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Ann Thorac Surg 2003;75:1856-1865
© 2003 The Society of Thoracic Surgeons
a Denver Department of Veterans Affairs Medical Center, and University of Colorado Health Sciences Center, Denver, Colorado, USA
b Duke Clinical Research Institute, Durham, North Carolina, USA
c The Society of Thoracic Surgeons, Chicago, Illinois, USA
d LSU Health Sciences Center, New Orleans, Louisiana, USA
e University of Florida Health Sciences Center, Jacksonville, Florida, USA
* Address reprint requests to Dr Shroyer, Denver Department of Veterans Affairs Medical Center, 1055 Clermont St (112R), Denver, CO 80220, USA
e-mail: laurie.shroyer{at}med.va.gov
Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
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Abstract |
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METHODS: For CABG procedures, the 1997 to 1999 Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database was used to develop ROM and risk-adjusted morbidity (ROMB) models. Risk factors were selected using standard STS univariate screening and multivariate logistic regression approaches. Risk model performance was assessed. Across STS participating sites, the association of observed-to-expected (O/E) ratios for ROM and ROMB was evaluated.
RESULTS: The 30-day operative death and major complication rates for STS CABG procedures were 3.05% and 13.40%, respectively (503,478 CABG procedures), including stroke (1.63%), renal failure (3.53%), reoperation (5.17%), prolonged ventilation (5.96%), and sternal infection (0.63%). Risk models were developed (c-indexes for stroke [0.72], renal failure [0.76], reoperation [0.64], prolonged ventilation [0.75], sternal infection [0.66], and the composite endpoint [0.71]). Only a slight correlation was found, however, between ROMB and ROM indicators.
CONCLUSIONS: Used in combination, ROMB and ROM may provide the surgical team with additional information to evaluate the quality of their care as well as valuable insights to allow them to focus on areas for improvement.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
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Although operative mortality is obviously the most deleterious clinical endpoint, limitations exist to using mortality alone to evaluate a surgical team’s quality of care. Over the past decade, 30-day operative mortality rates for CABG-only procedures have declined significantly. In spite of a significant increase in the preoperative risks of the patients [2], this indicates a very significant improvement in the quality of cardiac surgical care rendered by STS members.
It is clearly recognized that complications of cardiac surgery may not be fatal but can significantly impact a patient’s functional status and quality of life. The ability of CABG surgery to improve overall health-related quality of life has been demonstrated and is considered a major indication for a CABG operation [3]. Therefore, the addition of risk-adjusted morbidity reports for CABG procedures may provide valuable insights on areas to focus improved quality of care.
Similar to 30-day mortality, complications are influenced by preoperative patient characteristics that must be accounted for in any comparisons between surgical programs and benchmarks. Using the STS National Adult Cardiac Surgery Database, a primary objective of this study was to determine the frequency of major complications and to provide a new composite morbidity endpoint (based on the presence of either 30-day operative mortality or the presence of any major complication). The key preoperative clinical risk factors associated with a set of major morbidities were identified. Logistic regression risk models for each major morbidity endpoint (as well as the summary composite endpoint for mortality and morbidity) were developed and their performance assessed. Using regression analyses of the observed to expected ratios for 30-day operative death in comparison with this set of major morbidities (each assessed individually), the supplementary information provided by using these two different types of risk-adjusted outcome measures together in combination was assessed across the STS participating member sites.
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
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From the set of records with CABG-only procedural designation, records with missing age (or out-of-range age) or missing sex were excluded from this analysis. After exclusion criteria were applied, the resultant population for this study’s risk modeling analyses consisted of 503,478 CABG-only patient records from 495 participating sites throughout the United States.
Selection of major morbidity endpoints
In collaboration with the Duke Clinical Research Institute (DCRI) National Database Warehouse activities, the STS National Database Risk Stratification Sub-Committee identified a subgroup of major complications (either life threatening or potentially resulting in permanent functional disability) that appeared to be most uniformly reported. Five STS major morbidity endpoints were selected: permanent stroke, renal dysfunction or renal failure requiring dialysis, any cardiac surgery reoperation, prolonged ventilation greater than 48 hours, and deep sternal wound infection. For clarification, the renal morbidity endpoint was defined as acute postoperative renal insufficiency resulting in one or more of the following: an increase of serum creatinine to more than 2.0; 50% or greater increase in creatinine over base line preoperative value; a new requirement for dialysis.
Although several other STS morbidity outcomes might normally been considered as major (such as septicemia and perioperative myocardial infarction), a review of the data for these adverse events revealed too much variation in reporting, indicating a problem with definition or interpretation or uniformity of tests. Therefore, these other major morbidity endpoints were not included in this analysis. Rigorous data quality standards for the coding of these five major perioperative complications used for this analysis were previously established [4, 5].
Analytic methods
With the exception of body surface area (where a gender-specific median value was used), all missing or out-of-range values were imputed using the variable-specific median value. Records were initially randomly assigned based on an approximate split into an 80/20 learning and test groupings to determine model test-retest reliability. For the final 1997 to 1999 CABG model, the learning population included 403,325 records and the testing population included 100,153 records. Among the 403,325 patients in the learning data set there were 12,374 30-day operative deaths and 54,156 cases where either a major morbidity or 30-day operative death occurred. In spite of the large sample size of the STS National Cardiac Database, there were no clinically important differences between characteristics of patients in the learning and testing subpopulations.
Before proceeding with developing a multivariate analysis, univariate screening of all model-eligible risk factors was performed. Based on the univariate screening, 30 potential risk factors were identified. A multivariate stepwise logistic regression analysis was then performed for each of the seven dependent variables: (1) 30-day operative death; (2) permanent stroke; (3) renal dysfunction or renal failure requiring dialysis; (4) any reoperation; (5) prolonged ventilation; (6) deep sternal wound infection; and (7) the summary composite endpoint (the presence of any major morbidity or 30-day operative mortality). For all STS models developed, the proposed limit for number of model eligible variables was not exceeded [6].
Model performance
For all statistical risk models developed, traditional approaches were used to assess model performance [7]. The logistic risk model’s accuracy for prediction was measured using the c-index (a measure of model discrimination). Generally, the value for a c-index ranges from 0.5 (ie, 50/50 with no discrimination better than chance alone) to 1.0 (perfect prediction). Model calibration (the degree to which observed outcomes are similar to the predicted outcomes from the model across patients) was examined by comparing average observed and predicted values within each of 10 equal-sized subgroups arranged in increasing order of patient risk. To evaluate model calibration, the Hosmer-Lemeshow (H-L) test for the lack of "goodness of fit" was applied. As noted in the literature, the value for the H-L test is limited because of the large STS sample size [8].
Evaluating association between STS member site mortality and morbidity observed-to-expected ratios
The final STS risk-models were applied to the CABG-only records to calculate the risk for 30-day operative mortality and morbidity. For each STS hospital that performed at least 20 CABG procedures during the study period, an observed-to-expected (O/E) ratio was calculated (with 95% confidence intervals [CI]) for 30-day operative mortality and for each of five major morbidities. Based on these STS member site-specific O/E ratios, a Spearman rank correlation coefficient was used to evaluate whether the five O/E ratios for major morbidities were associated with the O/E ratios for 30-day operative mortality. Using this approach, the degree of association was evaluated to determine if these different risk-adjusted major morbidity measures provided duplicative or complementary information to the traditional risk-adjusted mortality information.
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Results |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
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Model performance
To evaluate model performance, both a c-index (measure of model discrimination) and H-L test (measure of model calibration across risk groups to evaluate "goodness of fit") were calculated. Generally, there was generally an acceptable degree of model predictive power. The c-index was lower for deep sternal wound infection and reoperation models. Based on a comparison of the split-sample learning and testing sets, the predictive accuracy of these models was acceptable.
Figures 1 and 2 demonstrate the calibration of models or how well the predicted event rates match the observed event rates among patient subgroups of risk. As noted by the close agreement between these results, these models appear to be relatively accurate across the ranges of patient risk subgroups. The details of model performance metrics are provided in Table 4.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
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Although mortality is obviously the most extreme adverse clinical endpoint, limitations exist to using operative mortality alone to evaluate a surgical team’s quality of care. Major complications often impact not only the perioperative period but also the patient’s quality of life in the future and may often pose serious threats to a patient’s longer-term survival, functional capabilities, and overall well being after the CABG procedure.
Complementary outcome measures for risk-adjusted major morbidities were developed. This supplementary analysis created a window of opportunity to examine the patient risk characteristics that are most likely to influence major morbidity, as well as to examine the overall impact of morbidity models on the evaluation of current CABG outcomes as part of the STS national continuous quality improvement reporting initiative.
For future STS research, morbidity risk models also may play important role in evaluating different clinical treatment strategies. As part of several ongoing STS studies evaluating different cardiac surgical approaches (eg, the use of internal mammary artery grafting in the elderly), these new STS morbidity models have been implemented successfully. Even if a short-term survival benefit is demonstrated for a specific approach, the probability for the occurrence of a major morbid event needs to be an important consideration in the surgeon’s decision-making process—weighing the advantages and disadvantages before proceeding toward implementation in daily clinical practice.
From the results in Table 3, there appears to be a high degree of overlap between the risk factors that are predictive for both the 30-day operative mortality and the major morbidity risk models. For example, the variables for age, sex, BSA, previous myocardial infarction, cerebrovascular and peripheral vascular disease, diabetes, and use of intraaortic balloon pump are a subset of the risk factors that were predictive across all of the seven mortality and morbidity models developed. A smaller set of patient clinical characteristics may be identified in the future to constitute a "core" set of patient risk factors for the most serious adverse events [10].
Generally, the previously reported CABG morbidity models in the literature had been developed from populations of small size (usually single-center studies), focused on a single major morbidity outcome, or developed using data from high-risk patient groups [11–14]. From an STS national reporting perspective, therefore, these existing morbidity models had limited applicability as broad risk-evaluation tools for STS CABG patients.
Overall, the set of risk models developed in this study performed acceptably. The clinical implications are that preoperative patient risk factors have a significant influence on the likelihood for major morbid events (ie, older, sicker patients are at higher risk for occurrence of perioperative complications). For both deep sternal wound infection and reoperation morbidity endpoints, there are several potential reasons for the lower model discrimination that was observed, including (1) the patient preoperative risk factors most relevant to these two endpoints may not be captured adequately; (2) these two complications may have reporting reliability challenges; or (3) patient preoperative factors may not have as a high impact upon the likelihood for these two events occurring. That is, these two major morbidities may be potentially more related to processes and structures of cardiac surgical care (for example, reoperation may potentially be related to surgeon technical skill and surgical infection may possibly be related to operative time or technique) rather than a patient’s inherent risk profile.
It may be of interest to note, that the directionality and impact of a given risk factor may vary across the risk models developed for different outcomes. As previously reported, female gender is an important predictor of 30-day operative mortality [15, 16]. In the major morbidity risk models developed, however, the impact of female gender is not consistent across different complications. For example, the impact of female gender appears to be slightly protective for the major morbidity endpoints of renal failure requiring dialysis and reoperation. However, female gender appears to predispose to higher adverse event rates for the outcomes of 30-day operative death, stroke, prolonged ventilation, and deep sternal wound infection. Moreover, female gender appears to maintain this overall adverse impact when the summary composite endpoint (combining both mortality and major morbidity) is assessed.
As might be anticipated clinically, the impact of emergent salvage, emergent, urgent, or elective status are in that order predictive of an adverse event. In reviewing the odds ratio for the status variable across models, the impact on mortality appears higher than the impact on major morbidity endpoints. Importantly, the incidence of the composite endpoint (an adverse outcome combining both mortality and morbidity) even for relatively low risk the elective and urgent patient subgroups is sufficiently high (as noted in Table 1) to suggest that focusing on the combined endpoint may have value for this subgroup of CABG patients.
A key question addressed by this study was if calculating an O/E ratio for five individual major morbidities added additional information that may be potentially helpful to individual surgeons and groups beyond the information obtained from risk-adjusted mortality alone. A high degree of association between mortality and morbidity O/E ratios would indicate that one approach might be a substitute for the other. A low degree of association, however, would indicate that both measures together provide complementary information.
From the results in Table 5, it is clear that there was not a statistically significant association between O/E ratios for deep sternal wound infection with 30-day operative mortality. For the other four major morbidity outcomes (stroke, renal failure, prolonged ventilation, and reoperation), there was a statistically significant association between these morbidities and 30-day operative mortality. Given the low degree of association found between O/E ratios for mortality with major morbidity (correlation coefficients ranging from 0.03 to 0.26), it appears that reporting risk-adjusted morbidity provides additional information, but not duplicative of, risk-adjusted mortality information currently provided to all STS member sites.
This low degree of association may be due in part to the fact that mortality is an objective "hard" endpoint, whereas there may be greater variability in the collection of morbidity uniformly across hospitals. There was a higher association between risk-adjusted mortality and the three major complications of permanent stroke (Spearman’s correlation coefficient = 0.20), renal failure requiring dialysis (Spearman’s correlation coefficient = 0.21), and prolonged ventilation (Spearman’s correlation coefficient = 0.26) in comparison with reoperation (Spearman’s correlation coefficient = 0.13). Again, the reasons for this discordance may well be related to other clinical factors (eg, the conduct of the operation) that contribute to the occurrence of these postoperative complications. Although the reliability of STS morbidity reporting cannot be readily assessed, the first step toward improving morbidity data is to begin to provide local surgical teams with their risk-adjusted morbidity results. In summary, these new individual morbidity models and the new composite model complement to a high degree the previous CABG 30-day operative mortality model generated for the STS National Adult Cardiac Surgery Database. Together, these risk-adjusted mortality and risk-adjusted morbidity data provide a broader range of outcomes to screen and focus quality of care improvement activities after CABG, both at an individual site and nationwide. Based on these analyses, the STS Database has documented that 87% of patients coming to CABG can have the expectation of surviving the procedure without a major morbid event. [17]
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Acknowledgments |
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Discussion |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
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DR EDWARDS: DCRI has an audit protocol to insure high quality of the data. That has considerably cleaned up the data as compared with 5 or 6 years ago. Now, as far as knowing that each one of the individual participating organizations reports every case they have done: there is simply not a way to do that in a voluntary database. As you know, some of the other databases are involuntary, like the VA system, and the New York State system in particular. They have ways of actually going out to the institutions to make sure that if a case was done it gets entered into the database. With a voluntary database, you simply do not have that luxury and clearly that is one of the disadvantages of a voluntary database.
In regard to missing data, there are standard ways that we can use imputation techniques or substitution techniques to allow us to use a patient with some degree of missing data. Ejection fraction, as you point out, is often missing, often for very good clinical reasons, and that is one of the ideal circumstances in which we use imputation data.
DR JOHN C. CHEN (Honolulu, HI): As you are developing this model, are you going to use the same variables for on pump versus off pump for all calculations?
DR EDWARDS: We did not take that into account with the models developed here. I think it would make a very good follow-up study to be able to break the population into on-pump and off-pump groups and develop different models for each. You could also just run simple univariate and multivariate analyses of the risk factors to see if perhaps the risk factors are different for each one of the populations. But up to this point we have not done that.
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M. Singh, B. J. Gersh, S. Li, J. S. Rumsfeld, J. A. Spertus, S. M. O'Brien, R. M. Suri, and E. D. Peterson Mayo Clinic Risk Score for Percutaneous Coronary Intervention Predicts In-Hospital Mortality in Patients Undergoing Coronary Artery Bypass Graft Surgery Circulation, January 22, 2008; 117(3): 356 - 362. [Abstract] [Full Text] [PDF]
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 V. A. Ferraris, F. H. Edwards, D. M. Shahian, and S. P. Ferraris Risk Stratification and Comorbidity Card. Surg. Adult, January 1, 2008; 3(2008): 199 - 246. [Full Text]
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E. Gongora and T. M. Sundt III Myocardial Revascularization with Cardiopulmonary Bypass Card. Surg. Adult, January 1, 2008; 3(2008): 599 - 632. [Full Text]
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S. M. O'Brien, E. R. DeLong, R. S. Dokholyan, F. H. Edwards, and E. D. Peterson Exploring the Behavior of Hospital Composite Performance Measures: An Example From Coronary Artery Bypass Surgery Circulation, December 18, 2007; 116(25): 2969 - 2975. [Abstract] [Full Text] [PDF]
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S. M. O'Brien, J. P. Jacobs, D. R. Clarke, B. Maruszewski, M. L. Jacobs, H. L. Walters III, C. I. Tchervenkov, K. F. Welke, Z. Tobota, G. Stellin, et al. Accuracy of the Aristotle Basic Complexity Score for Classifying the Mortality and Morbidity Potential of Congenital Heart Surgery Operations Ann. Thorac. Surg., December 1, 2007; 84(6): 2027 - 2037. [Abstract] [Full Text] [PDF]
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 T. Abe, M. Kajiyama, K. Ohara, M. Asaoka, M. Toyama, and A. Kobayashi Combined Coronary Artery Re-operation and Pulmonary Resection for Hemoptysis Asian Cardiovasc Thorac Ann, December 1, 2007; 15(6): e75 - e76. [Abstract] [Full Text] [PDF]
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J. D. Puskas, F. H. Edwards, P. A. Pappas, S. O'Brien, E. D. Peterson, P. Kilgo, and T. B. Ferguson Jr Off-Pump Techniques Benefit Men and Women and Narrow the Disparity in Mortality After Coronary Bypass Grafting Ann. Thorac. Surg., November 1, 2007; 84(5): 1447 - 1456. [Abstract] [Full Text] [PDF]
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O. M. Lattouf, J. D. Puskas, V. H. Thourani, J. Noora, P. D. Kilgo, and R. A. Guyton Does the Number of Grafts Influence Surgeon Choice and Patient Benefit of Off-Pump Over Conventional On-Pump Coronary Artery Revascularization in Multivessel Coronary Artery Disease? Ann. Thorac. Surg., November 1, 2007; 84(5): 1485 - 1495. [Abstract] [Full Text] [PDF]
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J. D. Puskas, P. D. Kilgo, M. Kutner, S. V. Pusca, O. Lattouf, and R. A. Guyton Off-Pump Techniques Disproportionately Benefit Women and Narrow the Gender Disparity in Outcomes After Coronary Artery Bypass Surgery Circulation, September 11, 2007; 116(11_suppl): I-192 - I-199. [Abstract] [Full Text] [PDF]
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A. F. Hernandez, J. D. Grab, J. S. Gammie, S. M. O'Brien, B. G. Hammill, J. G. Rogers, M. T. Camacho, M. K. Dullum, T. B. Ferguson, and E. D. Peterson A Decade of Short-Term Outcomes in Post Cardiac Surgery Ventricular Assist Device Implantation: Data From the Society of Thoracic Surgeons' National Cardiac Database Circulation, August 7, 2007; 116(6): 606 - 612. [Abstract] [Full Text] [PDF]
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S. L.C. Reddy, A. D. Grayson, E. M. Griffiths, D. M. Pullan, and A. Rashid Logistic Risk Model for Prolonged Ventilation After Adult Cardiac Surgery Ann. Thorac. Surg., August 1, 2007; 84(2): 528 - 536. [Abstract] [Full Text] [PDF]
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P. E. Antunes, L. Eugenio, J. Ferrao de Oliveira, and M. J. Antunes Mortality risk prediction in coronary surgery: a locally developed model outperforms external risk models Interactive CardioVascular and Thoracic Surgery, August 1, 2007; 6(4): 437 - 441. [Abstract] [Full Text] [PDF]
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M. McNeil, K. Buth, A. Brydie, A. MacLaren, and R. Baskett The impact of diffuseness of coronary artery disease on the outcomes of patients undergoing primary and reoperative coronary artery bypass grafting Eur. J. Cardiothorac. Surg., May 1, 2007; 31(5): 827 - 833. [Abstract] [Full Text] [PDF]
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G. L. Grunkemeier and Y. Wu What Are the Odds? Ann. Thorac. Surg., April 1, 2007; 83(4): 1240 - 1244. [Full Text] [PDF]
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S. M. O'Brien, D. M. Shahian, E. R. DeLong, S.-L. T. Normand, F. H. Edwards, V. A. Ferraris, C. K. Haan, J. B. Rich, C. M. Shewan, R. S. Dokholyan, et al. Quality Measurement in Adult Cardiac Surgery: Part 2--Statistical Considerations in Composite Measure Scoring and Provider Rating Ann. Thorac. Surg., April 1, 2007; 83(4_Supplement): S13 - S26. [Full Text] [PDF]
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E. L. Hannan, C. Wu, E. V. Bennett, R. E. Carlson, A. T. Culliford, J. P. Gold, R. S.D. Higgins, C. R. Smith, and R. H. Jones Risk Index for Predicting In-Hospital Mortality for Cardiac Valve Surgery Ann. Thorac. Surg., March 1, 2007; 83(3): 921 - 929. [Abstract] [Full Text] [PDF]
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K. Kaya, M. Oguz, A. R. Akar, S. Durdu, A. Aslan, S. Erturk, R. Tasoz, and U. Ozyurda The effect of sodium nitroprusside infusion on renal function during reperfusion period in patients undergoing coronary artery bypass grafting: a prospective randomized clinical trial Eur. J. Cardiothorac. Surg., February 1, 2007; 31(2): 290 - 297. [Abstract] [Full Text] [PDF]
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V. L. Vida, H. Berggren, W. J. Brawn, W. Daenen, D. Di Carlo, R. Di Donato, H. L. Lindberg, A. F. Corno, J. Fragata, M. J. Elliott, et al. Risk of Surgery for Congenital Heart Disease in the Adult: A Multicentered European Study Ann. Thorac. Surg., January 1, 2007; 83(1): 161 - 168. [Abstract] [Full Text] [PDF]
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J. M. Murkin, S. J. Adams, R. J. Novick, M. Quantz, D. Bainbridge, I. Iglesias, A. Cleland, B. Schaefer, B. Irwin, and S. Fox Monitoring Brain Oxygen Saturation During Coronary Bypass Surgery: A Randomized, Prospective Study Anesth. Analg., January 1, 2007; 104(1): 51 - 58. [Abstract] [Full Text] [PDF]
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A. Royse and C. Royse A standardised intraoperative ultrasound examination of the aorta and proximal coronary arteries Interactive CardioVascular and Thoracic Surgery, December 1, 2006; 5(6): 701 - 704. [Abstract] [Full Text] [PDF]
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B E Keogh Logistic, additive or historical: is EuroSCORE an appropriate model for comparing individual surgeons' performance? Heart, December 1, 2006; 92(12): 1715 - 1716. [Abstract] [Full Text] [PDF]
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V. J. DiSesa, S. M. O'Brien, K. F. Welke, S. M. Beland, C. K. Haan, M. S. Vaughan-Sarrazin, and E. D. Peterson Contemporary Impact of State Certificate-of-Need Regulations for Cardiac Surgery: An Analysis Using the Society of Thoracic Surgeons' National Cardiac Surgery Database Circulation, November 14, 2006; 114(20): 2122 - 2129. [Abstract] [Full Text] [PDF]
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C. R. Parikh, S. G. Coca, G. L. Smith, V. Vaccarino, and H. M. Krumholz Impact of Chronic Kidney Disease on Health-Related Quality-of-Life Improvement After Coronary Artery Bypass Surgery. Arch Intern Med, October 9, 2006; 166(18): 2014 - 2019. [Abstract] [Full Text] [PDF]
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R. Salem, A. Y. Denault, P. Couture, S. Belisle, A. Fortier, M.-C. Guertin, M. Carrier, and R. Martineau Left ventricular end-diastolic pressure is a predictor of mortality in cardiac surgery independently of left ventricular ejection fraction Br. J. Anaesth., September 1, 2006; 97(3): 292 - 297. [Abstract] [Full Text] [PDF]
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R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): e1 - e148. [Full Text] [PDF]
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R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): 598 - 675. [Full Text] [PDF]
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A. Haverich, S. K. Shernan, J. H. Levy, J. C. Chen, M. Carrier, K. M. Taylor, F. Van de Werf, M. F. Newman, P. X. Adams, T. G. Todaro, et al. Pexelizumab Reduces Death and Myocardial Infarction in Higher Risk Cardiac Surgical Patients Ann. Thorac. Surg., August 1, 2006; 82(2): 486 - 492. [Abstract] [Full Text] [PDF]
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J. Nilsson, M. Ohlsson, L. Thulin, P. Hoglund, S. A.M. Nashef, and J. Brandt Risk factor identification and mortality prediction in cardiac surgery using artificial neural networks J. Thorac. Cardiovasc. Surg., July 1, 2006; 132(1): 12 - 19. [Abstract] [Full Text] [PDF]
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K. F. Welke, I. Shen, and R. M. Ungerleider Current assessment of mortality rates in congenital cardiac surgery. Ann. Thorac. Surg., July 1, 2006; 82(1): 164 - 170. [Abstract] [Full Text] [PDF]
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C. W. Hogue Jr, C. A. Palin, and J. E. Arrowsmith Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices. Anesth. Analg., July 1, 2006; 103(1): 21 - 37. [Abstract] [Full Text] [PDF]
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J. R. Edgerton, M. A. Herbert, S. L. Prince, J. L. Horswell, L. Michelson, M. J. Magee, T. M. Dewey, Z. J. Edgerton, and M. J. Mack Reduced Atrial Fibrillation in Patients Immediately Extubated After Off-Pump Coronary Artery Bypass Grafting Ann. Thorac. Surg., June 1, 2006; 81(6): 2121 - 2127. [Abstract] [Full Text] [PDF]
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T. A. Vassiliades Jr, J. S. Douglas, D. C. Morris, P. C. Block, Z. Ghazzal, S. T. Rab, and C. U. Cates Integrated coronary revascularization with drug-eluting stents: Immediate and seven-month outcome J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 956 - 962. [Abstract] [Full Text] [PDF]
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D. S. Likosky, W. C. Nugent, R. A. Clough, P. W. Weldner, H. B. Quinton, C. S. Ross, and G. T. O'Connor Comparison of Three Measurements of Cardiac Surgery Mortality for the Northern New England Cardiovascular Disease Study Group Ann. Thorac. Surg., April 1, 2006; 81(4): 1393 - 1395. [Abstract] [Full Text] [PDF]
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L. Abrahamyan, A. Demirchyan, M. E Thompson, and H. Hovaguimian Determinants of Morbidity and Intensive Care Unit Stay after Coronary Surgery Asian Cardiovasc Thorac Ann, April 1, 2006; 14(2): 114 - 118. [Abstract] [Full Text] [PDF]
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O. V. Hein, J. Birnbaum, K. Wernecke, M. England, W. Konertz, and C. Spies Prolonged Intensive Care Unit Stay in Cardiac Surgery: Risk Factors and Long-Term-Survival Ann. Thorac. Surg., March 1, 2006; 81(3): 880 - 885. [Abstract] [Full Text] [PDF]
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Preoperative statin treatment is associated with reduced postoperative mortality and morbidity in patients undergoing cardiac surgery: an 8-year retrospective cohort study. J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 679 - 685.
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W. A. Cooper, S. M. O'Brien, V. H. Thourani, R. A. Guyton, C. R. Bridges, L. A. Szczech, R. Petersen, and E. D. Peterson Impact of Renal Dysfunction on Outcomes of Coronary Artery Bypass Surgery: Results From the Society of Thoracic Surgeons National Adult Cardiac Database Circulation, February 28, 2006; 113(8): 1063 - 1070. [Abstract] [Full Text] [PDF]
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W. S. Weintraub Evaluating the Risk of Coronary Surgery and Percutaneous Coronary Intervention J. Am. Coll. Cardiol., February 7, 2006; 47(3): 669 - 671. [Full Text] [PDF]
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E. L. Hannan, C. Wu, E. V. Bennett, R. E. Carlson, A. T. Culliford, J. P. Gold, R. S.D. Higgins, O. W. Isom, C. R. Smith, and R. H. Jones Risk Stratification of In-Hospital Mortality for Coronary Artery Bypass Graft Surgery J. Am. Coll. Cardiol., February 7, 2006; 47(3): 661 - 668. [Abstract] [Full Text] [PDF]
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F. Seccareccia, C. A. Perucci, P. D'Errigo, M. Arca, D. Fusco, S. Rosato, D. Greco, and on behalf of the research group of the Italian CAB The Italian CABG Outcome Study: short-term outcomes in patients with coronary artery bypass graft surgery Eur. J. Cardiothorac. Surg., January 1, 2006; 29(1): 56 - 62. [Abstract] [Full Text] [PDF]
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F. H. Edwards, R. M. Engelman, P. Houck, D. M. Shahian, and C. R. Bridges The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic Prophylaxis in Cardiac Surgery, Part I: Duration Ann. Thorac. Surg., January 1, 2006; 81(1): 397 - 404. [Full Text] [PDF]
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 P. F. Hoilund-Carlsen, A. Johansen, H. W. Christensen, W. Vach, M. Moldrup, P. Bartram, A. Veje, T. Haghfelt, and for the Myocardial Ischemia Logistics Evaluation S Potential impact of myocardial perfusion scintigraphy as gatekeeper for invasive examination and treatment in patients with stable angina pectoris: observational study without post-test referral bias Eur. Heart J., January 1, 2006; 27(1): 29 - 34. [Abstract] [Full Text] [PDF]
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K. F. Welke, M. J. Barnett, M. S. Vaughan Sarrazin, and G. E. Rosenthal Limitations of Hospital Volume as a Measure of Quality of Care for Coronary Artery Bypass Graft Surgery Ann. Thorac. Surg., December 1, 2005; 80(6): 2114 - 2119. [Abstract] [Full Text] [PDF]
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K. Karkouti, G. Djaiani, M. A. Borger, W. S. Beattie, L. Fedorko, D. Wijeysundera, J. Ivanov, and J. Karski Low Hematocrit During Cardiopulmonary Bypass is Associated With Increased Risk of Perioperative Stroke in Cardiac Surgery Ann. Thorac. Surg., October 1, 2005; 80(4): 1381 - 1387. [Abstract] [Full Text] [PDF]
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D. N. Wijeysundera, W. S. Beattie, G. Djaiani, V. Rao, M. A. Borger, K. Karkouti, and R. J. Cusimano Off-Pump Coronary Artery Surgery for Reducing Mortality and Morbidity: Meta-Analysis of Randomized and Observational Studies J. Am. Coll. Cardiol., September 6, 2005; 46(5): 872 - 882. [Abstract] [Full Text] [PDF]
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G. Ambler, R. Z. Omar, P. Royston, R. Kinsman, B. E. Keogh, and K. M. Taylor Generic, Simple Risk Stratification Model for Heart Valve Surgery Circulation, July 12, 2005; 112(2): 224 - 231. [Abstract] [Full Text] [PDF]
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R. Jin, G. L. Grunkemeier, A. P. Furnary, J. R. Handy Jr, and for the Providence Health System Cardiovascular St Is Obesity a Risk Factor for Mortality in Coronary Artery Bypass Surgery? Circulation, June 28, 2005; 111(25): 3359 - 3365. [Abstract] [Full Text] [PDF]
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A. Zacharias, T. A. Schwann, C. J. Riordan, S. J. Durham, A. Shah, T. J. Papadimos, M. Engoren, and R. H. Habib Is Hospital Procedure Volume a Reliable Marker of Quality for Coronary Artery Bypass Surgery? A Comparison of Risk and Propensity Adjusted Operative and Midterm Outcomes Ann. Thorac. Surg., June 1, 2005; 79(6): 1961 - 1969. [Abstract] [Full Text] [PDF]
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F. H. Edwards, V. A. Ferraris, D. M. Shahian, E. Peterson, A. P. Furnary, C. K. Haan, and C. R. Bridges Gender-Specific Practice Guidelines for Coronary Artery Bypass Surgery: Perioperative Management Ann. Thorac. Surg., June 1, 2005; 79(6): 2189 - 2194. [Abstract] [Full Text] [PDF]
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M. J. Mack, M. Herbert, S. Prince, T. M. Dewey, M. J. Magee, and J. R. Edgerton Does reporting of coronary artery bypass grafting from administrative databases accurately reflect actual clinical outcomes? J. Thorac. Cardiovasc. Surg., June 1, 2005; 129(6): 1309 - 1317. [Abstract] [Full Text] [PDF]
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P.-E. Falcoz, S. Chocron, C. Binquet, L. Stoica, D. Kaili, C. Quantin, and J.-P. Etievent Revascularization of the Right Coronary Artery: Grafting or Percutaneous Coronary Intervention? Ann. Thorac. Surg., April 1, 2005; 79(4): 1232 - 1239. [Abstract] [Full Text] [PDF]
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F. Kerendi, J. D. Puskas, J. M. Craver, W. A. Cooper, E. L. Jones, O. M. Lattouf, J. D. Vega, and R. A. Guyton Emergency Coronary Artery Bypass Grafting Can Be Performed Safely Without Cardiopulmonary Bypass in Selected Patients Ann. Thorac. Surg., March 1, 2005; 79(3): 801 - 806. [Abstract] [Full Text] [PDF]
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A. A. Fox and N. A. Nussmeier Does Gender Influence the Likelihood or Types of Complications Following Cardiac Surgery? Seminars in Cardiothoracic and Vascular Anesthesia, December 1, 2004; 8(4): 283 - 295. [Abstract] [PDF]
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M. Caputo, B. C. Reeves, C. A. Rogers, R. Ascione, and G. D. Angelini Monitoring the performance of residents during training in off-pump coronary surgery J. Thorac. Cardiovasc. Surg., December 1, 2004; 128(6): 907 - 915. [Abstract] [Full Text] [PDF]
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J. P. Gold, K. E. Torres, W. Maldarelli, I. Zhuravlev, D. Condit, and J. Wasnick Improving Outcomes in Coronary Surgery: The Impact of Echo-Directed Aortic Cannulation and Perioperative Hemodynamic Management in 500 Patients Ann. Thorac. Surg., November 1, 2004; 78(5): 1579 - 1585. [Abstract] [Full Text] [PDF]
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D. M. Shahian, E. H. Blackstone, F. H. Edwards, F. L. Grover, G. L. Grunkemeier, D. C. Naftel, S. A.M. Nashef, W. C. Nugent, and E. D. Peterson Cardiac Surgery Risk Models: A Position Article Ann. Thorac. Surg., November 1, 2004; 78(5): 1868 - 1877. [Abstract] [Full Text] [PDF]
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C. Weissman Pulmonary Complications After Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2004; 8(3): 185 - 211. [Abstract] [PDF]
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S. Garwood Renal Insufficiency After Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2004; 8(3): 227 - 241. [Abstract] [PDF]
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