Publications by authors named "Daniel T Engelman"

49 Publications

Commentary: Can we do better during a potential second wave of coronavirus disease 2019 (COVID-19)?

JTCVS Open 2020 Dec 2;4:115-116. Epub 2020 Nov 2.

Divisions of General Surgery and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Tex.

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http://dx.doi.org/10.1016/j.xjon.2020.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605862PMC
December 2020

Selecting Elements for a Cardiac Enhanced Recovery Protocol.

J Cardiothorac Vasc Anesth 2021 May 11. Epub 2021 May 11.

University of Massachusetts-Baystate, Heart, Vascular and Critical Care Units, Baystate Medical Center, Springfield, MA.

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http://dx.doi.org/10.1053/j.jvca.2021.05.006DOI Listing
May 2021

Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

J Card Surg 2021 Jun 12. Epub 2021 Jun 12.

Division of Cardiothoracic Surgery, UC Davis Medical Center, Sacramento, California, USA.

Background: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

Methods: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed.

Results: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies.

Conclusions: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.
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http://dx.doi.org/10.1111/jocs.15681DOI Listing
June 2021

Commentary: After the train has left the station: The utility of a late biomarker for cardiac surgery-associated acute kidney injury.

J Thorac Cardiovasc Surg 2021 Apr 2. Epub 2021 Apr 2.

Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.069DOI Listing
April 2021

Commentary: "How to Slay the Aortic Dissection Beast in a COVID-19 World".

Semin Thorac Cardiovasc Surg 2021 16;33(2):313-315. Epub 2021 Feb 16.

Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2021.01.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885634PMC
May 2021

Expert Consensus of Data Elements for Collection for Enhanced Recovery After Cardiac Surgery.

World J Surg 2021 Apr 31;45(4):917-925. Epub 2021 Jan 31.

Heart and Vascular Program, Baystate Health, Springfield, MA, USA.

Background: Despite the emergence of Enhanced Recovery Protocols (ERPs) in cardiac surgery, there is no consensus on the essential elements for data reporting for quality improvement efforts, as well as accountability and standardization of outcome reporting across institutions. The aim of this study was to establish a consensus on essential data elements for cardiac ERAS®.

Methods: A 2-round modified Delphi technique was utilized based on existing recommendations from the recently published ERAS® cardiac surgery consensus guidelines. Round 1 included a steering committee of 10 experts who oversaw formulation of a focused list of data elements into 3 main areas: Preoperative, intraoperative and postoperative. Round 2 consisted of a multidisciplinary, multinational, heterogenous group of 50 voting experts from across the United States and Europe. All participants evaluated their level of agreement with each data element using a 5-point Likert scale with consensus threshold of 70%.

Results: In round 1, 17 data elements were considered essential (consensus >  = 70%, either positive or negative) and 6 were considered marginal (consensus <  = 70%, either positive or negative). In round 2, positive consensus was achieved for 15/17 (88.2%) data elements in the essential category, and all six data elements (100%) in the marginal category, indicating a high level of overall agreement.

Conclusion: This initial study, which identified 21 key data elements for collection in an ERAS® cardiac program, will aid clinicians in establishing a framework for evaluating the quality of their contemporary ERP processes and will allow acquisition of data to help benchmark performance metrics between hospitals.
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http://dx.doi.org/10.1007/s00268-021-05964-1DOI Listing
April 2021

Longitudinal Outcomes in Octogenarian Critically Ill Patients with a Focus on Frailty and Cardiac Surgery.

J Clin Med 2020 Dec 23;10(1). Epub 2020 Dec 23.

3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.

Cardiac surgery (CSX) can be lifesaving in elderly patients (age ≥ 80 years) but may still be associated with complications and functional decline. Frailty represents a determinant to outcomes in critically ill patients, but little is known about its influence on elderly CSX-patients. This is a secondary exploratory analysis of a multi-center, prospective observational cohort study of 610 elderly patients admitted to the ICU and followed for one year to document long-term outcomes. CSX-ICU-patients ( = 49) were compared to surgical ICU patients ( = 184) with regard to demographics, frailty, and outcomes. Of all surgical patients, 102 (43%) were considered vulnerable or frail. The subdistribution hazard ratio (SHR) of time to discharge home (TTDH) for vulnerable/frail vs. fit/well patients was 0.54 (95% confidence interval (CI), 0.34, 0.86, = 0.007). The -value for effect modification between surgery group (CSX vs. surgical ICU patients) and Clinical Frailty Scale (CFS) group was not significant ( = 0.37) suggesting that the observed difference in the CFS effect between the CSX and surgical ICU patients is consistent with random error. A further subgroup analysis shows that among surgical ICU patients, the SHR of time to discharge home (TTDH) for vulnerable/frail vs. fit/well patients was 0.49 (95% CI, 0.29, 0.83) while the corresponding SHR for CSX patients was 0.77 (0.32-1.88). In conclusion, preoperative frailty reduced the rate of discharge to home in both surgical and CSX patients, but a larger sample of CSX patients is needed to adequately address this question in this patient group.
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http://dx.doi.org/10.3390/jcm10010012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793078PMC
December 2020

Stress Biomarkers Do Not Correlate With Risk Factors for Kidney Injury After Cardiac Surgery.

Ann Thorac Surg 2021 Aug 1;112(2):532-538. Epub 2020 Nov 1.

Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.

Background: The urinary cell cycle arrest biomarkers (UBs) insulin-like growth factor-binding protein-7 and tissue inhibitor of metalloproteinases-2 provide early detection of kidney stress, and elevations may predict cardiac surgery-associated acute kidney injury (CS-AKI). We sought to determine whether known clinical risk factors for CS-AKI correlated with increased UB values.

Methods: UBs were measured over a 12-month period the morning after on-pump cardiac surgery. Patients with a preoperative serum creatinine level greater than 2.0 mg/dL or patients undergoing dialysis were excluded. Known clinical AKI risk factors in patients with elevated UB (>0.3 (ng/mL)/1000), that is known to correlate with kidney stress, were compared with patients with low scores (≤0.3 (ng/mL)/1000) by using logistic regression; the analysis was repeated with UB as a continuous variable.

Results: A total of 412 patients met inclusion criteria. Unadjusted results demonstrated a clinically similar CS-AKI risk profile in patients with either elevated or low UB values. The Pearson correlation between preoperative estimated glomerular filtration rate and UB was low (r = 0.16). Clinical risk factors for CS-AKI were not associated with elevated UB values in the logistic regression model, thus producing an area under the receiver operating characteristic curve of 0.63. Linear regression analysis also found few associations between CS-AKI clinical risk factors and UB when measured as a continuous variable, (R) = 0.15.

Conclusions: Traditional CS-AKI clinical risk factors do not differ between patients with normal or elevated UB values. This UB test may identify patients at increased risk for AKI who otherwise would appear to be at low risk by traditional metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.025DOI Listing
August 2021

The Journey from Fast Tracking to Enhanced Recovery.

Crit Care Clin 2020 10;36(4):xv-xviii

Heart and Vascular Program, Baystate Health and University of Massachusetts Medical School-Baystate, 759 Chestnut Street, Springfield, MA 01199, USA.

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http://dx.doi.org/10.1016/j.ccc.2020.07.010DOI Listing
October 2020

Prevention of Acute Kidney Injury.

Crit Care Clin 2020 Oct 13;36(4):691-704. Epub 2020 Aug 13.

Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication after cardiac surgery and associated with a worse outcome. The pathogenesis of CSA-AKI is complex and multifactorial. Therapeutic options for severe CSA-AKI are limited to renal replacement therapy constituting a supportive measure. Therefore, risk identification, prevention, and early diagnosis are of utmost importance to improve patient outcomes. This review aims to provide an overview of the diagnosis, pathophysiologic mechanisms, and risk factors of CSA-AKI and delineates the strategies for AKI prevention available to improve patient outcomes after cardiac surgery.
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http://dx.doi.org/10.1016/j.ccc.2020.07.002DOI Listing
October 2020

Delirium Prevention in Postcardiac Surgical Critical Care.

Crit Care Clin 2020 Oct;36(4):675-690

Cardiac Sciences Program, St. Boniface Hospital, CR3015-369 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada; Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.
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http://dx.doi.org/10.1016/j.ccc.2020.06.001DOI Listing
October 2020

Preoperative Treatment of Malnutrition and Sarcopenia in Cardiac Surgery: New Frontiers.

Crit Care Clin 2020 Oct 14;36(4):593-616. Epub 2020 Aug 14.

Department of Intensive Care Medicine, 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen D-52074, Germany; Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Würzburg, Würzburg, Germany.

Cardiac surgery is performed more often in a population with an increasing number of comorbidities. Although these surgeries can be lifesaving, they disturb homeostasis and may induce a temporary overall loss of physiologic function. The required postoperative intensive care unit and hospital stay often lead to a mid- to long-term decline of nutritional and physical status, mental health, and health-related quality of life. Prehabilitation before elective surgery might be an opportunity to optimize the state of the patient. This article discusses current evidence and potential effects of preoperative optimization of nutrition and physical status before cardiac surgery.
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http://dx.doi.org/10.1016/j.ccc.2020.06.002DOI Listing
October 2020

Cardiac Surgery-Enhanced Recovery Programs Modified for COVID-19: Key Steps to Preserve Resources, Manage Caseload Backlog, and Improve Patient Outcomes.

J Cardiothorac Vasc Anesth 2020 Dec 10;34(12):3218-3224. Epub 2020 Aug 10.

University of Massachusetts-Baystate and Medical Director of the Heart, Vascular and Critical Care Units, Baystate Medical Center, Springfield, MA.

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http://dx.doi.org/10.1053/j.jvca.2020.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416680PMC
December 2020

Commentary: The need for better identification of postoperative delirium.

J Thorac Cardiovasc Surg 2020 Jul 15. Epub 2020 Jul 15.

Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.039DOI Listing
July 2020

Adult cardiac surgery during the COVID-19 pandemic: A tiered patient triage guidance statement.

J Thorac Cardiovasc Surg 2020 Aug 16;160(2):452-455. Epub 2020 Apr 16.

Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

In the setting of the current novel coronavirus pandemic, this document has been generated to provide guiding statements for the adult cardiac surgeon to consider in a rapidly evolving national landscape. Acknowledging the risk for a potentially prolonged need for cardiac surgery procedure deferral, we have created this proposed template for physicians and interdisciplinary teams to consider in protecting their patients, institution, and their highly specialized cardiac surgery team. In addition, recommendations on the transition from traditional in-person patient assessments and outpatient follow-up are provided. Lastly, we advocate that cardiac surgeons must continue to serve as leaders, experts, and relevant members of our medical community, shifting our role as necessary in this time of need.
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http://dx.doi.org/10.1016/j.jtcvs.2020.04.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161470PMC
August 2020

Adult cardiac surgery and the COVID-19 pandemic: Aggressive infection mitigation strategies are necessary in the operating room and surgical recovery.

J Thorac Cardiovasc Surg 2020 08 27;160(2):447-451. Epub 2020 Apr 27.

Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.

The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Preoperative, intraoperative, and postoperative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be used for all patients while local COVID-19 disease burden remains elevated.
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http://dx.doi.org/10.1016/j.jtcvs.2020.04.059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185923PMC
August 2020

Effect of Skeletonization of Bilateral Internal Thoracic Arteries on Deep Sternal Wound Infections.

Ann Thorac Surg 2021 02 26;111(2):600-606. Epub 2020 Jun 26.

Society of Thoracic Surgeons Research Center, Chicago, Illinois.

Background: Bilateral internal thoracic arteries (BITA) coronary bypass grafting may improve long-term outcomes but is associated with increased deep sternal wound infections (DSWIs). We analyzed whether BITA skeletonization impacts DSWIs and operative mortality (OM) using The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

Methods: Primary, isolated, nonemergent/nonsalvage BITA patients (July 2017 to December 2018) in The Society of Thoracic Surgeons Adult Cardiac Surgery Database were divided into groups based on BITA harvesting technique: both skeletonized (ssBITA) and ≥1 nonskeletonized (Non-ssBITA). DSWI and OM observed-to-expected (O/E) ratios were compared using The Society of Thoracic Surgeons Perioperative Risk Models. ssBITA versus Non-ssBITA DSWI and OM adjusted odds ratios were calculated by multivariable logistic regression and corroborated by propensity score matching.

Results: We analyzed 11,269 patients (42.8% ssBITA, 57.2% Non-ssBITA, 770 hospitals, 1448 surgeons). The ssBITA group had a higher incidence of comorbidities and off-pump surgery. Overall incidences of DSWIs and OM were 0.98% (O/E ratio, 5.1) and 1.72% (O/E ratio, 1.4), respectively, and were 28% (P = .129) and 23% (P = .096) lower in ssBITA. The DSWI O/E ratio was highest (5.9) in Non-ssBITA and lowest in ss-BITA (4.1). After multivariable adjustment, ssBITA was associated with a decreased risk of DSWIs (adjusted odds ratio, 0.66; 95% confidence interval, 0.44-1.00; P = .05), with no difference in OM. These results were confirmed among 3884 propensity score-matched pairs. DSWIs increased sharply with increasing number of risk factors for DSWIs regardless of harvesting technique, with a trend for higher DSWIs among Non-ssBITA for all risk categories.

Conclusions: The observed high O/E ratio indicates that BITA grafting is associated with increased risk of DSWIs. Risk-adjusted DSWI rate and a lower O/E ratio in ssBITA support the protective role of skeletonization.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7890569PMC
February 2021

Commentary: Rethinking surgical protocols in the COVID-19 era.

J Thorac Cardiovasc Surg 2020 08 13;160(2):e41. Epub 2020 Apr 13.

Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.04.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7153524PMC
August 2020

Ramping Up Delivery of Cardiac Surgery During the COVID-19 Pandemic: A Guidance Statement From The Society of Thoracic Surgeons COVID-19 Task Force.

Ann Thorac Surg 2020 08 12;110(2):712-717. Epub 2020 May 12.

Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.

The coronavirus disease 2019 (COVID-19) pandemic has had a profound global impact. Its rapid transmissibility has transformed healthcare delivery and forced countries to adopt strict measures to contain its spread. The vast majority of the United States cardiac surgical programs have deferred all but truly emergent/urgent operative procedures in an effort to reduce the burden on the healthcare system and to mobilize resources to combat the pandemic surge. While the number of COVID-19 cases continue to increase worldwide, the incidence of new cases has begun to decline in many North American cities. This "flattening of the curve" has prompted interest in reopening the economy, relaxing public health restrictions, and resuming nonurgent healthcare delivery. The following document provides a template whereby adult cardiac surgical programs may begin to ramp-up the care delivery in a deliberate and graded fashion as the COVID-19 pandemic burden begins to ease. "Resuscitating" the timely delivery of care is guided by three principles: (1) Collaborate to permit increased case volumes, balancing the clinical needs of patients awaiting surgical procedures with the local resources available within each healthcare system. (2) Prioritize patients awaiting elective procedures while proactively engaging all stakeholders, focusing on those with high-risk anatomy, changing/symptomatic clinical status, and, once these variables have been addressed, prioritizing by waiting times. (3) Reevaluate local conditions continuously to assess for any increase in admissions due to a recrudescence of cases, to assure adequate resources to care for patients, and to monitor in-hospital infectious transmissions to both patients and healthcare workers.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7215160PMC
August 2020

Adult Cardiac Surgery and the COVID-19 Pandemic: Aggressive Infection Mitigation Strategies Are Necessary in the Operating Room and Surgical Recovery.

Ann Thorac Surg 2020 08 27;110(2):707-711. Epub 2020 Apr 27.

Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.

The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Preoperative, intraoperative, and postoperative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be used for all patients while local COVID-19 disease burden remains elevated.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185911PMC
August 2020

Commentary: Quality metrics are important, but we must also become stewards of health care value.

J Thorac Cardiovasc Surg 2020 Mar 4. Epub 2020 Mar 4.

Department of Thoracic Surgery, St Charles Medical Center, Bend, Ore.

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http://dx.doi.org/10.1016/j.jtcvs.2020.02.081DOI Listing
March 2020

Adult Cardiac Surgery During the COVID-19 Pandemic: A Tiered Patient Triage Guidance Statement.

Ann Thorac Surg 2020 08 16;110(2):697-700. Epub 2020 Apr 16.

Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

In the setting of the current novel coronavirus pandemic, this document has been generated to provide guiding statements for the adult cardiac surgeon to consider in a rapidly evolving national landscape. Acknowledging the risk for a potentially prolonged need for cardiac surgery procedure deferral, we have created this proposed template for physicians and interdisciplinary teams to consider in protecting their patients, institution, and their highly specialized cardiac surgery team. In addition, recommendations on the transition from traditional in-person patient assessments and outpatient follow-up are provided. Lastly, we advocate that cardiac surgeons must continue to serve as leaders, experts, and relevant members of our medical community, shifting our role as necessary in this time of need.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161520PMC
August 2020

Cardiac Enhanced Recovery After Surgery: A Guide to Team Building and Successful Implementation.

Semin Thorac Cardiovasc Surg 2020 Summer;32(2):187-196. Epub 2020 Feb 29.

Heart and Vascular Program, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.

Enhanced Recovery After Surgery (ERAS) is a bundled approach to perioperative care based upon the philosophy that patients do better when emotional and physiologic stresses are minimized during surgery. The goal of ERAS is to return patients to normal functional status as quickly as possible. Initially designed for patients having colorectal surgery, ERAS programs have now been developed for nearly every surgical subspecialty. Multiple studies examining the effect of ERAS have demonstrated decreased postoperative complications, length of stay, costs, and increased patient and staff satisfaction. Interest in the application of ERAS to cardiac surgery has grown significantly over the last few years. Several core principles transcend all ERAS cardiac programs. Implementation of cardiac ERAS is more than simply the installation of a protocol. ERAS involves a methodical shift in culture, meeting the challenges of initiating and sustaining meaningful organizational change, and pivoting to a patient-centered system of care to optimize speed and completeness of recovery. Herein we detail the crucial team building, education, planning, and processes needed to develop and sustain a successful ERAS cardiac program.
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http://dx.doi.org/10.1053/j.semtcvs.2020.02.029DOI Listing
September 2020

Commentary: A little is way too much: What we have learned about perioperative acute kidney injury.

J Thorac Cardiovasc Surg 2021 07 21;162(1):153-154. Epub 2020 Jan 21.

Heart and Vascular Program, Baystate Health, Springfield, Mass; University of Massachusetts Medical School-Baystate, Springfield, Mass.

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http://dx.doi.org/10.1016/j.jtcvs.2019.12.100DOI Listing
July 2021

Commentary: Low hanging fruit-reducing hospital-acquired pressure injuries associated with cardiac surgery.

J Thorac Cardiovasc Surg 2020 07 22;160(1):164-166. Epub 2020 Jan 22.

Heart and Vascular Program, Baystate Health, Springfield, Mass; University of Massachusetts Medical School-Baystate, Springfield, Mass.

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http://dx.doi.org/10.1016/j.jtcvs.2019.12.101DOI Listing
July 2020

Using urinary biomarkers to reduce acute kidney injury following cardiac surgery.

J Thorac Cardiovasc Surg 2020 11 17;160(5):1235-1246.e2. Epub 2019 Oct 17.

Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Mass.

Background: Prediction of acute kidney injury (AKI) following cardiac surgery is unreliable through the use of serum creatinine or urinary output alone. Cell cycle arrest urinary biomarkers insulin-like growth factor-binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinases-2 (TIMP2) provide early detection of kidney stress and possibly AKI. We sought to determine whether therapeutic interventions driven by elevated urinary biomarkers (UB) reduces post-cardiac surgery stage 2/3 AKI.

Methods: A quality improvement initiative based on UB was undertaken in all adult on-pump cardiac surgical patients with a preoperative serum creatinine level ≤2.0 mg/dL. A UB score the morning after cardiac surgery that was considered positive for kidney stress (≥0.3 [ng/mL]/1000) triggered activation of a multidisciplinary acute kidney response team (AKRT) with implementation of a predefined staged protocol, including targeted goal-directed fluid management, liberalized transfusion thresholds, continued invasive hemodynamic monitoring and its optimization in the intensive care unit, and avoidance of nephrotoxins. We compared the incidence of stage 2/3 AKI before (pre-UB) versus after (post-UB) implementation of the Kidney Disease: Improving Global Outcomes quality improvement initiative. Standardized, protocolized, evidence-based care pathways were used pre-UB.

Results: The incidence of stage 2/3 AKI was compared in 435 pre-UB patients and 412 post-UB patients. Fifty-five percent of the post-UB patients had a moderate or high UB score (≥0.3 [ng/mL]/1000). Ten patients (2.30%) had stage 2/3 AKI pre-UB, compared with 1 patient (0.24%) post-UB, a relative reduction of 89% (P = .01). The total and postoperative lengths of stay, cost, mortality, and readmissions were similar in the 2 groups. The negative predictive value for AKI of UB <0.3 [ng/mL]/1000 was 100%.

Conclusions: The routine measurement of UB and subsequent activation of an AKRT are useful post-cardiac surgery therapeutic adjuncts. They are associated with early detection of kidney stress, allowing for targeted proactive intervention, and a significant decrease in postoperative stage 2/3 AKI without increases in cost or length of stay.
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http://dx.doi.org/10.1016/j.jtcvs.2019.10.034DOI Listing
November 2020

Clinical use of [TIMP-2]•[IGFBP7] biomarker testing to assess risk of acute kidney injury in critical care: guidance from an expert panel.

Crit Care 2019 06 20;23(1):225. Epub 2019 Jun 20.

The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, 3347 Forbes Avenue, Suite 220, Pittsburgh, PA, 15213, USA.

Background: The first FDA-approved test to assess risk for acute kidney injury (AKI), [TIMP-2]•[IGFBP7], is clinically available in many parts of the world, including the USA and Europe. We sought to understand how the test is currently being used clinically.

Methods: We invited a group of experts knowledgeable on the utility of this test for kidney injury to a panel discussion regarding the appropriate use of the test. Specifically, we wanted to identify which patients would be appropriate for testing, how the results are interpreted, and what actions would be taken based on the results of the test. We used a modified Delphi method to prioritize specific populations for testing and actions based on biomarker test results. No attempt was made to evaluate the evidence in support of various actions however.

Results: Our results indicate that clinical experts have developed similar practice patterns for use of the [TIMP-2]•[IGFBP7] test in Europe and North America. Patients undergoing major surgery (both cardiac and non-cardiac), those who were hemodynamically unstable, or those with sepsis appear to be priority patient populations for testing kidney stress. It was agreed that, in patients who tested positive, management of potentially nephrotoxic drugs and fluids would be a priority. Patients who tested negative may be candidates for "fast-track" protocols.

Conclusion: In the experience of our expert panel, biomarker testing has been a priority after major surgery, hemodynamic instability, or sepsis. Our panel members reported that a positive test prompts management of nephrotoxic drugs as well as fluids, while patients with negative results are considered to be excellent candidates for "fast-track" protocols.
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http://dx.doi.org/10.1186/s13054-019-2504-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585126PMC
June 2019

Commentary: Should goal-directed fluid therapy be used in every cardiac surgery patient to prevent acute kidney injury?

J Thorac Cardiovasc Surg 2020 05 29;159(5):1878-1879. Epub 2019 Apr 29.

Heart and Vascular Program, Baystate Health, Springfield, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.04.044DOI Listing
May 2020

Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations.

JAMA Surg 2019 08;154(8):755-766

Department of Cardiac Surgery, St Charles Medical Center, Bend, Oregon.

Enhanced Recovery After Surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing cardiac surgery. A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and reviews was conducted for each protocol element. The quality of the evidence was graded and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery After Surgery Society.
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http://dx.doi.org/10.1001/jamasurg.2019.1153DOI Listing
August 2019

Commentary: Cardiac surgery, nutrition, and recovery-First define the problem.

J Thorac Cardiovasc Surg 2019 10 4;158(4):1109-1110. Epub 2019 Apr 4.

Heart & Vascular Program, Baystate Health, Springfield, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.03.065DOI Listing
October 2019
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