Publications by authors named "Alan R Hartman"

23 Publications

  • Page 1 of 1

Paucicellular Fibroma of the Ascending Aorta.

Aorta (Stamford) 2021 Oct 12. Epub 2021 Oct 12.

Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York.

Primary tumors of the aorta are extremely rare. To the best of our knowledge, herein, we present the first case in the literature of a paucicellular fibroma originating from the aortic wall.
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http://dx.doi.org/10.1055/s-0041-1730006DOI Listing
October 2021

Association between multimodality measures of aortic stenosis severity and quality-of-life improvement outcomes after transcatheter aortic valve replacement.

Eur Heart J Qual Care Clin Outcomes 2021 Mar 5. Epub 2021 Mar 5.

Department of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, 300 Community Drive, Manhasset, NY 11030, USA.

Aims: Up to 40% of patients with aortic stenosis (AS) present with discordant grading of AS severity based on common transthoracic echocardiography (TTE) measures. Our aim was to evaluate the utility of TTE and multi-detector computed tomography (MDCT) measures in predicting symptomatic improvement in patients with AS undergoing transcatheter aortic valve replacement (TAVR).

Methods And Results: A retrospective review of 201 TAVR patients from January 2017 to November 2018 was performed. Pre- and post-intervention quality-of-life was measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Pre-intervention measures including dimensionless index (DI), stroke volume index (SVI), mean transaortic gradient, peak transaortic velocity, indexed aortic valve area (AVA), aortic valve calcium score, and AVA based on hybrid MDCT-Doppler calculations were obtained and correlated with change in KCCQ-12 at 30-day follow-up. Among the 201 patients studied, median KCCQ-12 improved from 54.2 pre-intervention to 85.9 post-intervention. In multivariable analysis, patients with a mean gradient >40 mmHg experienced significantly greater improvement in KCCQ-12 at follow-up than those with mean gradient ≤40 mmHg (28.1 vs. 16.4, P = 0.015). Patients with MDCT-Doppler-calculated AVA of ≤1.2 cm2 had greater improvements in KCCQ-12 scores than those with computed tomography-measured AVA of >1.2 cm2 (23.4 vs. 14.1, P = 0.049) on univariate but not multivariable analysis. No association was detected between DI, SVI, peak velocity, calcium score, or AVA index and change in KCCQ-12.

Conclusion: Mean transaortic gradient is predictive of improvement in quality-of-life after TAVR. This measure of AS severity may warrant greater relative consideration when selecting the appropriateness of patients for TAVR.
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http://dx.doi.org/10.1093/ehjqcco/qcab017DOI Listing
March 2021

Degenerative Pulmonary Valve Insufficiency in a Patient With a Prior Bentall Procedure.

Ann Thorac Surg 2021 05 8;111(5):e333-e334. Epub 2020 Oct 8.

Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra Northwell, Manhasset, New York.

Adult pulmonary valve regurgitation most commonly presents after congenital cardiac surgery, with limited reports of pure degenerative valvular disease. We present a patient who underwent a Bentall procedure for annuloaortic ectasia with severe aortic insufficiency 14 years prior now presenting with degenerative, severe, symptomatic pulmonary valve regurgitation and normal pulmonary pressures. The patient underwent successful valve replacement with a bovine prosthesis. Recovery was unremarkable, and he continues to do well without further cardiac surgical requirements.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.058DOI Listing
May 2021

The use of innominate artery cannulation for antegrade cerebral perfusion in aortic dissection.

J Cardiothorac Surg 2020 Jul 31;15(1):205. Epub 2020 Jul 31.

Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA.

Background: Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection.

Methods: A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis.

Results: Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%).

Conclusions: This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.
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http://dx.doi.org/10.1186/s13019-020-01249-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7393698PMC
July 2020

Acute Type A Aortic Dissection Repair After Hours: Does It Influence Outcomes?

Ann Thorac Surg 2020 11 28;110(5):1622-1628. Epub 2020 Mar 28.

Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, New York.

Background: Time of day has been associated with adverse outcomes in certain surgical pathologies. Because acute type A aortic dissection typically mandates immediate repair, relatively little attention has been paid to the potential impact of the day-night timing of the operation itself. We sought to determine whether patients with acute dissection treated during typical working hours demonstrated a difference in outcomes compared with those who required surgery after hours.

Methods: We undertook a comprehensive review of our prospectively collected database from July 2014 to October 2018. A total of 164 consecutive patients underwent primary repair of an acute type A dissection. Based on the procedure start time, patients were divided into 2 groups: working hours (7 am to 4 pm, Monday to Friday; n = 60), and after hours (all other times, including weekends and holidays; n = 104). We propensity-matched 58 pairs of patients and analyzed perioperative data and short-term clinical outcomes.

Results: Thirty-day mortality for all 164 patients was 10.4% (17 deaths), which was not significantly different between the matched groups (working-hours: 8 deaths [13.8%] versus after hours: 4 deaths [6.9%]; P = .36). Perfusion, cross-clamp, and circulatory arrest times did not differ between groups, nor did the types of aortic repairs performed. Postoperative complications were also comparable, including stroke, reoperation for bleeding, and new-onset renal failure requiring dialysis.

Conclusions: Thirty-day mortality and major morbidity after acute type A dissection repair are independent of when the operation is performed. Expeditious surgical intervention is recommended for all primary acute type A dissection, irrespective of time of day.
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http://dx.doi.org/10.1016/j.athoracsur.2020.02.048DOI Listing
November 2020

Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome.

Innovations (Phila) 2020 May/Jun;15(3):235-242. Epub 2020 Mar 31.

232890 Department of Cardiovascular and Thoracic Surgery at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Lenox Hill Hospital, New Hyde Park, NY, USA.

Objective: The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform.

Methods: We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed.

Results: This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; = 0.004), more nodal stations sampled (5 versus 4; < 0.001), and more N1 nodes (8 versus 6; = 0.010) and N2 nodes (6 versus 4; = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS ( = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield.

Conclusions: RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.
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http://dx.doi.org/10.1177/1556984520911670DOI Listing
April 2021

Reoperative mitral valve surgery via sternotomy or right thoracotomy: A propensity-matched analysis.

J Card Surg 2019 Oct 2;34(10):976-982. Epub 2019 Aug 2.

Department of Cardiothoracic Surgery, Northwell Health, North Shore University Hospital, Manhasset, New York.

Background: There is, as yet, no broad consensus regarding the optimal surgical approach for patients requiring reoperative mitral valve surgery. Consequently, we sought to evaluate the perioperative outcomes for patients undergoing redo mitral surgery via right mini thoracotomy as compared with traditional resternotomy.

Methods: A comprehensive retrospective review of our prospectively collected database was undertaken from January 2011 to December 2017. We propensity matched 90 patients who underwent reoperative mitral valve surgery via right mini thoracotomy with a concurrent cohort of patients who had redo median sternotomy. Intraoperative data and short-term clinical outcomes were analyzed.

Results: The 30-day mortality was 3.3% (six deaths) in the entire cohort, not significantly different between redo sternotomy and mini thoracotomy groups. Patients who had their procedure via right mini thoracotomy had reduced intensive care unit (P = .029) and overall hospital (P < .0001) lengths of stay, a diminished requirement for perioperative transfusion (P = .023), and a trend towards faster postoperative extubation. Right thoracotomy patients experienced shorter cardiopulmonary bypass (P = .012) and cardiac arrest (P < .0001) times than did the sternotomy cases. Peripheral cannulation was utilized more frequently in the mini thoracotomy group, as were fibrillatory arrest techniques.

Conclusion: Reoperative mitral valve surgery via right mini thoracotomy is safe, and is associated with shorter extracorporeal circulation times, reduced transfusion, and faster postoperative recovery.
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http://dx.doi.org/10.1111/jocs.14170DOI Listing
October 2019

Should high risk patients with concomitant severe aortic stenosis and mitral valve disease undergo double valve surgery in the TAVR era?

J Cardiothorac Surg 2017 Dec 29;12(1):123. Epub 2017 Dec 29.

Department of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine, 300 Community Drive, 1DSU, Manhasset, NY, 11030, USA.

Background: Significant mitral regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR) is associated with increased mortality. The aim of this study is to determine if surgical correction of both aortic and mitral valves in high risk patients with concomitant valvular disease would offer patients better outcomes than TAVR alone.

Methods: A retrospective analysis of 43 high-risk patients who underwent concomitant surgical aortic valve replacement and mitral valve surgery from 2008 to 2012 was performed. Immediate and long term survival were assessed.

Results: There were 43 high-risk patients with severe aortic stenosis undergoing concomitant surgical aortic valve replacement and mitral valve surgery. The average age was 80 ± 6 years old. Nineteen (44%) patients had prior cardiac surgery, 15 (34.9%) patients had chronic obstructive lung disease, and 39 (91%) patients were in congestive heart failure. The mean Society of Thoracic Surgeons Predicted Risk of Mortality for isolated surgical aortic valve replacement for the cohort was 10.1% ± 6.4%. Five patients (11.6%) died during the index admission and/or within thirty days of surgery. Mortality rate was 25% at six months, 35% at 1 year and 45% at 2 years. There was no correlation between individual preoperative risk factors and mortality.

Conclusions: High-risk patients with severe aortic stenosis and mitral valve disease undergoing concomitant surgical aortic valve replacement and mitral valve surgery may have similar long term survival as that described for such patients undergoing TAVR. Surgical correction of double valvular disease in this patient population may not confer mortality benefit compared to TAVR alone.
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http://dx.doi.org/10.1186/s13019-017-0688-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747188PMC
December 2017

Impact of Postoperative Hypothermia on Outcomes in Coronary Artery Bypass Surgery Patients.

J Cardiothorac Vasc Anesth 2017 Aug 4;31(4):1257-1261. Epub 2017 Feb 4.

Department of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine, Manhasset, NY.

Objectives: To determine the impact of postoperative hypothermia on outcomes in coronary artery bypass graft surgery (CABG) patients.

Design: A retrospective study was performed on patients who underwent isolated CABG between 2011 and 2014.

Setting: Single-center study at a university hospital.

Participants: All patients who underwent isolated CABG with cardiopulmonary bypass between 2011 and 2014.

Interventions: Patients underwent isolated CABG on cardiopulmonary bypass.

Measurements And Main Results: Patients were propensity-score matched based on the likelihood of being hypothermic (<36ºC) or normothermic (≥36ºC) on arrival to the cardiac surgery intensive care unit (ICU) from the operating room. Total transfusion requirements, composite in-hospital morbidity and/or mortality endpoint, total hours in the ICU, and length of hospital stay were compared between the 2 groups. Of the 1,030 patients undergoing isolated CABG, 529 (51.3%) were hypothermic on arrival to the ICU. The hypothermic cohort were older, had more females, had lower body mass indices, had lower starting hematocrit values, were cooled to lower temperatures while on cardiopulmonary bypass, and had longer cardiopulmonary bypass runs compared with the normothermic group. Of the 748 patients who were propensity matched, there were no differences in blood and blood product transfusion requirements, mortality and complication rates, time on the ventilator, length of ICU stay, and length of hospital stay between hypothermic and normothermic patients.

Conclusions: Hypothermia at ICU admission after CABG was not associated with increased adverse outcomes, possibly suggesting that complete rewarming before separation from cardiopulmonary bypass may not be essential in all patients.
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http://dx.doi.org/10.1053/j.jvca.2017.02.017DOI Listing
August 2017

Bedside Vein Mapping for Conduit Size in Coronary Artery Bypass Surgery.

JSLS 2017 Apr-Jun;21(2)

Department of Cardiovascular and Thoracic Surgery, Hofstra Northwell School of Medicine Manhasset, New York, USA.

Background And Objectives: The greater saphenous vein has been used in coronary artery bypass grafting (CABG) for more than 50 years. Endoscopic vein harvesting has greatly reduced the morbidity associated with obtaining the vein, but the quality of the vein could not be assessed before its was exposed surgically or after the endoscopic procedure had been performed. This study was conducted to evaluate the accuracy of preoperative mapping of the greater saphenous vein at the bedside in assessing suitable conduit size for use in CABG.

Methods: Seventy-two consecutive patients undergoing saphenous vein harvesting for use as a conduit during CABG underwent preoperative ultrasonographic vein mapping on the operating table after the leg was positioned for vein harvesting. Vein diameters at 3 distinct locations were measured by ultrasonography after vein harvesting and preparation. Similar linear regression was used to determine the correlation between measurements by ultrasonography and the true vein size after harvesting. Standard methods of computing 95% lower and upper confidence limits for single predicted values were also used.

Results: Two hundred twenty measurements were obtained from 72 patients. Mean vein diameters were 3.4 ± 0.9 and 4.6 ± 0.9 mm as measured by ultrasonography and after vein harvest, respectively. True vein size was an average of 1.2 ± 0.4 mm larger than that measured by ultrasonography. Ultrasonographic determination of vein diameters closely correlated with the true vein diameter (correlation coefficient, 0.91; < .001), and the measurement obtained predicted the true measurement within 1.6 mm with 95% confidence.

Conclusion: Bedside ultrasonographic vein mapping provides an accurate noninvasive method for preoperative assessment to determine the suitability of the greater saphenous vein for use as a bypass conduit. It is therefore an important component of preoperative planning before CABG.
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http://dx.doi.org/10.4293/JSLS.2016.00083DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385143PMC
September 2017

Standardizing Robotic Lobectomy: Feasibility and Safety in 128 Consecutive Lobectomies Within a Single Healthcare System.

Innovations (Phila) 2017 Mar/Apr;12(2):77-81

From the *Division of Thoracic Surgery, PinnacleHealth CardioVascular Institute, Harrisburg, PA USA; †Division of Cardiothoracic Surgery, Northwell Health, Manhasset, NY USA; and ‡Division of Cardiothoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY USA.

Objective: Single-surgeon cohorts assessing robotically assisted video-assisted thoracic (RA-VATS) lobectomy have reported good outcomes, but there are little data regarding multiple surgeons applying a standard technique in separate hospitals. The purpose of this study was to show how a standardized robotic technique is both safe and reproducible between surgeons and institutions.

Methods: From July 1, 2012, to October 1, 2013, patients undergoing RA-VATS lobectomy for both benign and malignant disease were identified from a prospectively collected database of two thoracic surgeons from different hospitals within the same healthcare system and retrospectively analyzed. Each surgeon employed an identical "rule of 10" completely port-based approach through all 128 cases. The primary end points of the study were in-hospital and 30-day mortality. Secondary end points were differences in morbidity and perioperative outcomes between the two surgeons based on their "rule of 10" technique.

Results: A total of 128 cases were performed with 121 lobectomies, 3 bilobectomies, and 4 pneumonectomies for both malignant and benign disease. Each surgeon had 64 cases without a single in-hospital or 30-day mortality. Overall morbidity was 16.4%. Each surgeon had one readmission and take back to operating room (a washout and a mechanical pleurodesis). The most common complication was prolonged air leak (38.1%, 8/21 patients). There was no statistical difference in length of stay, complications, severity of illness, and clinical staging between the two surgeons. There was a significant difference in resected lymph nodes (11.79 vs 14.45, P = 0.0086). Compared with published national meta-analysis on RA-VAT lobectomies, there was a significantly reduced length of stay (4.2 vs 6 days, P = 0.0436) and bleeding (0.8 vs 1.8%, P = 0.0003). Nodal upstaging from cN0 to pN1 was 8% and cN0 to pN2 was 2% for an overall nodal upstaging of 10% for stage I nonsmall cell lung cancer.

Conclusions: By standardizing how a robotic lobectomy is performed, we were able to show that RA-VATS lobectomy is safe and may allow for the expansion of minimally invasive lobectomy to surgeons who otherwise have failed to adopt traditional VATS. When compared with the most recent national meta-analysis, we had reduced morbidity, mortality, bleeding, and length of stay. Robotic nodal upstaging for stage I nonsmall lung cancer was consistent with larger multicenter study. We hope that these results will help lead to the standardization robotic lobectomy and a larger multisurgeon/institutional study that could pave the way for greater adoption of minimally invasive lobectomy.
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http://dx.doi.org/10.1097/IMI.0000000000000352DOI Listing
September 2017

Opioid and Opiate Immunoregulatory Processes.

Crit Rev Immunol 2017 ;37(2-6):213-248

Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York.

The discovery of the ability of the nervous system to communicate through "public" circuits with other systems of the body is attributed to Ernst and Berta Scharrer, who described the neurosecretory process in 1928. Indeed, the immune system has been identified as another important neuroendocrine target tissue. Opioid peptides are involved in this communication (i.e., neuroimmune) and with that of autoimmunoregulation (communication between immunocytes). The significance of opioid neuropeptide involvement with the immune system is ascertained from the presence of novel δ, μ., and κ receptors on inflammatory cells that result in modulation of cellular activity after activation, as well as the presence of specific enzymatic degradation and regulation processes. In contrast to the relatively uniform antinociceptive action of opiate and opioid signal molecules in neural tissues, the presence of naturally occurring morphine in plasma and a novel μ3 opiate-specific receptor on inflammatory cells adds to the growing knowledge that opioid and opiate signal molecules may have antagonistic actions in select tissues. In examining various disorders (e.g., human immunodeficiency virus, substance abuse, parasitism, and the diffuse inflammatory response associated with surgery) evidence has also been found for the involvement of opiate/opioid signaling in prominent mechanisms. In addition, the presence of similar mechanisms in man and organisms 500 million years divergent in evolution bespeaks the importance of this family of signal molecules. The present review provides an overview of recent advances in the field of opiate and opioid immunoregulatory processes and speculates as to their significance in diverse biological systems.
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http://dx.doi.org/10.1615/CritRevImmunol.v37.i2-6.40DOI Listing
April 2019

Outcomes of Patients With Prolonged Intensive Care Unit Length of Stay After Cardiac Surgery.

J Cardiothorac Vasc Anesth 2016 Dec 23;30(6):1550-1554. Epub 2016 Mar 23.

Hofstra Northwell School of Medicine, Department of Cardiovascular and Thoracic Surgery, Bay Shore, NY.

Objective: To determine in-hospital and post-discharge long-term survival in patients with prolonged intensive care unit (ICU) stays after cardiac surgery.

Design: Retrospective, cohort study of cardiac surgery patients from May 2007 to June 2012.

Setting: Single-center cardiac surgery ICU.

Participants: Patients were grouped according to length of ICU stay: between 1 and 2 weeks, between 2 and 4 weeks, and>4 weeks.

Interventions: None.

Measurements And Main Results: Of 4,963 patients, 3.3%, 1.6%, and 2.9% of patients stayed 1 to 2 weeks, 2 to 4 weeks, and>4 weeks in the ICU, respectively. In-hospital mortality was 11.1%, 26.6%, and 31.0% for patients with 1 to 2 weeks, 2 to 4 weeks, and>4 weeks ICU stay, respectively. Patients with ICU stays between 1 and 2 weeks had 6 months, 1 year, and 2 year survival rates of 84.4%, 80.0%, and 75.3% after discharge, respectively. Patients with ICU stay between 2 and 4 weeks had similar 6 months, 1 year, and 2 year survival rates of 84.7%, 79.9%, and 74.1%, respectively. In contrast, patients with>4 week ICU stays had significantly lower postdischarge survival rates of 63.3%, 56.4%, and 41.1% at 6 months, 1 year, and 2 years, respectively. Postoperative stroke conferred the greatest risk of death within 1 year after discharge (odds ratio 7.6, p = 0.0140).

Conclusions: In-hospital mortality rates post-cardiac surgery correlate with length of ICU stay but appear to plateau after 4 weeks. However, a>4 week ICU length of stay confers a worse long-term outcome post-hospital discharge, especially in patients with postoperative stroke.
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http://dx.doi.org/10.1053/j.jvca.2016.03.145DOI Listing
December 2016

Utility of Established Risk Models to Predict Surgical Mortality in Acute Type-A Aortic Dissection.

J Cardiothorac Vasc Anesth 2016 Jan 11;30(1):39-43. Epub 2015 Aug 11.

Hofstra North Shore - LIJ School of Medicine, Hempstead, NY.

Objective: The objective of this study was to determine the predictive value of 2 established risk models for surgical mortality in a contemporary cohort of patients undergoing repair of acute type-A aortic dissection.

Design: Retrospective analysis.

Setting: Single tertiary care hospital.

Participants: Seventy-nine consecutive patients undergoing emergent repair of acute type-A aortic dissection between 2008 and 2013.

Intervention: All patients underwent emergent repair of acute type-A aortic dissection.

Measurements And Main Results: The receiver operating characteristic curve was compared for each scoring system. Of the 79 patients undergoing emergent repair of acute type-A aortic dissection, 23 (29.1%) were above the age of 70. Seventeen (21.5%) patients presented with hypotension, 25 (31.6%) presented with limb ischemia, and 10 (12.7%) presented with evidence of visceral ischemia. Overall operative mortality was 16.5%. Increasing age was the only preoperative variable associated with increased operative mortality. The areas under the receiver operating characteristic curve for operative mortality was 0.62 and 0.66 for the scoring systems developed by Rampoldi et al and Centofanti et al, respectively. The area under the receiver operating characteristic curve for operative mortality for age was 0.67. The areas under the receiver operating characteristic curve for operative mortality between the 2 scoring systems and for age were not statistically different.

Conclusions: Existing predictive risk models for acute type-A aortic dissection provide moderate discriminatory power for operative mortality. Age as a single variable may provide equivalent discriminatory power for operative mortality as the established risk models.
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http://dx.doi.org/10.1053/j.jvca.2015.08.008DOI Listing
January 2016

Myocardial Infarction Classification on Outcomes in Nonemergent Coronary Artery Bypass Grafting.

Ann Thorac Surg 2015 Nov 21;100(5):1588-93. Epub 2015 Jul 21.

Department of Cardiovascular and Thoracic Surgery, Hofstra North Shore-LIJ School of Medicine, Hempstead, New York.

Background: Although patients with ST elevation myocardial infarctions (STEMIs) are known to have worse outcomes than patients with non-ST elevation myocardial infarctions (NSTEMIs), such differences are not well described in the subset of patients undergoing coronary artery bypass grafting. The purpose of this study is to compare postoperative outcomes of patients undergoing nonemergent coronary artery bypass grafting within 1 week after an STEMI versus NSTEMI.

Methods: A retrospective study was performed on patients undergoing isolated coronary artery bypass grafting between 1 and 7 days from an MI from 2008 to 2012. Postoperative outcomes, including mortality and composite postoperative morbidity for patients with STEMI versus NSTEMI, were compared within each group.

Results: Of the 446 patients undergoing nonemergent isolated coronary artery bypass grafting between 1 and 7 days after an MI, 122 patients (27.3%) had an STEMI. The STEMI cohort was younger with less incidence of hypertension than the NSTEMI cohort. However, aside from having a lower incidence of congestive heart failure, STEMI patients had an overall poorer cardiac status than NSTEMI patients. No differences were found in mortality, rates of major complication, length of intensive care unit stay, and length of hospital stay between STEMI and NSTEMI patients.

Conclusion: Despite differences in preoperative characteristics and pathophysiology of patients undergoing coronary artery bypass grafting between 1 and 7 days after NSTEMI versus STEMI, no difference was found in early surgical outcome. The classification of MI should therefore not influence surgical decision making in such patients.
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http://dx.doi.org/10.1016/j.athoracsur.2015.05.003DOI Listing
November 2015

Journey to top performance: a multipronged quality improvement approach to reducing cardiac surgery mortality.

Jt Comm J Qual Patient Saf 2015 Feb;41(2):52-61

Cardiothoracic Surgery, Long Island Jewish Medical Center, New Hyde Park, New York, USA.

Background: In 2006, leadership at Long Island Jewish Medical Center (New Hyde Park, New York) noted significantly higher cardiac surgery mortality rates for isolated valve and valve/coronary artery bypass graft procedures compared to the New York State Department of Health's Cardiac Surgery Reporting System statewide average.

Methods: Long Island Jewish Medical Center, a 583-bed nonprofit, tertiary care teaching hospital, is one of the clinical and academic hubs of North Shore-LIJ Health System. Senior leadership launched an evaluation of the cardiac surgery program to determine why cardiac surgery mortality rates were higher than expected. As a result, the cardiac surgery program was redesigned, and interventions were implemented related to preoperative care, intraoperative monitoring, postoperative care, and the cardiac surgery quality management program.

Results: According to the most recent New York State Department of Health reporting period (2009-2011), Long Island Jewish Medical Center had the lowest risk-adjusted mortality rate in New York State for adult patients undergoing surgeries to repair or replace heart valves and for adult patients in need of valve/coronary artery bypass graft surgery. The medical center has sustained significantly lower mortality rates compared to the statewide average for the past three cardiac surgery reporting periods.

Conclusions: Cardiac surgery mortality rates can be significantly reduced and sustained below comparative norms when the organization is committed to clinical excellence and quality and is involved in continuously assessing organizational performance. The evaluation launched at Long Island Jewish Medical Center led to the redesign of the cardiac surgery program and prompted widespread improvement efforts and cultural change across the entire organization.
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http://dx.doi.org/10.1016/s1553-7250(15)41009-8DOI Listing
February 2015

Acute surgical pulmonary embolectomy: a 9-year retrospective analysis.

Tex Heart Inst J 2015 Feb 1;42(1):25-9. Epub 2015 Feb 1.

Acute pulmonary embolism is a substantial cause of morbidity and death. Although the American College of Chest Physicians Evidence-Based Clinical Practice Guidelines recommend surgical pulmonary embolectomy in patients with acute pulmonary embolism associated with hypotension, there are few reports of 30-day mortality rates. We performed a retrospective review of acute pulmonary embolectomy procedures performed in 96 consecutive patients who had severe, globally hypokinetic right ventricular dysfunction as determined by transthoracic echocardiography. Data on patients who were treated from January 2003 through December 2011 were derived from health system databases of the New York State Cardiac Surgery Reporting System and the Society of Thoracic Surgeons. The data represent procedures performed at 3 tertiary care facilities within a large health system operating in the New York City metropolitan area. The overall 30-day mortality rate was 4.2%. Most patients (68 [73.9%]) were discharged home or to rehabilitation facilities (23 [25%]). Hemodynamically stable patients with severe, globally hypokinetic right ventricular dysfunction had a 30-day mortality rate of 1.4%, with a postoperative mean length of stay of 9.1 days. Comparable findings for hemodynamically unstable patients were 12.5% and 13.4 days, respectively. Acute pulmonary embolectomy can be a viable procedure for patients with severe, globally hypokinetic right ventricular dysfunction, with or without hemodynamic compromise; however, caution is warranted. Our outcomes might be dependent upon institutional capability, experience, surgical ability, and careful patient selection.
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http://dx.doi.org/10.14503/THIJ-13-3877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378038PMC
February 2015

Dose-dependent effects of intraoperative low volume red blood cell transfusions on postoperative outcomes in cardiac surgery patients.

J Cardiothorac Vasc Anesth 2014 Dec 26;28(6):1545-9. Epub 2014 Sep 26.

North Shore University Hospital.

Objective: To determine the incremental risk associated with each intraoperative red blood cell transfusion in cardiac surgery patients.

Design: Retrospective analysis on prospectively collected data.

Setting: Single tertiary care hospital.

Participants: Seven hundred forty-five patients undergoing on-pump cardiac surgery between January 2010 and June 2012 who received between 1 and 3 units of red blood cell transfusion intraoperatively.

Interventions: All patients received between 1 and 3 units of red blood cell transfusions. All transfusions were with leukoreduced blood that had been stored for < 14 days.

Measurements And Main Results: Postoperative complications and length of intubation were associated with the number of red blood cell units transfused. Transfusion of each additional unit of red blood cells was associated with incrementally worse outcomes. Median length of intubation was 11 hours, 12 hours, and 13 hours in patients receiving 1, 2, and 3 units of red blood cell transfusions, respectively (p < 0.005). Similarly, each additional unit of red blood cell transfusion was associated with increasing postoperative septicemia (0% v 0.35% v 2.29%, p < 0.006) and postoperative pneumonia (0% v 0.70% v 2.29%, p < 0.013).

Conclusions: There is a step-wise increase in length of postoperative intubation with each red blood cell transfusion in patients undergoing cardiac surgery. Each additional unit of intraoperative RBC transfusion also may increase postoperative infectious complications. Thus, even single-unit reductions in red blood cell transfusions may have significant impact on outcomes.
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http://dx.doi.org/10.1053/j.jvca.2014.05.025DOI Listing
December 2014

Propensity-matched analysis of the effect of preoperative intraaortic balloon pump in coronary artery bypass grafting after recent acute myocardial infarction on postoperative outcomes.

Crit Care 2014 Sep 23;18(5):531. Epub 2014 Sep 23.

Introduction: There is substantial variability in the preoperative use of intraaortic balloon pumps (IABPs) in patients undergoing coronary artery bypass grafting post myocardial infarction. The objective of this study is to determine the effect of preoperative IABPs on postsurgical outcomes in this subset of patients.

Methods: From 2007 to 2012, 877 patients underwent isolated coronary artery bypass post myocardial infarction. Four hundred and six patients were propensity-score matched based on the likelihood of receiving a preoperative balloon pump. Total blood transfusion requirements, composite in-hospital morbidity and/or mortality end point, total hours in the intensive care unit, and length of hospital stay were compared between the two groups.

Results: No significant differences in demographics, preoperative risk factors, intraoperative variables or length of hospital stay were found between patients with and without balloon pumps after propensity score matching. Compared to patients without balloon pumps, a higher percentage of patients with preoperative IABPs required transfusions. Patients with preoperative balloon pumps were more likely to have the composite end point of in-hospital morbidity (24.1% versus 12.8%, P <0.004), and increased hours in the intensive care unit (median hours: 69.0 versus 46.0, P <0.013) as compared to patients without balloon pumps.

Conclusions: The use of preoperative IABPs in patients undergoing isolated coronary artery bypass grafting after myocardial infarction is associated with increased transfusion requirements, increased in-hospital morbidity and longer postoperative intensive care unit stay as compared to patients without IABPs.
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http://dx.doi.org/10.1186/s13054-014-0531-zDOI Listing
September 2014

Impact of Preoperative Prealbumin on Outcomes After Cardiac Surgery.

JPEN J Parenter Enteral Nutr 2015 Sep 4;39(7):870-4. Epub 2014 Jun 4.

North Shore University Hospital, Manhasset, New York.

Background: Preoperative malnutrition is increasingly prevalent in patients undergoing cardiac surgery. Although prealbumin is a widely used indicator of nutrition status, its use in the preoperative assessment of patients undergoing cardiac surgery is not well defined. The purpose of this study is to determine the impact of preoperative prealbumin levels on outcomes after cardiac surgery.

Materials And Methods: Data were prospectively gathered from February 2013 to July 2013 on 69 patients undergoing cardiac surgery. Prealbumin levels were obtained within 24 hours of surgery. Patients were divided into 2 groups based on a prealbumin cutoff value of 20 mg/dL.

Results: Of the 69 patients, 32 (46.4%) had a preoperative prealbumin ≤ 20 mg/dL. There was no correlation between prealbumin levels and body mass index (r = -0.13, P = .28). Likewise, there was no correlation between preoperative albumin and prealbumin levels (r = 0.09, P = .44). Nine of 32 (28.1%) patients with low preoperative prealbumin levels had postoperative infections compared with 2 of 37 (5.4%) patients with high prealbumin levels (P = .010). Patients with low prealbumin levels also had increased risk of postoperative intubation for > 12 hours (P = .010).

Conclusions: Patients undergoing cardiac surgery with preoperative prealbumin levels of ≤ 20 mg/dL have an increased risk for postoperative infections and the need for longer mechanical ventilation. If feasible, nutrition optimization of such patients may be considered prior to cardiac surgery.
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http://dx.doi.org/10.1177/0148607114536735DOI Listing
September 2015

Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions.

Ann Thorac Surg 2014 May 6;97(5):1488-93; discussion 1493-5. Epub 2014 Mar 6.

Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital, Manhasset, New York; Hofstra North Shore-LIJ School of Medicine, Hempstead, New York.

Background: We designed and tested an innovative transitional care program, involving cardiac surgery nurse practitioners, to improve care continuity after patient discharge home from coronary artery bypass graft (CABG) operations and decrease the composite end point of 30-day readmission and death.

Methods: A total of 401 consecutive CABG patients were eligible between May 1, 2010, and August 31, 2011, for analysis. Patient data were entered prospectively into The Society of Thoracic Surgeons database and the New York State Cardiac Surgery Reporting System and retrospectively analyzed with Institutional Review Board approval. The "Follow Your Heart" program enrolled 169 patients, and 232 controls received usual care. Univariate and multivariate analyses were used to identify readmission predictors, and propensity score matching was performed with 13 covariates.

Results: Binary logistic regression analysis identified "Follow Your Heart" as the only independently significant variable in preventing the composite outcome (p=0.015). Odds ratios for readmission were 3.11 for dialysis patients, 2.17 for Medicaid recipients, 1.87 for women, 1.86 for non-Caucasians, 1.78 for chronic obstructive pulmonary disease, 1.26 for diabetes, and 1.09 for congestive heart failure. Propensity score matching yielded matches for 156 intervention patients (92%). The intervention showed a significantly lower 30-day readmission/death rate of 3.85% (6 of 156) compared with 11.54% (18 of 156) for the usual care matched group (p=0.023).

Conclusions: A home transition program providing continuity of care, communication hub, and medication management by treating hospital nurse practitioners significantly reduced the 30-day composite end point of readmission/death after CABG. More targeted resource allocation based on odds ratios of readmission may further improve results and be applicable to other patient groups.
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http://dx.doi.org/10.1016/j.athoracsur.2013.12.049DOI Listing
May 2014

P2Y12 platelet function assay for assessment of bleeding risk in coronary artery bypass grafting.

J Card Surg 2014 May 2;29(3):312-6. Epub 2014 Mar 2.

North Shore University Hospital, Manhasset, New York.

Background: The use of platelet function testing has been advocated to individualize the time needed between discontinuation of P2Y12 inhibitors and coronary artery bypass grafting (CABG). However, the use of specific point-of-care assays to predict bleeding risk in patients on P2Y12 inhibitors prior to CABG has not been fully validated.

Methods: From September 2012 to May 2013, 81 patients on P2Y12 inhibitors underwent isolated CABG. Preoperative level of P2Y12 receptor blockade was measured using the VerifyNow P2Y12 assay. Packed red blood cell (pRBC) and platelet transfusions and postoperative chest tube output were correlated with preoperative P2Y12 reaction units (PRUs).

Results: Patients who stopped P2Y12 inhibitors for ≤3 days received significantly more platelet transfusions as compared to those whose inhibitors were stopped for longer (0.71 ± 1.05 units vs. 0.20 ± 0.71 units, p = 0.01). They also had increased postoperative chest tube output (552.5 ± 325.5 mL vs. 399.8 ± 146.5 mL, p = 0.03). There was no significant difference in platelet transfusions and chest tube output between patients whose preoperative PRU value was <250 compared to those whose values were ≥250. pRBC requirements were correlated with preoperative hematocrit and age but not with timing of discontinuation of P2Y12 inhibitors or with PRU levels.

Conclusions: In patients on P2Y12 inhibitors undergoing CABG surgery, discontinuation of P2Y12 inhibitors three days prior to surgery rather than VerifyNow PRU values predicts postoperative bleeding and the need for platelet transfusions. Sole reliance on platelet function testing to determine the timing of surgery for patients on P2Y12 inhibitors should therefore be done with caution.
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http://dx.doi.org/10.1111/jocs.12312DOI Listing
May 2014

Surgical repair of a left atrial-esophageal fistula after radiofrequency catheter ablation for atrial fibrillation.

Ann Thorac Surg 2012 Oct;94(4):e91-3

Department of Cardiovascular and Thoracic Surgery, Hofstra North Shore-LIJ Health System School of Medicine, Manhasset, New York 11030, USA.

Left atrial-esophageal fistula is a highly lethal complication of ablative therapy for atrial fibrillation. Because of its unusual rate of occurrence, there has not been a uniform approach to either the diagnosis or corrective therapy. We offer 1 such surgical option based on presumptive and early diagnosis-left atrial repair with cardiopulmonary bypass followed by repair of the esophagus with an omental wrap and supported with decompressive gastrostomy and feeding jejunostomy.
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http://dx.doi.org/10.1016/j.athoracsur.2012.04.052DOI Listing
October 2012
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