

				F. B. Vanky, E. Hakanson, E. Tamas, and R. Svedjeholm Risk Factors for Postoperative Heart Failure in Patients Operated on for Aortic Stenosis Ann. Thorac. Surg., April 1, 2006; 81(4): 1297 - 1304. [Abstract] [Full Text] [PDF]

				W. C. Nugent Building and Supporting Sustainable Improvement in Cardiac Surgery: The Northern New England Experience Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2005; 9(2): 115 - 118. [Abstract] [PDF]

				R. C. Groom and Cardiovascular Disease Study Group A Systematic Approach to the Understanding and Redesigning of Cardiopulmonary Bypass Seminars in Cardiothoracic and Vascular Anesthesia, June 1, 2005; 9(2): 159 - 161. [Abstract] [PDF]

				S. F. Khuri, N. A. Healey, M. Hossain, V. Birjiniuk, M. D. Crittenden, M. Josa, P. R. Treanor, S. F. Najjar, D. J. Kumbhani, and W. G. Henderson Intraoperative regional myocardial acidosis and reduction in long-term survival after cardiac surgery J. Thorac. Cardiovasc. Surg., February 1, 2005; 129(2): 372 - 381. [Abstract] [Full Text] [PDF]

				R C Groom, D S Likosky, R J Forest, G T O'Connor, J R Morton, C S Ross, C Clark, and R Kramer A model for cardiopulmonary bypass redesign Perfusion, July 1, 2004; 19(4): 257 - 261. [Abstract] [PDF]

				D. S. Likosky, W. H. Likosky, and T. L. Cress Re: Relationship Between Process and Outcome in Stroke Care Stroke, September 1, 2003; 34 (9): e158 - e158. [Full Text] [PDF]

				A. P. Furnary, G. Gao, G. L. Grunkemeier, Y. Wu, K. J. Zerr, S. O. Bookin, H. S. Floten, and A. Starr Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting J. Thorac. Cardiovasc. Surg., May 1, 2003; 125(5): 1007 - 1021. [Abstract] [Full Text] [PDF]

				R. M. Mentzer Jr, R. D. Lasley, A. Jessel, and M. Karmazyn Intracellular sodium hydrogen exchange inhibition and clinical myocardial protection Ann. Thorac. Surg., February 1, 2003; 75(2): S700 - 708. [Abstract] [Full Text] [PDF]

				R. H. Mehta, D. Bruckman, S. Das, T. Tsai, P. Russman, D. Karavite, H. Monaghan, S. Sonnad, M. J. Shea, K. A. Eagle, et al. Implications of increased left ventricular mass index on in-hospital outcomes in patients undergoing aortic valve surgery J. Thorac. Cardiovasc. Surg., November 1, 2001; 122(5): 919 - 928. [Abstract] [Full Text] [PDF]

				J. L. Robinson, D. B. Nash, E. Moxey, and J. P. O'Connor Certificate of Need and the Quality of Cardiac Surgery American Journal of Medical Quality, September 1, 2001; 16(5): 155 - 160. [Abstract] [PDF]

				W. Nugent Collaborative practice: a personal journey Ann. Thorac. Surg., March 1, 2001; 71(3): 765 - 765. [Full Text] [PDF]

				G. R. DeFoe, C. S. Ross, E. M. Olmstead, S. D. Surgenor, M. P. Fillinger, R. C. Groom, R. J. Forest, J. W. Pieroni, C. S. Warren, M. E. Bogosian, et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting Ann. Thorac. Surg., March 1, 2001; 71(3): 769 - 776. [Abstract] [Full Text] [PDF]

				S. D. Surgenor, G. T. O'Connor, S. J. Lahey, R. Quinn, D. C. Charlesworth, L. J. Dacey, R. A. Clough, B. J. Leavitt, G. R. Defoe, M. Fillinger, et al. Predicting the Risk of Death from Heart Failure After Coronary Artery Bypass Graft Surgery Anesth. Analg., March 1, 2001; 92(3): 596 - 601. [Abstract] [Full Text] [PDF]

				N. J.O. Birkmeyer, C. A.S. Marrin, J. R. Morton, B. J. Leavitt, S. J. Lahey, D. C. Charlesworth, F. Hernandez, E. M. Olmstead, and G. T. O'Connor Decreasing mortality for aortic and mitral valve surgery in northern New England Ann. Thorac. Surg., August 1, 2000; 70(2): 432 - 437. [Abstract] [Full Text] [PDF]

				W. L. Holman, E. D. Peterson, C. L. Athanasuleas, R. M. Allman, M. Sansom, C. Kiefe, and R. G. Sherrill Alabama Coronary Artery Bypass Grafting Cooperative Project: baseline data Ann. Thorac. Surg., November 1, 1999; 68(5): 1592 - 1598. [Abstract] [Full Text] [PDF]

				W. C. Nugent Innovative uses of a cardiothoracic database Ann. Thorac. Surg., August 1, 1999; 68(2): 359 - 361. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Lawrence J. Dacey Charles A.S. Marrin Jeremy R. Morton Bruce J. Leavitt Christopher T. Maloney Felix Hernandez Robert A. Clough William C. Nugent David C. Charlesworth Stephen K. Plume Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by O’Connor, G. T. Articles by Plume, S. K. Search for Related Content PubMed PubMed Citation Articles by O’Connor, G. T. Articles by Plume, S. K.