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Objective: To evaluate the effect of a blood conservation program on trends in use of donor blood products and early clinical outcomes in infants undergoing open heart surgery.

Methods: Four hundred nine patients younger than age 1 year undergoing open-heart surgery between October 1, 2020, and June 30, 2023, were reviewed. The study period was divided into 4 eras with the first era as a before blood conservation baseline using traditional blood management. The following 3 eras comprised incremental implementation and evolution of blood conservation strategies. The total volume of blood products transfused for each surgical hospitalization was calculated and indexed to body weight at time of surgery.

Results: There was no significant difference in age at surgery, body weight, distribution of The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery categories, and in postoperative length of mechanical ventilation, intensive care unit or hospital length of stay, or postoperative mortality (P > .05 for all) across the 4 eras. Median total volume of blood products administered during hospitalization decreased from 128 mL/kg (range, 92-220 mL/kg) during the baseline period to 21 mL/kg (range, 6-44 mL/kg) during the last era (P < .01). Multivariate analysis demonstrated that later eras were associated with decreased odds of experiencing exposure to blood products during hospitalization.

Conclusions: Blood conservation is associated with significant reduction in usage of blood products during open heart surgery in infants with no significant effect on early outcomes. This trend is observed across all categories of surgical complexity. Additional studies are needed to prove consistency and to determine the longer-term clinical impact of this strategy.

Objectives: This study aims to investigate the association between interatrial conduction block and postoperative atrial fibrillation, which can precipitate acute cardiopulmonary instability and is associated with subsequent heart failure, stroke, and mortality following cardiac surgery.

Methods: Perioperative 12-channel electrocardiograms from 3405 patients undergoing myocardial revascularization, valve surgery, aortic surgery, or combinations thereof, were considered. Clinical and electrographic parameters were compared between patients with and without atrial fibrillation, and significant variables were analyzed using univariate and multivariate logistic regression.

Results: Among 2108 analyzed patients, 764 (36.2%) developed atrial fibrillation. Preoperative interatrial block was a strong independent risk factor (3.18; 95% CI, 2.55, 3.96; P < .001), significantly improving area under the receiver operator characteristics curve from 71.8% to 75.6% (Delong's test: P = .013). Other risk factors included advanced age (1.05; 95% CI, 1.03, 1.07; P < .001), female gender (1.86; 95% CI, 1.45, 2.38; P < .001), history of cardiogenic shock (1.44; 95% CI, 0.99, 2.09; P = .057), reduced left ventricular ejection fraction <40% (1.57; 95% CI, 1.06, 2.33; P = .024), cessation of preoperative β-blockers (1.17; 95% CI, 0.95, 1.46; P = .145), score for clinical prediction rules for estimating the risk of stroke in people with non-rheumatic atrial fibrillation (CHAS₂DS₂-VASc) and European System for Cardiac Operative Risk Evaluation II score (0.87; 95% CI, 0.79, 0.97; P = .01) and (1.04; 95% CI, 0.99, 1.11; P = .138), preexisting left bundle branch block (1.59; 95% CI, 0.92, 2.74; P = .097), cardiopulmonary bypass time (1.00; 95% CI, 1.00, 1.00; P = .049), bicaval cannulation (1.45; 95% CI, 0.88, 2.41; P = .035), cardiac surgery-associated acute kidney injury (3.19; 95% CI, 2.45, 4.15; P < .001), and postoperative atrioventricular block (1.20; 95% CI, 0.96, 1.51; P = .105), particularly Mobitz I (6.73; 95% CI, 1.98, 31.51; P = .005).

Conclusions: Perioperative electrocardiogram-derived parameters, especially interatrial block, are associated with postoperative atrial fibrillation. Further research is needed to clarify the link between conduction abnormalities and postoperative atrial fibrillation, enabling targeted prophylactic therapies for high-risk patients.

Objective: To develop a model for preoperatively predicting postcardiotomy cardiogenic shock (PCCS) in patients with poor left ventricular (LV) function undergoing cardiac surgery.

Methods: From the Society of Thoracic Surgeons Adult Cardiac Database, 11,493 patients with LV ejection fraction ≤35% underwent isolated on-pump surgery from 2018 through 2019, of whom 3428 experienced PCCS. In total, 68 preoperative clinical variables were considered in machine-learning algorithms trained and optimized using scikit-learn software.

Results: Compared with patients with ideal recovery, those that did were younger (65 vs 67 years), more likely female, Black, with low LV ejection fraction (26.5 vs 28.9%), previous myocardial infarction, chronic lung disease, diabetes, reoperation, or advanced heart failure. Among those with PCCS versus ideal recovery, operative mortality was 27% (925/3428) versus 0.1% (5/8065). PCCS occurred more often after coronary artery bypass grafting with concomitant mitral valve repair or after longer perfusion and clamp times. Reliable preoperative PCCS predictors were more advanced cardiac, liver, and renal failure; frailty; and greater white cell count. Out of sample test set receiver operating curve achieved an area under the curve of 0.74 with acceptable calibration Hosmer-Lemeshow statistic χ² = 1.33, P = .25.

Conclusions: In patients with severe LV dysfunction undergoing cardiac surgery, risk of PCCS is elevated by preoperative failure of other organ systems and complexity of the planned operation that prolongs myocardial ischemia and cardiopulmonary bypass. This risk calculator could serve as an important tool to preoperatively identify patients in need of advanced levels of support.

Objective: The advent of video-assisted thoracoscopic surgery in Mongolia has faced funding and accessibility challenges, leading to languid adoption. A Mongolian-Canadian collaboration was inaugurated to support the development of a self-sustainable, self-governed minimally invasive thoracic surgery (MITS) program in Mongolia.

Methods: A multidisciplinary Canadian thoracic surgery team collaborated with the National Cancer Center of Mongolia Thoracic Surgery service from 2016 to 2023. The team engaged in patient rounds, MITS procedures, and service education. Program and patient outcomes were reviewed.

Results: Thirty-four patients underwent MITS procedures as part of the Mongolian-Canadian collaboration. Median age was 51 years (range, 16-76 years), and 41% (14 out of 34) were men. Lung, esophageal, and mediastinal procedures composed 50% (17 out of 34), 21% (7 out of 34), and 21% (7 out of 34) of procedures, respectively. Conversion rate, median operative time, and hospital length of stay were 0%, 172.5 minutes, and 8 days, respectively. The complication rate was 9% (3 out of 34) with 3% (1 out of 34) being Clavien-Dindo >3 requiring re-operation. Thirty-day mortality was 0%. Mongolia's thoracic surgery team progressed from surgical assists to primary operators and a self-governed program. In 2023, the National Cancer Center of Mongolia's thoracic surgery service independently conducted 72% (50 out of 69) of esophagectomies and 91% (48 out of 53) of pulmonary resections via minimally invasive technique compared with 0% in 2015.

Conclusions: The Mongolian-Canadian collaboration demonstrated successful transfer of MITS proficiency through global noncolonialist surgical partnership, consequentially shifting the national thoracic surgical paradigm. Continued collaboration will focus on sustainability and supporting local surgeons in regional dissemination of MITS proficiency with the aim of globalizing thoracic surgical excellence.

Objective: For neonatal repair of coarctation of the aorta, patients may either undergo thoracotomy with extended end-to-end anastomosis or sternotomy for aortic arch reconstruction with cardiopulmonary bypass. The objective of this study was to evaluate the comparative effectiveness of the 2 approaches in patients with arch hypoplasia.

Methods: This is a single-center retrospective cohort study from July 2005 through May 2022 of patients who underwent neonatal repair for isolated coarctation of the aorta with additional arch hypoplasia. Inverse probability of treatment weighting is a statistical method for creating comparable pseudopopulations and was used to account for baseline differences in population. The primary outcome was aortic reintervention, and secondary outcomes were vocal cord dysfunction, length of stay, chylothorax, and phrenic nerve palsy.

Results: There were 130 patients who met inclusion criteria. After weighting, the interaction between distal transverse arch size and operative approach (sternotomy vs thoracotomy) was statistically significant, P < .05 for interaction. Among patients with a distal arch z-score <-3.5, patients undergoing thoracotomy with extended end-to-end anastomosis had an increased hazard for reintervention. Sternotomy was associated with an increased length of stay in the intensive care unit by 4.7 days, P < .001, and odds of vocal cord dysfunction were also greater, odds ratio 7.1 (95% confidence interval, 1.66 to 41.26; P = .01).

Conclusions: Among patients with a distal arch z-score smaller than -3.5, the hazard of reintervention was increased for patients undergoing thoracotomy with extended end-to-end anastomosis. However, length of stay and risk of vocal cord paresis was reduced in patients undergoing thoracotomy.