Fraser D Rubens

University of Ottawa, Ottawa, Ontario, Canada

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Publications (114)422.95 Total impact

  • Hadi Toeg, Fraser Rubens
    The Journal of thoracic and cardiovascular surgery 04/2014; 147(4):1437-8. · 3.41 Impact Factor
  • Hadi Toeg, Fraser Rubens
    The Journal of Thoracic and Cardiovascular Surgery. 01/2014;
  • Hadi Daood Toeg, Fraser Douglas Rubens
    The Journal of thoracic and cardiovascular surgery 10/2013; · 3.41 Impact Factor
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    ABSTRACT: OBJECTIVES: The impact of anaemia on patients undergoing aortic valve surgery has not been well studied. We sought to evaluate the effect of anaemia on early outcomes following aortic valve replacement (AVR). METHODS: All patients undergoing non-emergent aortic valve surgery (n = 2698) with or without other concomitant procedures between 1997 and 2010 were included. Preoperative anaemia was defined as per World Health Organization guidelines as haemoglobin (Hb) < 130 g/l in men and Hb < 120 g/l in women. Multivariable analyses were used to determine the association between preoperative anaemia and postoperative outcomes. RESULTS: The prevalence of preoperative anaemia was 32.2%. Patients with anaemia were older (71 ± 12 vs 66 ± 13 years, P < 0.001), more likely to have urgent surgery, recent MI, higher creatinine level and impaired preoperative left ventricular function. Overall unadjusted mortality was 2.8% in non-anaemic patients vs 8% in anaemic patients. Anaemic patients were more likely to require renal replacement therapy (11 vs 3%, P < 0.0001) and prolonged ventilation (24 vs 10%, P < 0.0001). Following multivariable adjustment, lower preoperative Hb was an independent predictor of mortality (odds ratio 1.19, 95% CI: 1.04-1.34, P = 0.007) and composite morbidity (odds ratio 1.36, 95% CI: 1.05-1.77, P = 0.02) after AVR. Mortality and composite morbidity were significantly higher with lower levels of preoperative Hb. CONCLUSIONS: Preoperative anaemia is a common finding in patients undergoing aortic valve surgery and is an important and potentially modifiable risk factor for postoperative morbidity and mortality.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2013; · 2.40 Impact Factor
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    ABSTRACT: OBJECTIVES: Postoperative neurocognitive deficits (POCDs) have been found to occur frequently after cardiac surgery. Although POCDs have received significant attention in the medical literature and public media, the true clinical impact of these deficits on patient outcomes and quality of life (QOL) is not well defined. METHODS: Neuropsychometric testing was performed on 696 patients undergoing coronary artery bypass surgery using a battery of tests divided into 4 domains; memory, attention, speed, and psychomotor function. These were performed preoperatively, at hospital discharge, and at 3 months postoperatively. POCDs were defined as a drop in scores by 1 standard deviation in 1 domain or more. QOL was assessed using Short Form 36 and clinical outcomes were recorded. RESULTS: POCDs were identified in 265 (38%) patients at discharge and in 132 (19%) at 3 months. There was no observed difference in mortality or major morbidity in patients with or without POCDs. Predictors of POCDs at discharge were elevated preoperative creatinine (P = .04), increased cardiopulmonary bypass time (P = .005), and diabetes (P = .003). At 3 months, patients had improvements in both physical and mental components of QOL, independent of the occurrence of POCDs (P > .5). Independent predictors of improved QOL included younger age, severe preoperative anginal symptoms, normal left ventricular function, absence of postoperative wound infection, but not POCDs. CONCLUSIONS: Neurocognitive deficits can be frequently detected on comprehensive neuropsychometric testing after cardiac surgery. However, they are not associated with any clinically important differences in patient outcome or in QOL after surgery.
    The Journal of thoracic and cardiovascular surgery 03/2013; · 3.41 Impact Factor
  • Elsayed Elmistekawy, Fraser D Rubens
    Interactive Cardiovascular and Thoracic Surgery 02/2013; 16(2):226. · 1.11 Impact Factor
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    ABSTRACT: BACKGROUND: Anemia is one of the most common complications of coronary artery bypass graft (CABG) surgery and has been shown to be associated with increased morbidity and mortality. The impact of anemia on hospital readmission after CABG, a potential measure of delayed complications, has not been addressed. STUDY DESIGN AND METHODS: We conducted a single-center retrospective study of 2102 patients who had CABG in Ontario to determine whether anemia at hospital discharge was associated with increased 30-day hospital readmissions, readmission secondary to cardiac disease, and 30-day mortality using administrative data. RESULTS: Of the 2102 patients, 224 patients (11%) were readmitted within 30 days of hospital discharge. Infection was the leading cause of readmissions (24%), followed by heart failure (13%), pulmonary disease (7%), and hemorrhagic disease (7%). Overall, 2.6% of patients were readmitted because of cardiac disease. Of patients discharged, 48% were discharged with a hemoglobin (Hb) level between 8 and 10 g/dL and 42% between 10 and 12 g/dL. Predischarge Hb concentration was not a significant independent predictor of 30-day readmission to the hospital due to all causes, readmission to the hospital due to cardiac causes, or 30-day mortality. A higher comorbidity score, adjusted odds ratio (OR) of 2.1 (95% confidence interval [CI], 1.3-3.6), leg and sternal wound infections OR of 1.9 (95% CI, 1.2-3.0), and postoperative renal failure OR of 1.4 (95% CI, 1.2-2.0) were associated with increased 30-day readmission rates. CONCLUSIONS: The predischarge Hb concentration after CABG was not associated with 30-day readmissions.
    Transfusion 12/2012; · 3.53 Impact Factor
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    ABSTRACT: No human physiological data exists on whether aspirin only is as effective as warfarin plus aspirin in preventing cerebral microembolization in the early postoperative period after bioprosthetic aortic valve replacement (bAVR). We prospectively enrolled 56 patients who had no other indication for oral anticoagulation, who underwent bAVR and received, in an open-label fashion, either daily warfarin (for INR 2.0-3.0) plus 81 mg of aspirin (n=28) or 325 mg of aspirin only (n=28). Cerebral microembolization was quantified at 4 hours (baseline) and at 1 month postoperatively, by recording 1-hour bilateral middle cerebral artery (MCA) microembolic signals (MES). Platelet-function analysis (PFA) of closure times (CT) on collagen was also used as a marker of platelet-dependent activation. Follow-up to 1 year was complete. Preoperative demographics and baseline platelet function were equivalent in both groups. There was no mortality, stroke, or transient ischemic attack at 1 year in either group. No significant differences were found in the proportion of patients with MES among those receiving warfarin plus aspirin versus aspirin only, at baseline (68% versus 82%, respectively; P=0.4) and at 1 month (46% versus 43%; P=1.0) after bAVR. The total MES and PFA were also equivalent between groups, at baseline and follow-up. Early after bAVR, the effects of these 2 antithrombotic regimens on cerebral microembolization and platelet function are equivalent. These data bring new mechanistic support to the premise that aspirin only may safely be used early after bAVR in patients who have no other indication for oral anticoagulation.
    Circulation 09/2012; 126(11 Suppl 1):S239-44. · 15.20 Impact Factor
  • Anna L McGuire, Fraser Rubens
    The Journal of thoracic and cardiovascular surgery 09/2012; 144(3):735; author reply 735-6. · 3.41 Impact Factor
  • Fraser D Rubens, Munir Boodhwani
    The Annals of thoracic surgery 08/2012; 94(2):687-8. · 3.45 Impact Factor
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    ABSTRACT: The internal thoracic artery is the gold standard conduit in coronary artery bypass grafting. Although the right and left internal thoracic arteries are excellent conduits, the use of the bilateral internal thoracic artery is not widespread. A recent report of the Society of Thoracic Surgery revealed that only a small percentage of patients receive a bilateral internal thoracic artery in North America. The aim of this study was to determine the current use of the bilateral internal thoracic artery during coronary artery bypass grafting among cardiac surgeons in Canada and identify the main concerns that limit the use of these conduits. We developed an online survey with 17 questions about the use of the bilateral internal thoracic artery in different clinical scenarios. An invitation to participate was sent to all the adult cardiac surgeons currently in practice in Canada. A total of 101 surgeons (69%) of 147 currently in practice across 27 different hospitals completed the survey. Forty percent of surgeons use the bilateral internal thoracic artery only sometimes (6%-25% of cases), 37% of surgeons use the bilateral internal thoracic artery very infrequently (<5% cases), 16% of surgeons use the bilateral internal thoracic artery often (26%-50%), and only 7% of surgeons use the bilateral internal thoracic artery very often (>50%). The most common concerns in the use of the bilateral internal thoracic artery are the risk of sternal wound infection and the unknown superiority of the right internal thoracic artery over other conduits. The majority of Canadian cardiac surgeons consider few clinical features, such as insulin-dependent diabetes mellitus or morbid obesity, as contraindications to the use of bilateral internal thoracic artery. However, the reported use of the bilateral internal thoracic artery is low. A wider diffusion of this technique is warranted to improve the results of coronary surgery.
    The Journal of thoracic and cardiovascular surgery 02/2012; 144(4):874-9. · 3.41 Impact Factor
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    ABSTRACT: Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered. The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm(2) (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm(2), we recommend early surgery (Grade 2C). These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.
    Chest 02/2012; 141(2 Suppl):e576S-600S. · 7.13 Impact Factor
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    ABSTRACT: Extensive mammary artery atherosclerosis is a rare finding with isolated reports in patients with peripheral vascular disease and after correction of aortic coarctation. The current case represents a rare finding of extensive atherosclerosis in a native right mammary artery in a patient without prior known vasculopathy.
    Indian Journal of Thoracic and Cardiovascular Surgery 01/2012;
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    ABSTRACT: Controversy exists regarding the perioperative renal effects of off-pump versus on-pump coronary artery bypass grafting. Large case-matched and randomized comparisons have shown conflicting results. This study focuses on this clinical controversy. We studied 5589 consecutive patients from a single center who underwent off-pump or on-pump coronary artery bypass grafting between 2002 and 2010. All preoperative, intraoperative, and postoperative data were prospectively collected. Patients were matched by using a nearest neighbor matching estimation method for average treatment effects, with bias correction (Stata 11.2, StataCorp, College Station, Tex). The matching characteristics were age, gender, body mass index, hypertension, diabetes, peripheral vascular disease, cerebrovascular disease, left ventricular grade, preoperative serum creatinine, operative priority, and Cardiac Anesthesia Risk Evaluation score. The mean patient age was 64.9 ± 10.0 years, and 4387 (78.5%) were male. Mean calculated preoperative creatinine clearance was 82.0 ± 32.6 mL/min. Perioperative mortality was 1.5% with off-pump coronary artery bypass grafting and 1.7% with on-pump coronary artery bypass grafting (P = .6). The mean change in creatinine clearance, from the preoperative value to the lowest postoperative value, was -6.3 ± 14.1 mL/min with off-pump coronary artery bypass grafting versus -5.0 ± 15.5 mL/min with on-pump coronary artery bypass grafting (P = .06). After matching, patients undergoing off-pump coronary artery bypass grafting had a greater creatinine increase and greater loss of creatinine clearance postoperatively compared with patients undergoing on-pump coronary artery bypass grafting (both P < .05). Requirements for de novo postoperative dialysis were equivalent at 2.6% in off-pump coronary artery bypass grafting versus 2.1% in on-pump coronary artery bypass grafting (P = .4). Median postoperative hospital stay was 8 days in both groups (P = .8). Off-pump coronary artery bypass grafting does not preserve renal function to a greater extent than on-pump coronary artery bypass grafting. In fact, a trend to the reverse exists with no clinically harmful effects.
    The Journal of thoracic and cardiovascular surgery 01/2012; 143(1):85-92. · 3.41 Impact Factor
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    ABSTRACT: This is a case report involving a middle-aged Jehovah's Witness patient who underwent a redo aortic valve replacement, coronary artery bypass graft, and Maze procedure facilitated by cardiopulmonary bypass. The consent process included a discussion of the management of bleeding and hemostasis in the perioperative period in the context of the patients' religious choice and the possible consequences of avoiding transfusion in massive bleeding. The medical team agreed to abide by the patient's wishes with respect to the blood and blood products deemed unacceptable by the patient irrespective of the consequences. The consent included a discussion of manufactured hemostatic agents that are designated by the Hospital Liaison Committee Network for Jehovah's Witnesses as subject to personal decision. There was also a discussion of recombinant agents available, all of which are acceptable to Jehovah's Witness patients. The patient accepted the use of cryoprecipitate, prothrombin complex concentrate, and recombinant factor VIIa. After separation from cardiopulmonary bypass and protamine administration, blood loss was 350 mL over a ten-minute period. The international normalized ratio (INR) was 3.5 at that time. Cryoprecipitate 15 U, 1-deamino-8-D-arginine vasopressin 16 U, and a prothrombin complex concentrate, Octaplex®, 60 mL were administered. Blood loss improved significantly. The INR in the cardiac surgical intensive care unit was 1.3. The sample was taken approximately one hour following the administration of the hemostatic agents. The patient's chest was closed, and chest tube drainage was 310 mL over the next 12 hr. This is a novel case involving the use of prothrombin complex concentrate in the setting of a Jehovah's Witness patient undergoing a complex operative procedure.
    Canadian Anaesthetists? Society Journal 12/2011; 59(3):299-303. · 2.31 Impact Factor
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    ABSTRACT: The strategy of bilateral mammary artery grafting is often not considered for elderly patients due to perceived concerns of increased morbidity and mortality. The objective of this study is to explore the safety of bilateral mammary in elderly patients. Out of 7746 patients who underwent coronary artery bypass grafting using at least one internal thoracic artery (ITA), there were 3940 patients aged 65 years or greater, and of those, 3581 patients had a single ITA (SITA) and 359 patients had bilateral ITAs (BITAs). The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (MACCEs). Secondary outcomes included re-exploration for bleeding, blood transfusions, sternal wound infections, and intensive care unit and hospital length of stay. The incidence of mortality and MACCE were similar in both groups (mortality BITA 2.6%, SITA 3.6%, p = 0.25, MACCE BITA 8.5%, SITA 6.1%, p = 0.13). Superficial and deep sternal site infections were significantly more prevalent in the BITA group than the SITA group [superficial OR 0.42, 95% CI [0.23-0.75] (p = 0.003) and deep OR 0.29, 95% CI [0.14-0.58 (p = 0.0005)]. Use of BITA is safe in the elderly with respect to mortality and early cardiovascular outcome. BITA use in the elderly is associated with an increased risk of sternal wound infection. Our experience in this situation suggests that there is a maximum age (approximately 74 years) beyond which the combined risk of MACCE and wound complications supersedes the benefits in terms of sternal infections.
    Journal of Cardiac Surgery 11/2011; 27(1):1-5. · 1.35 Impact Factor
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    ABSTRACT: Recent evidence indicated that the use of a bioprosthesis in young patients at first-time aortic valve replacement (AVR) is associated with an increased reoperation risk, but not with an increase in long-term mortality, when compared with the use of a mechanical valve. However, at reoperative AVR, follow-up data by prosthesis type have been lacking from the literature. Therefore, we examined long-term survival and valve-related complications according to the type of prosthesis used at reoperative AVR. We studied 437 patients who underwent reoperative AVR, at a mean age of 58.6 ± 14.2 years, for failure of a previously implanted aortic valve prosthesis. Thirty-day mortality at reoperative AVR was 6% (n = 27). A bioprosthesis was used in 135 (31%) patients. Patients were subsequently followed up for a mean of 7.6 ± 6.8 years after reoperative AVR. The use of a bioprosthesis at reoperative AVR was not associated with impaired survival on adjusted analysis (hazard ratio [HR], 0.8 ± 0.4; P = .6). Freedom from thromboembolism, and endocarditis were similar between valve types (both P > .05); however, late postoperative major hemorrhage occurred only in patients who received a mechanical prosthesis at reoperative AVR. Risk factors for third-time AVR included the use of a bioprosthesis (HR, 14.0) and younger age (HR, 1.05 per decreasing year) at reoperative AVR (both P < .001). Thirty-day mortality of third-time AVR was 4% (n = 1/27). At reoperative AVR, the use of a bioprosthesis is associated with equivalent long-term survival compared with a mechanical prosthesis. Patients who receive a bioprosthesis at reoperative AVR are less likely to experience major hemorrhage but more likely to require third-time AVR, albeit with an acceptable third-time perioperative mortality risk. Therefore, the patient's informed preferences regarding prosthesis choice should prevail, even in a reoperative context.
    The Journal of thoracic and cardiovascular surgery 09/2011; 144(1):146-51. · 3.41 Impact Factor
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    ABSTRACT: Evidence supporting the use of bioprostheses for heart valve replacement in young adults is accumulating. However, reoperation data, which may help guide clinical decision making in young patients, remains poorly defined in the literature. We examined the need for reoperation in 3975 patients who underwent first-time bioprosthetic aortic valve replacement (AVR) (n=3152) or mitral valve replacement (MVR) (n=823). There were 895 patients below the age of 60 years at bioprosthesis implant (AVR, n=636; MVR, n=259). The median interval to reoperation of contemporary, stented aortic bioprostheses was 7.74 years (95% CI 7.28 to 9.97 years) in patients less than 40 years, and 12.93 years (95% CI 11.10 to 15.76 years) in patients between 40 and 60 years of age. Multivariable risk factors associated with reoperation following bioprosthetic AVR include age (hazard ratio [HR] 0.94 per year, 95% CI 0.91 to 0.96, P<0.001) and concomitant coronary artery bypass grafting (HR 0.34, 95% CI 0.11 to 0.99, P=0.04). The median interval to reoperation of contemporary mitral bioprostheses was 8.11 years (95% CI 5.79 to 16.50 years) in patients less than 40 years, and 10.14 years (95% CI 8.64 to 11.14 years) in patients between 40 and 60 years of age. As for AVR, age (HR 0.96 per year, 95% CI 0.95 to 0.98, P<0.001) and concomitant coronary artery bypass grafting (HR 0.55, 95% CI 0.32 to 0.93, P=0.03) were associated with decreased reoperation risk following bioprosthetic MVR. These data constitute clinically relevant age-specific prognostic information regarding reoperation in young patients, who may wish to select a bioprosthesis at initial left heart valve replacement.
    Circulation 09/2011; 124(11 Suppl):S75-80. · 15.20 Impact Factor
  • E M Elmistekawy, F D Rubens
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    ABSTRACT: Deep hypothermic circulatory arrest is an essential tool in the surgeon's armamentarium. There are essentially three strategies to address cerebral ischemia during arrest periods. Early surgical case series pioneered the option of complete anoxia with deep hypothermia. Subsequent innovators introduced the concept of retrograde perfusion of the cerebral vessels through the venous system, and others have advocated the use of selective and non-selective antegrade perfusion of the cerebral arteries. Clinical studies assessing outcomes of the three approaches are compromised by small patient numbers, retrospective design and surgeon bias. In this review, the authors will briefly discuss the conceptual basis of these strategies and the literature comparing these approaches in terms of key neurologic outcomes. The importance of this topic will emphasize the key role the perfusion community plays in establishing guidelines for best practice in circulatory arrest to go forward with education and research in this area.
    Perfusion 09/2011; 26 Suppl 1:27-34. · 0.94 Impact Factor
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    ABSTRACT: We present a patient with recurrent constrictive physiology resulting from exuberant post-operative fibrosis after complete pericardiectomy. The patient underwent a repeat stripping procedure. At surgery, there was an extensive fibrotic and calcified rind around the heart. The recurrence of constriction physiology after complete pericardiectomy in non-tuberculous pericarditis is a rarely reported in literature. The management supports repeat surgery and the potential value of steroid administration.
    Heart Lung &amp Circulation 06/2011; 20(12):766-8. · 1.25 Impact Factor

Publication Stats

1k Citations
422.95 Total Impact Points

Institutions

  • 1998–2014
    • University of Ottawa
      • • Department of Medicine
      • • Department of Radiology
      • • Department of Surgery
      Ottawa, Ontario, Canada
  • 2004–2010
    • The Ottawa Hospital
      • Department of Radiology
      Ottawa, Ontario, Canada
  • 2007
    • Hôpital St-Boniface Hospital
      Winnipeg, Manitoba, Canada
  • 2006
    • Beth Israel Deaconess Medical Center
      • Department of Surgery
      Boston, MA, United States