АКШ

monotonically from 7.25% to 2.85%.

Crude mortality rates decrease monotonically from

9.09% for annual surgeon volumes between 1 to 54 to

2.89% for annual surgeon volumes ≥260.

Risk-adjusted rates decrease from 8.14% for patients of

surgeons with volumes <55 to 2.43% for patients of

surgeons with volumes ≥260.

Best results (risk-adjusted mortality 2.18%) in hospitals

performing ≥890 cardiac operations in 1989 and from

surgeons performing ≥260 cardiac operations.

The decline in CABG

To examine the

Observational

57,187 isolated CABG

1989 to 1992/30 NY CABG

Risk adjusted mortality

Risk-adjusted in-hospital mortality decreased for all

mortality in New York State.

longitudinal relationship

patients

hospitals

surgeon volume categories.

The role of surgeon volume.

between surgeon volume

1995 (206)

and in-hospital mortality

Low-volume surgeons (≤50 CABG/y) had largest

for CABG in NY.

reduction (60%) in risk-adjusted mortality over 4-y.

To explain changes in

Highest-volume surgeons (>150 CABG/y) had 34%

mortality over time.

reduction.

Percentage of patients having CABG by low-volume

surgeons decreased from 7.6% in 1989 to 5.7% in 1992

(25% reduction).

Part of decrease due to exodus of low-volume surgeons

with high risk-adjusted mortality; better performance

of surgeons who were new to the system; and

performance of surgeons who were not consistently

low-volume surgeons.

Volume and outcome in

To assess impact of

Systematic

1972 to 1992

CABG mortality

All 7 studies reported reduced mortality with increased

CABG: true association or

case-mix on CABG

review

volume.

artifact? 1995 (207)

volume-outcome studies

7 studies of CABG volume-

outcome association

Studies with better case-mix adjustment indicated less

reduction in mortality with increased volume (p=0.04).

US data

Apparent advantages of higher volume decreased over

time (p<0.001).

Do hospitals and surgeons

To investigate the

Observational

57,150 isolated CABG

NY CABG patients/1997 to

Risk-adjusted in-hospital

Significantly lower risk-adjusted mortality rates

with higher CABG volumes

CABG volume outcome

patients

1999

mortality

observed above all annual hospital volume thresholds

still have lower risk-adjusted

association with

between 200 to 800 and above all surgeon volume

mortality rates? 2003 (208)

contemporary data.

Cardiac Surgery Reporting

thresholds between 50 to 200.

System

Risk-adjusted mortality rate for surgeons with volumes

of ≥125 in hospitals with volumes of ≥600 was 1.89%.

Risk-adjusted mortality significantly higher (2.67%)

for surgeons with volumes of <125 in hospitals with

volumes of <600.

Is the impact of hospital and

To determine if volume-

Observational

57,150 isolated CABG

NY CABG patients (Cardiac

Risk-adjusted in-hospital

For annual hospital volume thresholds between 200

surgeon volumes on the in-

outcome association

patients

Surgery Reporting

mortality

and 600 cases, adjusted ORs of mortality for high-

hospital mortality rate for

only valid for high-risk

System)/1997 to 1999.

volume to low-volume hospitals =0.45 to 0.77 (all

CABG limited to patients at

patients.

significant) for low-risk group.

high risk? 2004 (209)

For moderateto high-risk group, OR: 0.62 to 0.91

(most significant).

As annual surgeon volume threshold increased from 50

to 150 cases, ORs for highto low-volume surgeons

increased from 0.43 to 0.74 for low-risk group.

For the moderateto high-risk group, ORs ranged from

0.79 to 0.86. Compared with patients treated by

surgeons with volumes of <125 in hospitals with

volumes of <600, patients treated by higher-volume

surgeons in higher-volume hospitals had significantly

lower risk of death (OR: 0.52 for low-risk group).

Higher volume associated with better outcomes for all

risk groups.

Outcome as a function of

To determine association

Observational

124,793 CABG patients

Isolated CABG patients/1991

Variability of outcome was significant in lower volume

annual CABG volume. 1996

between risk-adjusted

to 1993/>600 US hospitals.

practices (<600 cases/y) and varied little at >600

(210)

CABG mortality and

cases/y.

volume.

STS-NCD

No practice volume category had an observed/expected

1,200 surgeons

ratio of less than 0.8 or >1.2 if annual volume was

>100.

Practices of <100 cases/y had an observed/expected

ratio of 1.6.

No continuous relationship

To determine association

Observational

23,986 CABG

CABG patients/April 1987 to

30-d risk-adjusted

No statistically significant relationship between CABG

between Veterans Affairs

between CABG volume

September 1992/44 VA

mortality

volume and risk-adjusted operative mortality (p=0.10).

hospital coronary artery

and outcome in VA

hospitals.

bypass grafting surgical

hospitals.

Using ANOVA, hospitals with ≤100 cases per y have

volume and operative

higher observed to expected mortality ratios than

mortality. 1996 (211)

hospitals performing >100 cases per y (p=0.03).

Using Poisson regression models, volume threshold not

found.

Hospital CABG volume and

To assess the volume-

Observational

228,738 CABG patients

1998 to 2000 Nationwide

In-hospital mortality by

Crude in-hospital mortality rates=4.21% in low volume

patient mortality, 1998 to

outcome association for

Inpatient Sample

hospital CABG volume

hospitals, 3.74% in medium-volume hospitals, and

2000. 2004 (212)

CABG

group (low=12 to 249

3.54% in high-volume hospitals (trend p<0.001).

cases/y, medium=250 to

499 cases/y, high ≥500

Compared with high-volume hospitals, patients at low-

cases/y)

volume hospitals had increased adjusted mortality risk

(OR: 1.26; 95% CI: 1.15 to 1.39), as did medium

volume hospitals (OR: 1.11; 95% CI: 1.01 to 1.21).

Considerable outcomes heterogeneity at every volume

level.

207 of 243 (85%) low-volume and 151 of 169 (89%)

medium-volume hospital-y had risk-standardized

mortality rates that were statistically lower or

comparable to expected.

Only 11 of 169 (6%) high-volume hospital-y had

outcomes that were statistically better than expected

and 18 of 161 (11%) high-volume hospital-y had worse

than expected risk-standardized mortality rates.

“Volume is not a reliable marker of hospital CABG

quality”.

Limitations of Hospital

To assess the association

Observational

948,093 CABG procedures

Medicare CABG

Risk-adjusted mortality

Considerable mortality heterogeneity at all volume

Volume as a Measure of

between CABG volume

Patients/1996 to 2001/870 US

levels.

Quality of Care for CABG.

and outcomes

hospitals.

2005 (213)

Volume alone a poor predictor of mortality (c-

index=0.52), similar to “coin toss.”

253 of 660 hospitals (38%) with volume <450 cases

annually had risk-adjusted mortality rates similar to or

lower than the overall risk-adjusted mortality of high-

volume hospitals (5.2%).

© American College of Cardiology Foundation and American Heart Association, Inc.

Association of hospital

To examine the

Observational

144,526 isolated CABG

Isolated CABG

Risk-adjusted mortality,

Unadjusted mortality decreased across volume

coronary artery bypass

association of CABG

patients

patients/2007/733 hospitals

morbidity, NQF process

categories (2.6% for <100 cases, 1.7% for >450 cases;

volume with processes of

volume and mortality,

participating in the STS-NCD.

measure adherence.

p<0.0001).

care, mortality, morbidity,

morbidity, processes of

and the STS Surgeons

care, and STS CABG

After multivariable adjustment, mortality OR: 1.49

composite quality score.

composite score.

(lowest vs. highest volume).

2010 (214)

Most care processes and morbidity not associated with

volume.

Lowest volume group (<100 cases) had lowest

composite scores but volume only explained 1% of

latter.

Considerable performance heterogeneity at low

volumes, and low volume did not preclude excellent

performance.

Volume and outcome of

To assess changes in the

Systematic

16 CABG volume-outcome

Progressive increase of OR favoring high volume

CABG: are more and less

CABG volume-outcome

review

studies (1980 to 2002).

hospitals from 0.55 in 1972 to 0.95±0.07.

the same? 2004 (215)

association over time.

High and low volume cohorts

All OR estimates per 100 patients close to 1.0,

(200 case cut-point).

suggesting minimal effect of volume on mortality.

The role of hospital volume

To determine if low risk

Observational

2,029 CABG patients at 25

1997 administrative and

In-hospital mortality,

Significant differences in in-hospital mortality between

in coronary artery bypass

patients have improved

study

low-volume hospitals.

clinical data from Solucient

costs and LOS

lowand high-volume facilities in moderate (5.3% vs.

grafting: is more always

outcomes at high volume

EXPLORE.

2.2%; p=0.007) and high risk (22.6% vs. 11.9%;

better? 2001 (216)

hospitals.

11,615 CABG patients at 31

p=0.0026) but not minimal, lowor severe-risk

high-volume (≥200 annual

Patients classified into 5

patients.

cases) hospitals.

surgical risk groups: minimal

(<0.5%), low (0.5% to 2%),

Hospital costs and LOS similar across risk groups.

moderate (2% to 5%), high

(5% to 20%), and severe

Targeted regionalization for moderate to higher risk

(≥20%).

patients feasible.

Procedural volume as a

To determine the

Observational

267,089 isolated CABG

January 1, 2000 to December

Adjusted operative

Adjusted rates of operative mortality decreased with

marker of quality for CABG.

association between

procedures

31, 2001/439 US hospitals

mortality

increasing hospital CABG volume (0.07% for every

2004 (217)

CABG volume and

participating in the STS-NCD.

100 additional CABG procedures; adjusted OR: 0.98;

outcomes in a large

95% CI: 0.96 to 0.99; p=0.004).

clinical data registry.

Volume-mortality not observed in patients <65 y or in

those at low operative risk.

© American College of Cardiology Foundation and American Heart Association, Inc.

Study

Sample Characteristics

Sample Size

Stroke Rate:

Stroke Rate:

P-Value

Interval Between

On-Pump

Off-Pump

Surgery and Outcome

ROOBY 2009 (218)

All male

2203

0.7%

1.3%

p=0.28 (NS)

30 d

Nathoe et al. 2003 (Octopus) (219)

Low-risk patients

281

1.4%

0.7%

p=0.55 (NS)

1 y

SMART 2004 (220)

Single surgeon

197

2.0%

1.0%

(NS)

30 d

Best Bypass Surgery trial 2010 (221)

High-risk patients

341

3.7%

4.0%

p=1.00 (NS)

>30 d

BHACAS 1 / 2 2002 (222)

Single institution

401

3%/ 3%

2%/ 1%

(NS)

>30 d

Legare 2004 (223)

Single-center trial

300

0.0%

1.3%

p=0.50 (NS)

In-hospital

Muneretto 2003 (224)

Low-risk

176

2.2%

0.0%

(NS)

“early” outcome

Study

Year

Sample

Sample

Follow-Ip

Incidence of Decline

P-Value/Comments

Published

Characteristics

Size

Interval

On-Pump/Off-pump

Van Dijk D et al.

2002

Low risk

281

3 mo

29%

21%

NS

(Octopus Trial)

Patients

12 mo

34%

31%

NS

(225, 226)

2007

5 y

35%

33%

NS

St. Francis

2003

Single center

60

2 wk

15%

16%

NS

Medical Center

12 mo

15%

19%

NS

(227)

Lund (228)

2005

Single center

120

3 mo

23%

20%

NS

12 mo

23%

24%

NS

Jenson (substudy of

2006

High-risk

120

3 mon

24%

20%

NS

Best Bypass Surgery

patients

trial) (229, 230)

2008

1 y

19%

9%

NS

Ernest (231)

2006

Single institution

107

2 mo

N/A

N/A

No difference in incidence of cognitive impairment

6 mo

N/A

N/A

Lower incidence of cognitive impairment in off-pump

group for 1 test (word fluency)

Al-Ruzzeh (232)

Single institution

168

6 wk

N/A

N/A

Off-pump performed significantly better in 3/15 tests

(p≤0.001)

6 mo

N/A

N/A

Off-pump group performed significantly better in 2/15

tests (p<0.001)

Vedin (233)

2006

Single institution

70

1 wk

57%

58%

NS

1 mo

30%

12%

NS

6 mo

19%

15%

NS

Motallebzadeh (234)

2007

Single institution

212

Discharge

N/A

N/A

Higher global composite cognitive score (0.25 standard

deviation) in the off-pump group (p=0.01)

6 mo

N/A

N/A

No SD in global composite score between on-pump and

off-pump groups

6 mo

N/A

N/A

No SD in global composite score between on-pump and

off-pump groups

Hernandez (235)

2007

Single institution

201

Discharge

62%

52%

NS

6 mo

47%

44%

NS

ROOBY (218)

2009

VA Medical

2203

1 y

N/A

N/A

No difference between onand off-pump in change in

Centers

global z-score from baseline to follow-up

Study Name

Aim of Study

Study

Study Size

Patient Population/Inclusion &

Endpoints

Statistical Analysis

P Values

OR / HR

Study Summary

Type

Exclusion Criteria

Reported

& 95% CI

/ RR

Inclusion

Exclusion

Primary

Secondary

Criteria

Criteria

Endpoint

Endpoint

Impact of

To examine

Part of the

23,499

All patients

Patients

DSWI rate

Early hospital

VAC therapy (n=125)

p=0.01

N/A

DSWI remains a major and

DSWI

the outcome of

data was

total

undergoing

undergoing

mortality,

was associated with a

(mortality),

challenging complication of OHS.

management

patients with

collected

number of

open heart

thoracic aortic

hospital stay,

lower mortality (4.8% vs.

p=0.02 (1-,

VAC therapy with sternal

with VAC

DSWI now

retrospectiv

patients

surgery

surgery or heart

DSWI

14.1%, p=0.01). Early

2- and 3-

preservation followed by delayed

therapy

treated with

ely, and

(267

transplantation

recurrence, 1-

adjusted survival for

survival)

sternal osteosynthesis and

followed by

VAC therapy

part -

patients

as well as

, 2- and 3-y

patients with DSWI

pectoralis myocutaneous flaps has

sternal

as a bridge to

prospective

with

congenital cases

survival

treated with VAC therapy

been recently proposed as a new

osteosynthesis:

sternal

ly

DSWI)

were all

was 92.8%, 89.8% and

therapeutic strategy. Most

a 15-y review

osteosynthesis

excluded from

88.0%, respectively, at 1-

patients treated with VAC therapy

of 23,499

with horizontal

the present study

, 2- and 3-y, compared

showed decreased perioperative

sternotomies.

titanium plate

with 83.0%, 76.4% and

mortality and increased survival.

2010 (236)

fixation

61.3%, respectively, for

patients with DSWI

treated without VAC

(p=0.02).

VAC of DSWI

To examine

Prospective

22

All cardiac

N/A

Reduction of

Need for

VAC induced granulation

p<0.05

N/A

Adjunctive VAC therapy

in high-risk

the effect of

surgery

wound size

secondary

of 71% of the sternal

(reduction

markedly reduced required

patients after

VAC on

patients who

surgical

wound area by 7 d. By 14

of wound

surgical interventions, reoperation

cardiac surgery.

sternal wounds

developed

intervention,

d, there was a 54%

size)

for persistent infections, and the

2005 (237)

DSWI

LOS, VAC

reduction in wound size,

hospitalization period. VAC

complications

and patients were

provides a viable and efficacious

discharged after

adjunctive method by which to

approximately 19.5 d and

treat postoperative wound

placed on home therapy.

infection after medial sternotomy.

VAC was discontinued at

approximately 36.7 d

with an average reduction

in sternal wound size of

80%. Extensive

secondary surgical

closure, requiring muscle

flaps, was avoided in

64% of patients, whereas

28% of patients required

© American College of Cardiology Foundation and American Heart Association, Inc.

no surgical reconstruction

for wound closure.

The VAC

To report an

Prospective

11

Patients with

N/A

Length of

In-hospital

Median ICU stay of

N/A

N/A

In-hospital mortality was 0%, and

system for the

experience

DSWI after

ICU and

mortality, 30-

patients treated with

30-d survival was 100%. Median

treatment of

with the VAC

cardiac surgery

hospital stay

d survival,

pectoralis muscle flap

hospital stay ranged from 13 to 45

DSWI after

system (KCI

complication

closure without

d (median 30 d). Most

cardiac surgery.

Inc., San

rate

pretreatment with the

importantly, there were no VAC

2002 (238)

Antonio, TX)

VAC system was 9.5 d

device–related complications.

as an adjunct

(range 4 to 26 d),

in the

whereas patients with

treatment of

VAC treatment had an

DSWI after

ICU stay of median 1 d

cardiac

(range 1 to 4 d).

surgery

VAC as a

To assess the

Prospective

27

Patients who

N/A

Mortality

Healed scar

VAC-group mortality

N/A

N/A

VAC, used alone or before other

treatment

impact of

underwent

(%), duration

was 28.6% vs. 7.7% in

surgical treatment strategies, is an

modality for

VAC on the

cardiac surgery

of VAC,

VAC+ second procedure

acceptable treatment modality for

infections after

management

through a

LOS, cost of

group. A satisfactorily

infections in cardiac surgery with

cardiac surgery.

of sternal

median

treatment

healed scar was achieved

reasonable morbidity, mortality,

2003 (239)

wound

sternotomy and

in 64% of VAC-cases

and cost.

infections in

acquired

and in 77% of VAC+

terms of

sternal wound

second procedure cases.

wound

infections

Median durations of

healing,

VAC in VAC-group were

duration of

13.5 d (interquartile

VAC, and cost

range 8.8 to 32.2 d), and

of treatment

median hospital stay was

20 d (interquartile range

16.7 to 25.2 d). Median

duration of vacuum-

assisted closure in VAC+

second procedure group

was 8 d (interquartile

range 5.5 to 18 d), and

median hospital stay was

29 d (interquartile range

25.8 to 38.2 d). The total

cost (hospitalization and

treatment) per patient for

VAC was $16,400,

compared with $20,000

for the closed irrigation

© American College of Cardiology Foundation and American Heart Association, Inc.

system treatment.

The concept of

To report an

Prospective

3,668 total

Patients with

N/A

DSI rate

LOS, time

The detection of DSI and

N/A

N/A

In line with the mentioned articles

NPWT after

experience of

number of

DSI after

from

subsequent treatment

and reviews we come to the

poststernotomy

using NPWT

patients/54

cardiac surgery

operation to

with NPWT of the

conclusion, that negative pressure

mediastinitis--a

followed by

patients

procedures.

detection of

patients is clearly

wound treatment is a relatively

single center

muscular

with DSI

mediastinitis,

prolonged: the period of

new option for treatment of

experience with

pectoralis

time from the

time that patients stayed

devastating wounds after

54 patients.

plasty in

start of the

in hospital ranged from

sternotomy in cardiac surgery. As

2009 (240)

treatment of

NPWT

22 d up to 185 d (median

many institutions have presented

DSIs after

therapy until

64.5 d). The time period

their own approaches, it is

cardiac

date of

from the date of

important to find a strategy which

surgery

discharge,

operation until detection

may be used as a "standard

procedures

complication

of mediastinitis ranged

NPWT approach" if identified in

rate

from 5 d to 155 d (19 d).

the future.

Time period from the

start of the NPWT

therapy until date of

discharge from hospital

ranged from 7 d until 99

d with a median at 35 d.

No complications were

found in 74% of patients.

Management of

To report on

Retrospecti

409

Patients who

N/A

Mortality/mor

N/A

Mean hospital stay after

(p=0.005)

N/A

With aggressive early debridment

the infected

morbidity and

ve

developed

bidity

sternal wound

and flap the mortality and

median

mortality in

DSWI after

reconstruction declined

hospital stay after DSWI has

sternotomy

patients treated

cardiac surgery

from 18.6 d (1988 to

decreased over time

wound with

for DSWI with

1992) to 12.4 d (1993 to

muscle flaps.

sternal

1996)

The Emory 20-

debridment

y experience.

and flap

1997 (241)

Prospective trial

To determine

Prospective

43

Patients with

N/A

Wound

LOS, rate of

N/A

N/A

N/A

Irritation alone failed in 88% of

of catheter

the appropriate

sternal

resolution

complications

patients with DSWI. All patients

irrigation and

roles of

dehiscence or

treated with flap had a successful

muscle flaps for

closed-chest

infection

outcome.

sternal wound

catheter

infection. 1998

irrigation and

(242)

muscle flap

closure for

sternotomy

infection

Two-stage

To report on

Retrospecti

68

Patients with

N/A

Mortality/mor

N/A

91% survival at 1 y and

N/A

N/A

management of

morbidity and

ve

DSWI after

bidity

0% mortality for patients

sternal wound

mortality in

cardiac surgery

treated with flap after

infection using

patients treated

DSWI .

bilateral

for DSWI with

pectoralis major

sternal

advancement

debridment

flap. 2006 (243)

and flap

Study Name

Aim of Study

Study

Study

Patient Population/Inclusion &

Endpoints

Statistical

P-Values

OR / HR / RR

Study Summary

Type

Size

Exclusion Criteria

Analysis

& 95%

(95% CI)

Reported

CI

Inclusion

Exclusion

Primary

Secondary

Criteria

Criteria

Endpoint

Endpoint

Glycopeptides

To

Meta-

5,761

Trials that

N/A

Occurrence of

Chest SSI,

N/A

N/A

SSI RR: 1.14; (95% CI: 0.91 to

Neither agent proved to be

are no more

investigate

analysis

compared SSI in

SSI at 30 d

Deep-chest

1.42)

superior for prevention of

effective than

whether a

subjects receiving

SSI, Leg SSI,

Chest SSI RR: 1.47; (95% CI:

the primary outcome,

beta-lactam

switch from

glycopeptide

SSI due to

1.11 to 1.95)

occurrence of SSI at 30 d. In

agents for

beta-lactams

prophylaxis with

different

Deep-chest SSI RR: 1.33; (95%

subanalyses, beta-lactams

prevention of

to

SSI in those who

microorganis

CI: 0.91 to 1.94)

were superior to

SSI after

glycopeptides

received beta-

ms

Leg SSI RR: 0.77; (95% CI:

glycopeptides for prevention

cardiac surgery:

for cardiac

lactam

0.58 to 1.01)

of chest SSI and approached

a meta-analysis.

surgery

prophylaxis were

SSI due to gram positive

superiority for prevention of

2004 (244)

prophylaxis

pooled

bacteria RR: 1.36; (95% CI:

deep-chest SSI and SSI

should be

0.98 to 1.91)

caused by gram-positive

advised.

SSI due to meticillin-resistant

bacteria. Glycopeptides

gram-positive bacteria RR: 0.54;

approached superiority to

(95% CI: 0.33 to 0.90)

beta-lactams for prevention

SSI due to other organism RR:

of leg SSI and were superior

1.08; (95% CI: 0.75 to 1.55)

for prevention of SSI caused

by methicillin-resistant

gram-positive bacteria.

Standard prophylaxis for

cardiac surgery should

continue to be beta-lactams

in most circumstances.

Vancomycin

This study

RCT

885

All adult patients

Exclusion

SSI rates

Duration of

The overall SSI

p=0.8

N/A

The durations of

versus cefazolin

was

(≥18 y) scheduled

criteria

postoperative

rates were

(overall

postoperative hospitalization

prophylaxis for

undertaken to

for cardiac

included the

hospitalizatio

similar in the 2

SSI)

and the mortalities were