Publications by authors named "Chris C Cook"

28 Publications

  • Page 1 of 1

Robotic Aortic Valve Replacement: First 50 Cases.

Ann Thorac Surg 2021 Sep 21. Epub 2021 Sep 21.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV. Electronic address:

Background: Existing management challenges in selecting transcatheter versus surgical aortic valve replacement (SAVR) include bicuspid stenosis, low clinical risk, horizontal valve position, aortic insufficiency (AI), and need for concomitant procedures or mechanical valves. To address these gaps, we present our early experience with fully robotic-assisted aortic valve replacement (RAVR).

Methods: Between January 2020 and February 2021, 50 consecutive RAVR operations were performed utilizing a 3-4 cm lateral mini-thoracotomy three-port technique with transthoracic aortic clamping, similar to our robotic mitral platform. Conventional SAVR prostheses were implanted with interrupted braided sutures in all cases.

Results: Median age was 67.5 years, BMI was 29, calcified bicuspid disease was present in 28/50 (56%), and severe AI in 8/50 (16%). Ejection fraction was 54.8±8.4% (mean±SD), and STS PROM was 1.54±0.7%. Mechanical prostheses were used in 16/50 (32%), and 7 required concomitant procedures including Cox-Maze (3), left atrial appendage clipping (1), aortic root enlargement (2), mitral repair (1), and left atrial myxoma excision (1). Median times for cardiopulmonary bypass, cross-clamp, valvectomy, annular sutures, and aortotomy closure were 166, 117, 4, 20, and 31 minutes, respectively. All times plateaued after the initial five cases. Most patients (42/50, 84%) were extubated in the operating room, and the remainder (8/50, 16%) within 4 hours. There was no 30-day operative mortality or stroke. All had 30-day echocardiography demonstrating no valvular or perivalvular abnormalities.

Conclusions: RAVR appears to have procedural safety and short-term outcomes to rival alternatives. Incremental experience may facilitate the safe performance of concomitant procedures as deemed necessary.
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http://dx.doi.org/10.1016/j.athoracsur.2021.08.036DOI Listing
September 2021

Commentary: You cannot fix what you cannot see.

JTCVS Tech 2020 Sep 24;3:52-53. Epub 2020 Jun 24.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.

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http://dx.doi.org/10.1016/j.xjtc.2020.06.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8303054PMC
September 2020

Robotic assisted cryothermic biatrial Cox-Maze.

J Cardiovasc Electrophysiol 2021 10 16;32(10):2879-2883. Epub 2021 May 16.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia, USA.

Introduction: Robotic cryothermic Cox-Maze (CM) IV is a minimally invasive procedure that reliably replicates the biatrial lesion set of the CM III by utilizing cryothermia as a single power source.

Methods: Herein we describe a step by step creation of the biatrial CM III lesion sets utilizing the minimally invasive robotic platform.

Results: Technical details are reviewed for this single incision, single stage, highly effective option for stand-alone or concomitant surgical ablation of atrial fibrillation (AF).

Conclusion: Robotic cryothermic CM IV can be safely performed as a stand-alone or concomitant procedure, and offers a comprehensive surgical ablation solution for patients with AF.
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http://dx.doi.org/10.1111/jce.15075DOI Listing
October 2021

Robotic aortic valve replacement.

J Thorac Cardiovasc Surg 2021 May 16;161(5):1753-1759. Epub 2020 Nov 16.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.078DOI Listing
May 2021

Commentary: Aortic root endocarditis: Frozen solutions or free to style yourself.

J Thorac Cardiovasc Surg 2021 10 18;162(4):1060-1061. Epub 2020 Apr 18.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.

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http://dx.doi.org/10.1016/j.jtcvs.2020.04.025DOI Listing
October 2021

The opioid epidemic and intravenous drug-associated endocarditis: A path forward.

J Thorac Cardiovasc Surg 2020 04 15;159(4):1273-1278. Epub 2019 Oct 15.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.08.112DOI Listing
April 2020

Association between surgical volume and clinical outcomes following coronary artery bypass grafting in contemporary practice.

J Card Surg 2019 Oct 7;34(10):1049-1054. Epub 2019 Aug 7.

Department of Cardiovascular Surgery, West Virginia University, Morgantown, West Virginia.

Background: Studies assessing the association between surgical volume and coronary artery bypass grafting (CABG) outcomes yielded conflicting results. Given the substantial recent decrease in CABG volume, we sough to examine the volume-outcomes effect in contemporary practice.

Methods: The National Readmission Database was queried to identify patients undergoing CABG between January 1, 2015 and December 31, 2016. Risk-adjusted in-hospital morbidity, mortality, length-of-stay, cost, and 30-day readmission were compared between low-, intermediate-, and high-volume centers.

Results: A total of 411 159 CABG hospitalizations at 1558 hospitals were included. Hospitals were classified into three tertiles (high > 250, intermediate 100-250, and low-volume < 100). Hospitals in the highest tertile (n = 568) performed 73.9% of all CABG operations, while those in the intermediate (n = 452), and low (n = 538) volume tertiles performed only 21.7% and 4.4% of all CABGs, respectively. The median number of CABGs performed at high-, intermediate-, and low-volume hospitals was 45 316 335, respectively. After risk adjustment, undergoing CABG at low- or intermediate- volume hospital (vs high-volume hospitals) was associated with higher in-hospital death (odd ratio [OR] = 1.31, 95% confidence interval [CI], 1.19-1.44, and OR = 1.11, 95% CI, 1.05-1.17, respectively, P < .001). Similarly, adjusted odds of stroke, acute kidney injury, and blood transfusion were higher at low- and intermediate-volume centers compared with high-volume centers. Undergoing CABG at a low-volume center was associated with 50% higher adjusted cost and 77% higher adjusted 30-day readmissions.

Conclusions: In contemporary practice, in which one-third of CABG-capable hospitals perform < 100 CABG operations annually, a strong relationship is observed between surgical volume and adjusted in-hospital morbidity, mortality, cost, and 30-day readmission.
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http://dx.doi.org/10.1111/jocs.14205DOI Listing
October 2019

Incidence, Predictors, and Outcomes of Early Acute Myocardial Infarction Following Coronary Artery Bypass Grafting.

Am J Cardiol 2019 10 15;124(7):1027-1030. Epub 2019 Jul 15.

Department of Cardiothoracic Surgery, West Virginia University, Morgantown, West Virginia.

Large-scale data on early postdischarge acute myocardial infarction (AMI) after coronary artery bypass grafting (CABG) are lacking. We queried the National Readmission Database (2015 to 2016) to identify patients who underwent CABG between January 1 and June 31 (i.e., had 6 months of follow-up). The study's end points were the incidence, predictors, and outcomes of early post-CABG AMI. Of the 203,760 included patients, 3,829 (1.8%) were readmitted for AMI. Compared with patients without readmissions for AMI, those with AMI were younger (65 ± 11 vs 66 ± 10 years), had more females (35.5% vs 25.1%), and higher prevalence of hypertension, diabetes, obstructive lung disease, anemia, vascular disease, renal insufficiency, and liver cirrhosis, but less atrial fibrillation (p <0.001). They also had a distinctive profile of their index CABG surgery. The strongest predictors of post-CABG AMI readmission were female gender (odds ratio [OR] 1.46, 95% confidence interval [CI] = 1.36 to 1.57), heart failure (OR 1.37, 95% CI = 1.27 to 1.50), dialysis (OR 1.5%, 95% CI = 1.25 to 1.78), cirrhosis (OR 1.61, 95% CI = 1.14 to 2.27), nonelective CABG (OR 1.70, 95% CI = 1.57 to 1.84), perioperative mechanical circulatory support (OR 1.37, 95% CI = 1.23 to 1.51), low-volume centers (OR 1.36, 95% CI = 1.18 to 1.56), and nonhome discharge after CABG (OR 1.47, 95% CI = 1.35 to 1.59). In the patients who were readmitted for AMI, 86.3% had non-ST-elevation AMI and 13.7% had ST-elevation AMI. Coronary angiography was performed in 2,096 patients (54.7%). Of those, 63.5% received percutaneous coronary intervention, and 1.7% had redo-CABG. Readmissions for AMI were associated with significant in-hospital mortality (5.7%), acute kidney injury (22.1%), and new dialysis (2.1%). Median length-of-stay was 3 days (25th/75th percentile 2,6), and the mean hospital cost was $22,207 ± 29,071.
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http://dx.doi.org/10.1016/j.amjcard.2019.06.023DOI Listing
October 2019

Contemporary trends and outcomes of mitral valve surgery for infective endocarditis.

J Card Surg 2019 Jul 18;34(7):583-590. Epub 2019 Jun 18.

Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota.

Background: Contemporary data on mitral valve (MV) surgery in patients with infective endocarditis (IE) are limited.

Methods: The National Inpatient Sample was queried to identify patients with IE who underwent MV surgery between 2003 and 2016. We assessed (a) temporal trends in the incidence of MV surgery for IE, (b) morbidity, mortality, and cost of MV repair vs replacement, and (c) predictors of in-hospital mortality.

Results: The proportion of MV operations involving patients with IE increased from 5.4% in 2003 to 7.3%, and the proportion of MV repair among those undergoing surgery for IE increased from 15.2% to 25.0% (P  < .001). In-hospital mortality was higher in the replacement group (11.3% vs 8.1%; P < .001), and this excess mortality persisted after propensity score matching (11.2% vs 8.1%; P < .001), and in sensitivity analyses excluding concomitant surgery (unadjusted 11.3% vs 4.8%; adjusted 8.5% vs 4.5%; P < .001), and stratifying patients by the time of operation (within 7 days, 11.3% vs 6.8%; P < .001 and >7 days, 11.9% vs 9.1%; P = .012). In the propensity-matched cohorts, shock and need for tracheostomy were more frequent in the replacement group, but rates of stroke, pacemaker implantation, new dialysis, and blood transfusion were similar. Mitral valve repair was, however, associated with shorter hospitalizations, more home discharges, and less cost. In a multivariate regression analysis, age above 70 and chronic dialysis were the strongest predictors of in-hospital mortality.

Conclusion: Mitral valve repair in IE patients is associated with lower in-hospital mortality, resource utilization, and cost compared with MV replacement.
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http://dx.doi.org/10.1111/jocs.14116DOI Listing
July 2019

Machine-learning to stratify diabetic patients using novel cardiac biomarkers and integrative genomics.

Cardiovasc Diabetol 2019 06 11;18(1):78. Epub 2019 Jun 11.

Division of Exercise Physiology, West Virginia University School of Medicine, PO Box 9227, 1 Medical Center Drive, Morgantown, WV, 26505, USA.

Background: Diabetes mellitus is a chronic disease that impacts an increasing percentage of people each year. Among its comorbidities, diabetics are two to four times more likely to develop cardiovascular diseases. While HbA1c remains the primary diagnostic for diabetics, its ability to predict long-term, health outcomes across diverse demographics, ethnic groups, and at a personalized level are limited. The purpose of this study was to provide a model for precision medicine through the implementation of machine-learning algorithms using multiple cardiac biomarkers as a means for predicting diabetes mellitus development.

Methods: Right atrial appendages from 50 patients, 30 non-diabetic and 20 type 2 diabetic, were procured from the WVU Ruby Memorial Hospital. Machine-learning was applied to physiological, biochemical, and sequencing data for each patient. Supervised learning implementing SHapley Additive exPlanations (SHAP) allowed binary (no diabetes or type 2 diabetes) and multiple classification (no diabetes, prediabetes, and type 2 diabetes) of the patient cohort with and without the inclusion of HbA1c levels. Findings were validated through Logistic Regression (LR), Linear Discriminant Analysis (LDA), Gaussian Naïve Bayes (NB), Support Vector Machine (SVM), and Classification and Regression Tree (CART) models with tenfold cross validation.

Results: Total nuclear methylation and hydroxymethylation were highly correlated to diabetic status, with nuclear methylation and mitochondrial electron transport chain (ETC) activities achieving superior testing accuracies in the predictive model (~ 84% testing, binary). Mitochondrial DNA SNPs found in the D-Loop region (SNP-73G, -16126C, and -16362C) were highly associated with diabetes mellitus. The CpG island of transcription factor A, mitochondrial (TFAM) revealed CpG24 (chr10:58385262, P = 0.003) and CpG29 (chr10:58385324, P = 0.001) as markers correlating with diabetic progression. When combining the most predictive factors from each set, total nuclear methylation and CpG24 methylation were the best diagnostic measures in both binary and multiple classification sets.

Conclusions: Using machine-learning, we were able to identify novel as well as the most relevant biomarkers associated with type 2 diabetes mellitus by integrating physiological, biochemical, and sequencing datasets. Ultimately, this approach may be used as a guideline for future investigations into disease pathogenesis and novel biomarker discovery.
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http://dx.doi.org/10.1186/s12933-019-0879-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560734PMC
June 2019

Surgical Techniques for Mitral Valve Repair: A Pathoanatomic Grading System.

Semin Cardiothorac Vasc Anesth 2019 Mar 5;23(1):20-25. Epub 2018 Dec 5.

1 Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA.

Mitral valve surgery has evolved over 4 decades from one based on the principles of prosthetic replacement to a subspecialty with a foundation based on the principles of repair. This review will attempt to enumerate the contemporary techniques of mitral valve repair and a pathoanatomically directed approach with which to apply them by focusing on degenerative disease and associated complexities.
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http://dx.doi.org/10.1177/1089253218815465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6415492PMC
March 2019

Respectful resection to enhance the armamentarium of mitral valve repair: Is less really more?

J Thorac Cardiovasc Surg 2018 11 20;156(5):1854-1855. Epub 2018 Jul 20.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2018.07.011DOI Listing
November 2018

Mentoring the newly minted: Evolving the rules of engagement.

J Thorac Cardiovasc Surg 2018 12 20;156(6):2224-2225. Epub 2018 Jul 20.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2018.07.007DOI Listing
December 2018

Meta-analysis Comparing Transcatheter and Surgical Treatments of Paravalvular Leaks.

Am J Cardiol 2018 07 20;122(2):302-309. Epub 2018 Apr 20.

Division of Cardiology, West Virginia School of Medicine, Morgantown, West Virginia. Electronic address:

Percutaneous paravalvular leak (PVL) closure has emerged as a feasible alternative to redo valve surgery. However, comparative data on percutaneous and surgical treatment of PVL are scarce. We performed a systematic review and a meta-analysis of studies on percutaneous and surgical treatments of PVL. Of the 2,267 studies screened, 22 eligible studies were analyzed. Primary end points were technical success, 30-day mortality, stroke, and length of stay. Secondary end points were 1-year mortality, readmission for heart failure, reoperation, and symptomatic improvement at follow-up. A total of 2,373 patients were included, of whom 1,511 (63.7%) underwent percutaneous closure. Technical success was higher with surgery (96.7% vs 72.1%, odds ratio [OR] 9.7, p <0.001) but at the cost of higher 30-day mortality (8.6% vs 6.8%, OR 1.90, p <0.001), a trend toward higher stroke (3.3% vs 1.4%, OR 1.94, p = 0.069), and longer hospitalizations. However, surgery was associated with similar 1-year mortality (17.3% vs 17.2%, OR 1.07, p = 0.67), reoperation (9.1% vs 9.9%, OR 0.72, p = 0.1), readmission for heart failure (13.3% vs 26.4%, OR 0.51, p = 0.29), and improvement in New York Heart Association classification (67.4% vs 56%, OR 1.37, p = 0.74), compared with percutaneous closure. A sensitivity analysis including comparative studies only yielded similar results. Surgical treatment of PVL achieves higher technical success rates but is associated with higher early morbidity and mortality compared with percutaneous closure. Nevertheless, mortality rates and clinical efficacy parameters were similar at midterm with both procedures. Further studies are warranted to identify the ideal management approach to patients with symptomatic PVL.
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http://dx.doi.org/10.1016/j.amjcard.2018.03.360DOI Listing
July 2018

Balancing risk versus reward in isolated repair of severe tricuspid regurgitation.

J Thorac Cardiovasc Surg 2018 08 24;156(2):658-659. Epub 2018 Apr 24.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2018.04.069DOI Listing
August 2018

Aortic clamping strategy and postoperative stroke.

J Thorac Cardiovasc Surg 2018 10 13;156(4):1451-1457.e4. Epub 2018 Apr 13.

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa. Electronic address:

Objective: The effect of aortic clamping strategy on short-term stroke during proximal graft construction for coronary artery bypass grafting (CABG) remains undefined. The aim of this study was to test the hypothesis that partial occluding clamp (POC) technique does not increase incidence of postoperative stroke compared with single clamp (SC) technique for performing proximal coronary anastomoses.

Methods: We identified 52,611 patients who underwent on-pump CABG in the Society of Thoracic Surgeons Adult Cardiac Surgery Database from July 1, 2014 to March 31, 2015. Propensity scores for POC were calculated on the basis of validated Society of Thoracic Surgeons predicted risk of postoperative stroke scores and used to adjust for intergroup differences to derive 17,819 matched pairs for analysis.

Results: Despite a similar number of total bypass grafts between matched SC versus POC groups, myocardial ischemic times were shorter (74.1 ± 29.2 minutes vs 57.0 ± 23.3 minutes; P < .0001) as were cardiopulmonary bypass times (95.0 ± 35.0 minutes vs 89.7 ± 34.4 minutes; P < .0001) for the POC group. Postoperative stroke rates were similar between SC versus POC (0.9% vs 1.1%; risk ratio, 1.1; 95% confidence interval, 0.9-1.4; P = .3) as were mortality rates (1.3% vs 1.3%; risk ratio, 1.0; 95% confidence interval, 0.8-1.2; P = .9).

Conclusions: Aortic clamping strategy for constructing proximal anastomoses in CABG procedures does not affect short-term incidence of postoperative stroke or mortality. The use of POC incurred shorter myocardial ischemic and perfusion times compared with the SC technique with similar total number of bypass grafts.
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http://dx.doi.org/10.1016/j.jtcvs.2018.03.160DOI Listing
October 2018

Robotic mitral valve operations by experienced surgeons are cost-neutral and durable at 1 year.

J Thorac Cardiovasc Surg 2018 09 12;156(3):1040-1047. Epub 2018 Apr 12.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa. Electronic address:

Background: Robotic mitral valve surgery has potential advantages in patient satisfaction and 30-day outcome. Cost concerns and repair durability limit wider adoption of robotic technology. This study examined detailed cost differences between robotic and sternotomy techniques in relation to outcomes and durability following robotic mitral program initiation.

Methods: Between April 2013 and October 2015, 30-day and 1-year outcomes of 328 consecutive patients undergoing robotic or sternotomy mitral valve repair or replacement by experienced surgeons were examined. Multivariable logistic regression informed propensity matching to derive a cohort of 182 patients. Echocardiographic follow-up was completed at 1 year in all robotic patients. Detailed activity-based cost accounting was applied to include direct, semidirect, and indirect costs with special respect to robotic depreciation, maintenance, and supplies. A quantitative analysis of all hospital costs was applied directly to each patient encounter for comparative financial analyses.

Results: Mean predicted risk of mortality was similar in both the robotic (n = 91) and sternotomy (n = 91) groups (0.9% vs 0.8%; P > .431). The total costs of robotic mitral operations were similar to those of sternotomy ($27,662 vs $28,241; P = .273). Early direct costs were higher in the robotic group. There was a marked increase in late indirect cost with the sternotomy cohort related to increased length of stay, transfusion requirements, and readmission rates. Robotic repair technique was associated with no echocardiographic recurrence greater than trace to only mild regurgitation at 1 year.

Conclusions: Experienced mitral surgeons can initiate a robotic program in a cost-neutral manner that maintains clinical outcome integrity as well as repair durability.
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http://dx.doi.org/10.1016/j.jtcvs.2018.03.147DOI Listing
September 2018

Technology-Enhanced Simulation Improves Trainee Readiness Transitioning to Cardiothoracic Training.

J Surg Educ 2018 Sep - Oct;75(5):1395-1402. Epub 2018 Mar 9.

Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. Electronic address:

Objective: Transitioning from medical school and general surgery training to cardiothoracic (CT) surgical training poses unique challenges for trainees and patient care. We hypothesized that participation in technology-enhanced simulation modules that provided early exposure to urgent/emergent CT patient problems would improve cognitive skills and readiness to manage common urgencies/emergencies.

Design: Traditional and integrated cardiothoracic residents at our institution participated in a technology-enhanced simulation curriculum. The course comprised of didactics, hands-on simulation, virtual models, and mock oral examinations. Residents also were given a validated pretest and post-test to evaluate knowledge retention and integration. Resident performance was graded using a previously validated objective structured clinical examination. Resident perception of course usefulness and relevance was determined through the completion of a perception survey.

Setting: This study occurred at the University of Pittsburgh School of Medicine with the Department of Cardiothoracic Surgery. The facility used was the Peter Winter Institute for Simulation, Education and Research.

Participants: From 2013 to 2015, 25 traditional and integrated cardiothoracic residents participated in these training modules who have completed all portions of the simulation were used for analysis.

Results: For our participants, knowledge base significantly increased by 7.9% (pretest = 76.0% vs. post-test = 83.9%, p < 0.01). According to trained-rater evaluation, 93.6% of responses to the 11 objective structured clinical examination competencies were deemed adequate. Postcourse perception survey demonstrated 92% of participants scoring the sessions as important or very important toward development and confidence in managing the cardiothoracic scenarios. These findings were present despite historical assumption that these learners were prepared for complex patient care.

Conclusions: After completing a technology-enhanced course combining didactics, simulation, and real-time assessment, residents demonstrated objective improvements in cognitive skills and readiness in managing CT patients. Resident postcourse feedback indicated enhanced confidence, suggesting increased preparedness transitioning to CT surgery. This has strong implications for improved patient safety during these potentially labile transition periods.
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http://dx.doi.org/10.1016/j.jsurg.2018.02.009DOI Listing
September 2019

The importance of atrial fibrillation at the time of coronary artery bypass grafting: Join in the chorus.

J Thorac Cardiovasc Surg 2018 04 9;155(4):1534-1535. Epub 2017 Dec 9.

Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2017.12.023DOI Listing
April 2018

Effect of Aortic Clamping Strategy on Postoperative Stroke in Coronary Artery Bypass Grafting Operations.

JAMA Surg 2016 Jan;151(1):59-62

University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Importance: Aortic clamping technique has been implicated in stroke risk at the time of on-pump coronary artery bypass grafting (CABG) procedures. We hypothesized that partial aortic clamping (PAC) use in performing proximal coronary anastomosis does not increase risk of stroke.

Objective: To determine whether postoperative stroke incidence is influenced by single aortic clamping (SAC) or side-biting PAC use in performing proximal anastomosis during CABG procedures.

Design, Setting, And Participants: In a retrospective cohort study, we analyzed data from 1819 patients who underwent conventional, isolated, nonemergent, first-time, arrested-heart, on-pump CABG at a single US major academic, tertiary/quaternary medical center from January 1, 2005, to December 31, 2013. Postoperative stroke was defined according to Society of Thoracic Surgeons (STS) criteria as any confirmed neurological deficit of abrupt onset that did not resolve within 24 hours. Institutional STS data including STS predicted risk of postoperative stroke score were used to compare patients receiving proximal aortic anastomoses performed with either SAC (n = 1107) or combined PAC (n = 712) techniques.

Exposures: Use of SAC or PAC in performing proximal coronary anastomosis.

Main Outcomes And Measures: Thirty-day periprocedural postoperative stroke rates.

Results: There were no significant differences in preoperative risk or STS predicted risk of mortality between groups. Patients in the SAC group had longer myocardial ischemic time compared with those in the PAC group (mean [SD], 73.2 [22.8] vs 66.5 [22.8] minutes, respectively; P < .001) but shorter overall perfusion time (mean [SD], 96.6 [30.1] vs 102.2 [30.1] minutes, respectively; P < .001). The 30-day observed mortality rates between the SAC and PAC groups were equally low (21 of 1107 patients [1.9%] vs 13 of 712 patients [1.8%], respectively; P > .99) and congruent with STS predicted risk of mortality. Preoperative STS predicted risk of postoperative stroke scores were nearly identical between the SAC and PAC groups (mean [SD], 1.5% [1.4%] vs 1.6% [1.4%]; P = .95), and the 30-day actual observed postoperative stroke rates between the SAC and PAC groups were similar (17 of 1107 patients [1.5%] vs 10 of 712 patients [1.4%], respectively; P > .99).

Conclusions And Relevance: In this contemporary study of on-pump CABG, we did not identify any significant differences in the incidence of postoperative stroke regardless of the clamping method used to perform proximal anastomosis.
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http://dx.doi.org/10.1001/jamasurg.2015.3097DOI Listing
January 2016

The Effect of Comprehensive Society of Thoracic Surgeons Quality Improvement on Outcomes and Failure to Rescue.

Ann Thorac Surg 2015 Dec 20;100(6):2147-50; discussion 2150. Epub 2015 Aug 20.

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania. Electronic address:

Background: The Society of Thoracic Surgeons (STS) quality benchmarks guide clinical outcome improvement in cardiac surgery. Failure to rescue (FTR) from postoperative morbidity is a proposed metric of program quality. We examined the effect of a quality improvement initiative guided by STS quality measures on outcomes and FTR.

Methods: Prospectively collected STS data on 3,065 consecutive patients who underwent nonemergency cardiac operations at a single institution from January 1, 2010, to January 31, 2014, were retrospectively analyzed. On January 1, 2012, the quality improvement initiative was implemented. Clinical outcomes and FTR rates were compared between operations performed before (group A) and after (group B) implementation.

Results: STS predicted preoperative mortality and composite of mortality plus morbidity were similar in group A and group B (2.9% ± 3.7% vs 3.1% ± 4.0%, p = 0.21; 17.8% ± 12.1% vs 18.3% ± 12.4%, p = 0.24, respectively). However, the observed mortality and composite mortality plus morbidity were lower in group B vs group A (31 of 1,576 [2.0%] vs 46 of 1,489 [3.1%], p = 0.05; 168 of 1,576 [10.7%] vs 301 of 1,489 [20.2%], p = 0.0001, respectively). Despite clinical outcome improvement, no differences in FTR rates were observed across all seven major morbidity indicators in group A vs B (35 of 290 [12.1%] vs 19 of 156 [12.1%], p = 1.00, respectively). The finding of similarity in the FTR rate remained consistent during procedural subgroup analysis for isolated coronary artery bypass grafting in group A vs B (22 of 174 [12.6%] vs 9 of 77 [11.7%], p = 1.00, respectively).

Conclusions: Implementation of quality improvement initiatives significantly improves outcomes without affecting FTR rates. Further study is needed to determine if FTR provides additive value to quality assessment over existing STS metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2015.05.096DOI Listing
December 2015

Safety and efficacy of implementing a multidisciplinary heart team approach for revascularization in patients with complex coronary artery disease: an observational cohort pilot study.

JAMA Surg 2014 Nov;149(11):1109-12

Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania2Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

Importance: Since the advent of transcatheter aortic valve replacement, the multidisciplinary heart team (MHT) approach has rapidly become the standard of care for patients undergoing the procedure. However, little is known about the potential effect of MHT on patients with coronary artery disease (CAD).

Objective: To determine the safety and efficacy of implementing the MHT approach for patients with complex CAD.

Design, Setting, And Participants: Observational cohort pilot study of 180 patients with CAD involving more than 1 vessel in a single major academic tertiary/quaternary medical center. From May 1, 2012, through May 31, 2013, MHT meetings were convened to discuss evidence-based management of CAD. All cases were reviewed by a team of interventional cardiologists and cardiac surgeons within 72 hours of angiography. All clinical data were reviewed by the team to adjudicate optimal treatment strategies. Final recommendations were based on a consensus decision. Outcome measures were tracked for all patients to determine the safety and efficacy profile of this pilot program.

Exposures: Multidisciplinary heart team meeting.

Main Outcomes And Measures: Thirty-day periprocedural mortality and rate of major adverse cardiac events.

Results: Most of the patients underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG); a small percentage of patients underwent a hybrid procedure or medical management. Incidence of 30-day periprocedural mortality was low across all groups of patients (PCI group, 5 of 64 [8%]; CABG group, 1 of 87 [1%]). The rate of major adverse cardiac events during a median follow-up of 12.1 months ranged from 12 of 87 patients (14%) in the CABG group to 15 of 64 (23%) in the PCI group.

Conclusions And Relevance: Outcomes of patients with complex CAD undergoing the optimal treatment strategy recommended by the MHT were similar to those of published national standards. Implementation of the MHT approach for patients with complex CAD is safe and efficacious.
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http://dx.doi.org/10.1001/jamasurg.2014.2059DOI Listing
November 2014

Interdisciplinary approaches to the phenomenology of auditory verbal hallucinations.

Schizophr Bull 2014 Jul 5;40 Suppl 4:S246-54. Epub 2014 Jun 5.

Department of Psychology, Durham University, Durham, UK;

Despite the recent proliferation of scientific, clinical, and narrative accounts of auditory verbal hallucinations (AVHs), the phenomenology of voice hearing remains opaque and undertheorized. In this article, we outline an interdisciplinary approach to understanding hallucinatory experiences which seeks to demonstrate the value of the humanities and social sciences to advancing knowledge in clinical research and practice. We argue that an interdisciplinary approach to the phenomenology of AVH utilizes rigorous and context-appropriate methodologies to analyze a wider range of first-person accounts of AVH at 3 contextual levels: (1) cultural, social, and historical; (2) experiential; and (3) biographical. We go on to show that there are significant potential benefits for voice hearers, clinicians, and researchers. These include (1) informing the development and refinement of subtypes of hallucinations within and across diagnostic categories; (2) "front-loading" research in cognitive neuroscience; and (3) suggesting new possibilities for therapeutic intervention. In conclusion, we argue that an interdisciplinary approach to the phenomenology of AVH can nourish the ethical core of scientific enquiry by challenging its interpretive paradigms, and offer voice hearers richer, potentially more empowering ways to make sense of their experiences.
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http://dx.doi.org/10.1093/schbul/sbu003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4141308PMC
July 2014

The impact of scoliosis among patients with giant paraesophageal hernia.

J Gastrointest Surg 2011 Jan 8;15(1):23-8. Epub 2010 Sep 8.

Division of Thoracic and Foregut Surgery, Heart, Lung and Esophageal Surgery Institute, UPMC Health System, Pittsburgh, PA, USA.

Background: Kyphoscoliosis is seen in approximately 1.4-15% of the octogenarian population of the US. We hypothesized that patients with kyphoscoliosis are affected with a reduced intra-abdominal volume and progressive laxity of the diaphragmatic hiatal sling musculature leading to an increased risk of hiatal hernia formation and progression over time.

Methods: We retrospectively reviewed the clinical history and roentgenographic data of 320 paraesophageal hernia patients from 2003 to 2007. The prevalence of kyphoscoliosis among this patient cohort and the outcomes of surgical management were compared to paraesophageal hernia patients without kyphoscoliosis.

Results: Ninety-three of the 320 patients (29.1%) were found to have significant K/S (mean age 74; 83% female). Laparoscopic repair of paraesophageal hernia with fundoplication was performed in 91% of these patients. There was one death (1.1%; aspiration pneumonia) and 17.2% major postoperative morbidity. Mean length of hospital stay was 8 days (median = 4; range 2-71). Prolonged stays were related mainly to marginal pulmonary status. Kyphoscoliosis was associated with increased peri-operative pulmonary morbidity (16.1%) compared to patients without kyphoscoliosis (7.0%, p = 0.02).

Conclusion: Kyphoscoliosis may contribute to the development and progression of paraesophageal hernias. Surgeons approaching paraesophageal hernia repair should be aware of the increased pulmonary morbidity and the postoperative care required in managing these patients.
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http://dx.doi.org/10.1007/s11605-010-1307-7DOI Listing
January 2011

IMAGE CARDIO MED: Left atrial wall hematoma/dissection after mitral valve replacement.

Circulation 2010 Feb;121(4):584-5

Division of Cardiac Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, PUH C-900, Pittsburgh, PA 15213, USA.

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http://dx.doi.org/10.1161/CIR.0b013e3181cf3117DOI Listing
February 2010

Great vessel and cardiac trauma.

Surg Clin North Am 2009 Aug;89(4):797-820, viii

Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center Heart, Lung, and Esophageal Surgery Institute, PUH C-800, 200 Lothrop Street, Pittsburgh, PA 15213, USA.

Thoracic great vessel and cardiac trauma are characterized by anatomic location and mechanism of injury: blunt or penetrating. Management strategies are also directed by the extent and mechanism of injury. Advances in imaging and catheter-based technologies have allowed easier and more accurate diagnosis and less-invasive treatments. Although the advantages of endovascular techniques are attractive, open surgical repair remains the definitive treatment for many of these thoracic injuries. Given the increasing sophistication of these technologies and the demonstrated usefulness of a disease-oriented approach toward patient management, trauma centers have adopted a multidisciplinary team model for management of multitrauma victims. In this review, the authors detail the diagnosis and management of blunt aortic, nonaortic great vessel, blunt cardiac, and penetrating cardiac injuries.
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http://dx.doi.org/10.1016/j.suc.2009.05.002DOI Listing
August 2009

Natural history of carotid artery stenosis contralateral to endarterectomy: results from two randomized prospective trials.

J Vasc Surg 2003 Dec;38(6):1154-61

Department of Surgery, Robert C. Byrd Health Sciences Center at West Virginia University, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Ste 603, Charleston, WV 25304, USA.

Purpose: A few nonrandomized studies have reported the natural history of carotid artery stenosis (CAS) contralateral to carotid endarterectomy (CEA). This study analyzed this condition with data from two randomized prospective trials.

Methods: The contralateral carotid arteries in 534 patients from two randomized trials that compared CEA with primary closure versus patching were followed up clinically and with duplex ultrasound scanning at 1 month and then every 6 months. CAS was classified as less than 50%, 50% to 79%, 80% to 99%, and occlusion. Late contralateral CEA was performed to treat significant CAS. Progression was defined as progress to a higher category of stenosis. Kaplan-Meier life table analysis was used to estimate freedom from progression of CAS. The correlation of risk factors and CAS progression was also analyzed.

Results: Of 534 patients, 61 had initial contralateral CEA and 53 had contralateral occlusion. Overall, CAS progressed in 109 of 420 patients (26%) at mean follow-up of 41 months. Progression of CAS was noted in 5 of 162 patients (3%) with baseline normal carotid arteries. CAS progressed in 56 of 157 patients (36%) with less than 50% stenosis versus 45 of 95 patients (47%) with 50% to 79% stenosis (P =.003). Median time to progression was 24 months for less than 50% CAS, and 12 months for 50% to 79% CAS (P =.035). At 1, 2, 3, 4, and 5 years, freedom from disease progression in patients with baseline CAS <50% was 95%, 78%, 69%, 61%, 48%, respectively, and in patients with 50% to 79% CAS was 75%, 61%, 51%, 43%, and 33%, respectively (P =.003). Freedom from progression in patients with baseline normal carotid arteries at 1 through 5 years was 99%, 98%, 96%, 96%, and 94%, respectively. Late neurologic events referable to the CCA were infrequent (28 of 420 [6.7%] in the entire series; 28 of 258 [10.9%] patients with contralateral CAS), and included 10 strokes (2.4%) and 18 transient ischemic attacks (4.3%). However, late contralateral CEA was performed in 62 patients (62 of 420 [15%] in the entire series; 62 of 258 [24%] patients with contralateral CAS). Survival rates were 96%, 92%, 90%, 87%, and 82%, respectively, at 1 through 5 years.

Conclusions: Progression of CCA stenosis was noted in a significant number of patients with baseline contralateral CAS. Serial clinical studies and duplex ultrasound scanning every 6 to 12 months in patients with 50% to 79% CAS, and every 12 to 24 months in patients with 50% or less CAS is adequate.
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http://dx.doi.org/10.1016/j.jvs.2003.07.028DOI Listing
December 2003

Lysis/balloon angioplasty versus thrombectomy/ open patch angioplasty of failed femoropopliteal polytetrafluoroethylene bypass grafts.

J Vasc Surg 2002 Feb;35(2):307-15

Department of Surgery, Robert C. Byrd Health Sciences Center of West Virginia University, Charleston, USA.

Purpose: Several studies have reported on the outcome of lysis/percutaneous transluminal balloon angioplasty (PTA) of failed or failing femoropopliteal bypass grafts (FPGs) with mixed results. None of these studies have compared the results of lysis/PTA versus thrombectomy/open patch repair for failed above-knee polytetrafluoroethylene (PTFE) FPGs.

Methods: Patients with failed (thrombosed) above-knee FPGs (PTFE, Goretex) during a 10-year period were given the option to choose between thrombectomy/open patch repair for localized anastomotic short stenosis (less-than-or-equal2 cm; group A, 31 patients) and lysis/PTA or thrombectomy/balloon angioplasty when lysis failed or was contraindicated (group B, 26 patients). The cumulative patency rates were compared by using a Kaplan-Meier life table analysis. All patients underwent routine color duplex ultrasound scanning/ankle brachial index measurements at 30 days, 6 months, and every 6 months thereafter.

Results: Demographic and clinical characteristics and indications for intervention were comparable in both groups. The mean follow-up period was 54.1 and 46.2 months in group A and group B, respectively. There were four perioperative complications in group A (13%) and seven perioperative complications in group B (27%). Initial technical success and 30-day secondary graft patency rates were 100% in both groups. Overall, 17 of 31 patients (55%) had open grafts, with no further revisions in group A and six of 26 patients (23%) in group B requiring further revisions (P =.012). Nine of 31 grafts (29%) failed in group A versus 15 of 26 grafts (58%) in group B (P =.027). The rate of limb loss was comparable in both groups (6% vs 12%). The overall cumulative secondary patency rates at 6 months and 1, 2, 3, 4, and 5 years were 100%, 93%, 85%, 72%, 67%, and 62% for group A and 100%, 96%, 88%, 76%, 63%, and 45% for group B (P =.035). Thirty-five further interventions were needed to maintain graft patency in group B (mean, 1.35; range, 0-3) versus five further interventions in group A (mean, 0.16; range, 0-1; P <.05).

Conclusion: Thrombectomy/open surgical repair is superior to lysis/PTA (or thrombectomy/balloon angioplasty) for the treatment of failed above-knee PTFE FPGs with anastomotic stenoses. Therefore, balloon angioplasty should be reserved for patients who are at high risk for surgery.
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http://dx.doi.org/10.1067/mva.2002.121122DOI Listing
February 2002
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