title: Outcomes in patients undergoing complex cardiac repairs with cross clamp times over 300 minutes.
abstract: BACKGROUND
  Long cross clamp times have been associated with poor clinical outcomes, yet some patients require extremely long ischemic times to repair complex surgical problems. The purpose of this study was to examine short and mid-term survival and to identify risk factors for mortality and morbidity in patients with cross clamp times greater than or equal to 300 min.
  
  
  METHODS
  Review of our institution's Society of Thoracic Surgeons database identified 202 patients who underwent surgical procedures necessitating aortic cross clamp times 300 min or greater between 2001 and 2012. Short-term (30-day) clinical outcomes were derived from this database and survival was assessed utilizing the Social Security Death Index. Univariate and multivariate analyses were used to determine the relationship between independent variables and mortality and postoperative outcomes.
  
  
  RESULTS
  The average age of the patients was 69.5 ± 10.6 (mean ± standard deviation) years and the mean ejection fraction was 52 ± 12 %. 70.3 % of patients were male. Mean cross clamp time was 346 ± 45 min, and total bypass time was 421 ± 70 min. Thirty-day mortality was 12.4 %. The incidence of bleeding and stroke were 6.4 % and 4.0 % respectively. Prolonged ventilation occurred in 26.7 % of patients, and incidence of renal failure was 10.4 %. One, three, five, and seven year survival of the patients who survived the first 30 days post-surgery was 91.9 %, 83.2 %, 75.6 % and 65.7 % respectively. Proportional hazards analysis determined that the statistically significant hazard ratios for mid-term mortality for female gender, age, and prolonged postoperative ventilation were 2.11, 1.04 and 2.72, respectively (p < 0.05 for each).
  
  
  CONCLUSIONS
  Cardiac procedures requiring extremely long ischemic times have significant early mortality and morbidity. However, mid-term survival in the patients who survive is good. Decision-making regarding operability in complex cases should allow for long ischemic times.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, 100 Michigan St. NE, 49503, Grand Rapids, MI, USA. blake.shultz@yale.edu.|, 123 York Street Apt. #22V, New Haven, CT, 06511, USA. blake.shultz@yale.edu.
authors.forename: Blake
authors.identifier: http://orcid.org/0000-0003-2689-9088
authors.initials: B
authors.lastname: Shultz
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, 100 Michigan St. NE, 49503, Grand Rapids, MI, USA.
authors.forename: Tomasz
authors.initials: T
authors.lastname: Timek
authors.affiliation: Grand Rapids Medical Education Partners, 945 Ottawa Ave NW, Grand Rapids, MI, 49503, USA.|Department of Surgery, Michigan State University, 15 Michigan St. NE, Grand Rapids, MI, 49503, USA.
authors.forename: Alan T
authors.initials: AT
authors.lastname: Davis
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, 100 Michigan St. NE, 49503, Grand Rapids, MI, USA.
authors.forename: John
authors.initials: J
authors.lastname: Heiser
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, 100 Michigan St. NE, 49503, Grand Rapids, MI, USA.
authors.forename: Edward
authors.initials: E
authors.lastname: Murphy
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, 100 Michigan St. NE, 49503, Grand Rapids, MI, USA.
authors.forename: Charles
authors.initials: C
authors.lastname: Willekes
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, 100 Michigan St. NE, 49503, Grand Rapids, MI, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Hooker
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001011:Aorta / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods / Q000706:statistics & numerical data; D002315:Cardiopulmonary Bypass / Q000009:adverse effects* / Q000379:methods / Q000706:statistics & numerical data; D003250:Constriction; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Adult cardiac surgery; Cross-clamp time; Morbidity; Mortality