Publications by authors named "Eric J Charles"

76 Publications

Barriers to atrial fibrillation ablation during mitral valve surgery.

J Thorac Cardiovasc Surg 2021 Mar 17. Epub 2021 Mar 17.

Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.

Background: Nearly 40% of patients with atrial fibrillation (AF) undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. We assessed barriers to implementation of this evidence-based practice through a survey of cardiac surgeons in 2 statewide quality collaboratives.

Methods: Adult cardiac surgeons across 2 statewide collaboratives were surveyed on their knowledge and practice regarding AF ablation. Questions concerning experience, clinical practice, case scenarios, and barriers to implementation were included.

Results: Among 66 respondents (66 of 135; 48.9%), the majority reported "very comfortable/frequently use" cryoablation (53 of 66; 80.3%) and radiofrequency (55 of 66; 83.3%). Only 12.1% (8/66) were not aware of the recommendations. Approximately one-half of the respondents reported learning AF ablation in fellowship (50.0%; 33 of 66) or attending courses (47.0%; 31 of 66). Responses to clinical scenarios demonstrated wide variability in practice patterns. One-half of the respondents reported no barriers; others cited increased cross-clamp time, excessive patient risk, and arrhythmia incidence as obstacles. Desired interventions included cardiology/electrophysiology support, protocols, pacemaker rate information, and education in the form of site visits, videos and proctors.

Conclusions: Knowledge of evidence-based recommendations and practice patterns vary widely. These data identify several barriers to implementation of concomitant AF ablation and suggest specific interventions (mentorship/support, protocols, research, and education) to overcome these barriers.
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http://dx.doi.org/10.1016/j.jtcvs.2021.03.039DOI Listing
March 2021

Socioeconomic risk-adjustment with the Area Deprivation Index predicts surgical morbidity and cost.

Surgery 2021 Mar 12. Epub 2021 Mar 12.

Department of Surgery, University of Virginia Health, Charlottesville, VA. Electronic address:

Background: There is a strong association between socioeconomic status and surgical outcomes; however, the optimal method for socioeconomic risk-stratification remains elusive. We aimed to compare 2 metrics of socioeconomic ranking by ZIP code, the Distressed Communities Index, and the Area Deprivation Index and their association with surgical outcomes.

Methods: This retrospective study included all general surgery cases performed at a single institution from 2005 to 2015. Each patient was assigned Distressed Communities Index and Area Deprivation Index scores based on ZIP code. Both indices are normalized composite measures of socioeconomic status derived from census data. Primary outcome was 30-day morbidity; secondary outcomes included long-term mortality and cost, stratified by socioeconomic status. The utility of the addition of each metric to the American College of Surgeons National Surgical Quality Improvement Program risk calculator was assessed.

Results: The 9,843 patients had normally distributed Distressed Communities Index (47.3 ± 22.4) and Area Deprivation Index (35.4 ± 19.0). Patients who experienced any complication or readmission had significantly higher Distressed Communities Index (48.6 vs 47.1, P = .04) and Area Deprivation Index (37.2 vs 35.1, P = .002). Risk-adjusted models demonstrated that only Area Deprivation Index independently predicted postoperative complications (odds ratio 1.11, P = .02), improved the discrimination of risk-stratification when added to the American College of Surgeons National Surgical Quality Improvement Program risk calculator (area under curve 0.758-0.790, P = .02), and was associated with hospitalization cost ($1,811 ± 856/quartile, P = .03).

Conclusion: Area Deprivation Index provides improved socioeconomic risk-adjustment in this surgical population. The addition of Area Deprivation Index to risk-stratification tools would allow us to better inform our patients of their expected postoperative courses, more accurately account for the increased cost of providing their care, and identify patients and regions that are most in need of improvements in health and healthcare.
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http://dx.doi.org/10.1016/j.surg.2021.02.016DOI Listing
March 2021

Two Hours of In Vivo Lung Perfusion Improves Lung Function in Sepsis-Induced Acute Respiratory Distress Syndrome.

Semin Thorac Cardiovasc Surg 2021 Mar 11. Epub 2021 Mar 11.

Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Sepsis is the leading cause of acute respiratory distress syndrome (ARDS) in adults and carries a high mortality. Utilizing a previously validated porcine model of sepsis-induced ARDS, we sought to refine our novel therapeutic technique of in vivo lung perfusion (IVLP). We hypothesized that 2 hours of IVLP would provide non-inferior lung rehabilitation compared to 4 hours of treatment. Adult swine (n = 8) received lipopolysaccharide to develop ARDS and were placed on central venoarterial extracorporeal membrane oxygenation. Animals were randomized to 2 vs 4 hours of IVLP. The left pulmonary vessels were cannulated to IVLP using antegrade Steen solution. After IVLP treatment, the left lung was decannulated and reperfused for 4 hours. Total lung compliance and pulmonary venous gases from the right lung (control) and left lung (treatment) were sampled hourly. Biochemical analysis of tissue and bronchioalveolar lavage was performed along with tissue histologic assessment. Throughout IVLP and reperfusion, treated left lung PaO/FiO ratio was significantly higher than the right lung control in the 2-hour group (332.2 ± 58.9 vs 264.4 ± 46.5, P = 0.01). In the 4-hour group, there was no difference between treatment and control lung PaO/FiO ratio (258.5 ± 72.4 vs 253.2 ± 90.3, P = 0.58). Wet-to-dry weight ratios demonstrated reduced edema in the treated left lungs of the 2-hour group (6.23 ± 0.73 vs 7.28 ± 0.61, P = 0.03). Total lung compliance was also significantly improved in the 2-hour group. Two hours of IVLP demonstrated superior lung function in this preclinical model of sepsis-induced ARDS. Clinical translation of IVLP may shorten duration of mechanical support and improve outcomes.
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http://dx.doi.org/10.1053/j.semtcvs.2021.02.034DOI Listing
March 2021

Longitudinal analysis of National Institutes of Health funding for academic thoracic surgeons.

J Thorac Cardiovasc Surg 2021 Feb 3. Epub 2021 Feb 3.

Department of Cardiac Surgery, University of Michigan School of Medicine, Ann Arbor, Mich. Electronic address:

Objective: National Institutes of Health (NIH) funding for academic (noncardiac) thoracic surgeons at the top-140 NIH-funded institutes in the United States was assessed. We hypothesized that thoracic surgeons have difficulty in obtaining NIH funding in a difficult funding climate.

Methods: The top-140 NIH-funded institutes' faculty pages were searched for noncardiac thoracic surgeons. Surgeon data, including gender, academic rank, and postfellowship training were recorded. These surgeons were then queried in NIH Research Portfolio Online Reporting Tools Expenditures and Results for their funding history. Analysis of the resulting grants (1980-2019) included grant type, funding amount, project start/end dates, publications, and a citation-based Grant Impact Metric to evaluate productivity.

Results: A total of 395 general thoracic surgeons were evaluated with 63 (16%) receiving NIH funding. These 63 surgeons received 136 grants totaling $228 million, resulting in 1772 publications, and generating more than 50,000 citations. Thoracic surgeons have obtained NIH funding at an increasing rate (1980-2019); however, they have a low percentage of R01 renewal (17.3%). NIH-funded thoracic surgeons were more likely to have a higher professorship level. Thoracic surgeons perform similarly to other physician-scientists in converting K-Awards into R01 funding.

Conclusions: Contrary to our hypothesis, thoracic surgeons have received more NIH funding over time. Thoracic surgeons are able to fill the roles of modern surgeon-scientists by obtaining NIH funding during an era of increasing clinical demands. The NIH should continue to support this mission.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.088DOI Listing
February 2021

Lung Transplantation for Severe Post-Coronavirus Disease 2019 Respiratory Failure.

Transplantation 2021 Feb 16. Epub 2021 Feb 16.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, VA.

Background: The COVID-19 pandemic has resulted in more than 72 million cases and 1.6 million deaths. End-stage lung disease from COVID-19 is a new and growing entity that may benefit from lung transplant, however there is limited data on the patient selection, perioperative management and expected outcomes of transplantation for this indication.

Methods: A systematic review of the literature was performed with searches of MEDLINE and Web of Science databases as well the gray literature. All manuscripts, editorials, commentaries and gray literature reports of lung transplantation for COVID related respiratory failure were included. A case from the University of Virginia is described and included in the review.

Results: A total of 27 studies were included; 11 manuscripts, 5 commentaries, and 11 gray literature reports. The total number of transplantations for COVID related lung disease was 21. The mean age was 55 ± 12 years, 16 (76%) were male, and the acuity was high with 85% on extracorporeal membrane oxygenation preoperatively. There was a 95% early survival rate, with one additional late death. There is growing histopathologic evidence for permanent structural damage with no replicating virus at the time of transplantation.

Conclusions: Bilateral lung transplantation is an effective treatment option with reasonable short-term outcomes for patients suffering from end-stage lung failure secondary to COVID-19. However, specific considerations in this new population require a multidisciplinary approach. As we move into the second wave of the COVID-19 global pandemic, lung transplantation will likely have a growing role in management of these complex patients.
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http://dx.doi.org/10.1097/TP.0000000000003706DOI Listing
February 2021

Surgical versus transcatheter mitral valve replacement in functional mitral valve regurgitation.

Ann Cardiothorac Surg 2021 Jan;10(1):75-84

Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA.

Surgical mitral valve intervention for severe functional, or secondary mitral regurgitation is a viable option for patients deemed to be operative candidates and can be performed via traditional sternotomy or by minimally invasive techniques with similar outcomes. Transcatheter mitral valve replacement is an emerging technology with a potential role in the treatment of functional mitral valve regurgitation. A plethora of devices are currently in development and in various stages of clinical investigation. Operative approach to transcatheter mitral valve replacement varies from a percutaneous transseptal approach to a hybrid percutaneous/surgical apical approach. The Tendyne, Intrepid and Evoque systems show promising results from their early feasibility studies in treatment of patients with mitral regurgitation that were too high risk for surgery. In this review, we describe considerations for surgical and transcatheter mitral valve replacement for functional mitral valve regurgitation.
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http://dx.doi.org/10.21037/acs-2020-mv-217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867424PMC
January 2021

Commentary: Transplanting lungs during a global respiratory pandemic.

J Thorac Cardiovasc Surg 2020 Nov 23. Epub 2020 Nov 23.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.

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http://dx.doi.org/10.1016/j.jtcvs.2020.11.071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831649PMC
November 2020

Commentary: More R-E-S-P-E-C-T for the mitral subvalvular apparatus.

J Thorac Cardiovasc Surg 2020 Nov 5. Epub 2020 Nov 5.

Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.105DOI Listing
November 2020

Effect of Cardiac Surgery on One-Year Patient-Reported Outcomes: A Prospective Cohort Study.

Ann Thorac Surg 2020 Dec 9. Epub 2020 Dec 9.

Department of Surgery, Washington University School of Medicine, St. Louis, MO. Electronic address:

Background: Current cardiac surgery risk algorithms and quality measures focus on perioperative outcomes. However, delivering high-value, patient-centered cardiac care will require a better understanding of long-term patient-reported quality of life after surgery. Our objective was to prospectively assess the effect of cardiac surgery on long-term patient-reported outcomes.

Methods: Patients undergoing cardiac surgery at an academic medical center (2016-2017) were eligible for enrollment. Patient-reported outcomes were measured using the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) preoperatively and one year postoperatively across five domains: mental health, physical health, physical functioning, social satisfaction, and applied cognition. Baseline data and perioperative outcomes were obtained from the Society of Thoracic Surgeons database. The effect of cardiac surgery on long-term patient-reported quality of life was assessed.

Results: Ninety-eight patients were enrolled and underwent cardiac surgery, with 92.9% (91/98) successful follow-up. The most common operation was CABG (63.3% [62/98]), with 60.2% (59/98) undergoing an elective operation. One-year all-cause mortality was 5.1% (5/98). Rate of major morbidity was 11.2% (11/98). Cardiac surgery significantly improved patient-reported outcomes at one year across four domains: mental health (Preop: 47.3±7.7 vs. Postop: 51.1±8.9, p=0.0004), physical health (41.2±8.2 vs. 46.3±9.3, p=0.0003), physical functioning (39.8±8.6 vs. 44.8±8.5, p<0.0001), and social satisfaction (46.8±10.9 vs. 50.7±10.8, p=0.023). Hospital discharge to a facility did not impact one-year patient-reported outcomes.

Conclusions: Cardiac surgery improves long-term patient-reported quality of life. Mental, physical, and social well-being scores were significantly higher one year postoperatively. Data collection with NIH PROMIS provides meaningful, quantifiable results that may improve delivery of patient-centered care.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.061DOI Listing
December 2020

Pulsed Ultrasound of the Spleen Prolongs Survival of Rats With Severe Intra-abdominal Sepsis.

J Surg Res 2021 Mar 3;259:97-105. Epub 2020 Dec 3.

Department of Surgery, University of Virginia Health System, Charlottesville, Virginia. Electronic address:

Background: The spleen is an important contributor to the uncontrolled, excessive release of proinflammatory signals during sepsis that leads to the development of tissue injury and diffuse end-organ dysfunction. Therapeutic pulsed ultrasound (pUS) has been shown to inhibit splenic leukocyte release and reduce cytokine production in other inflammatory disease processes. We hypothesized that pUS treatment inhibits spleen-derived inflammatory responses and increases survival duration in rats with severe intra-abdominal sepsis leading to septic shock.

Materials And Methods: Rats with intra-abdominal sepsis, induced by cecal ligation and incision, underwent abdominal washout, intra-peritoneal administration of cefazolin, and then either no further treatment (control), splenectomy, or pUS of the spleen. Animals were observed for the primary endpoint of survival duration.

Results: Survival curves were significantly different for all groups (P < 0.01). Median survival increased from 9.5 h in control rats to 19.8 h in pUS rats and 35.0 h in splenectomy rats (P < 0.01). At 4 h after cecal ligation and incision, the pUS group had decreased splenic contraction and leukocyte count (P = 0.03) compared with control, indicating reduced exodus of splenic leukocytes. In addition, elevation in plasma TNF-α and MCP-1 was significantly attenuated in the pUS group (P < 0.05 versus control). Splenic β adrenergic receptor levels and phosphorylated Akt were significantly more elevated in the pUS group (P < 0.01 versus control).

Conclusions: pUS significantly prolonged the survival duration of rats with severe intra-abdominal sepsis. This treatment may be an effective, noninvasive therapy that dampens detrimental immune responses during septic shock by activating β adrenergic receptor-Akt phosphorylation in the cholinergic anti-inflammatory pathway.
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http://dx.doi.org/10.1016/j.jss.2020.11.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897287PMC
March 2021

Early Versus Delayed Pacemaker for Heart Block After Valve Surgery: A Cost-Effectiveness Analysis.

J Surg Res 2021 Mar 3;259:154-162. Epub 2020 Dec 3.

Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia.

Background: A significant percentage of patients who acutely develop high-grade atrioventricular block after valve surgery will ultimately recover, yet the ability to predict recovery is limited. The purpose of this analysis was to evaluate the cost-effectiveness of two different management strategies for the timing of permanent pacemaker implantation for new heart block after valve surgery.

Methods: A cost-effectiveness model was developed using costs and probabilities of short- and long-term complications of pacemaker placement, short-term atrioventricular node recovery, intensive care unit stays, and long-term follow-up. We aggregated the total expected cost and utility of each option over a 20-y period. Quality-adjusted survival with a pacemaker was estimated from the literature and institutional patient-reported outcomes. Primary decision analysis was based on an expected recovery rate of 36.7% at 12 d with timing of pacemaker implantation: early placement (5 d) versus watchful waiting for 12 d.

Results: A strategy of watchful waiting was more costly ($171,798 ± $45,695 versus $165,436 ± $52,923; P < 0.0001) but had a higher utility (9.05 ± 1.36 versus 8.55 ± 1.33 quality-adjusted life years; P < 0.0001) than an early pacemaker implantation strategy. The incremental cost-effectiveness ratio of watchful waiting was $12,724 per quality-adjusted life year. The results are sensitive to differences in quality-adjusted survival and rates of recovery of atrioventricular node function.

Conclusions: Watchful waiting for pacemaker insertion is a cost-effective management strategy compared with early placement for acute atrioventricular block after valve surgery. Although this is cost-effective from a population perspective, clinical risk scores predicting recovery will aid in personalized decision-making.
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http://dx.doi.org/10.1016/j.jss.2020.11.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897291PMC
March 2021

Commentary: Small packages, big questions: Mitochondrial transplantation in a preclinical model of pulmonary arterial hypertension.

J Thorac Cardiovasc Surg 2020 Sep 19. Epub 2020 Sep 19.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.

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http://dx.doi.org/10.1016/j.jtcvs.2020.09.061DOI Listing
September 2020

Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery.

Am Surg 2020 Oct 29:3134820950685. Epub 2020 Oct 29.

2358 Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Virginia, USA.

Background: Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery.

Methods: All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs.

Results: A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL ( < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%.

Conclusion: Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.
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http://dx.doi.org/10.1177/0003134820950685DOI Listing
October 2020

Minimally Invasive vs Open Coronary Surgery: A Multiinstitutional Analysis of Cost and Outcomes.

Ann Thorac Surg 2020 Sep 19. Epub 2020 Sep 19.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.

Background: Limited multiinstitutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raised concern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort.

Methods: Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis.

Results: Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P = .383) or major morbidity (7.9% open vs 7.2% MICS CABG, P = .795). However, open CABG patients received more blood products (22.2% vs 12.2%, P = .013), and had longer intensive care unit (45 vs 30 hours, P = .049) as well as hospital lengths of stay (7 vs 6 days, P = .005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P < .001) compared with MICS CABG.

Conclusions: Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.136DOI Listing
September 2020

Variability and Utilization of Concomitant Atrial Fibrillation Ablation During Mitral Valve Surgery.

Ann Thorac Surg 2021 01 18;111(1):29-34. Epub 2020 Jul 18.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.

Background: Concomitant surgical ablation for atrial fibrillation (AF) at the time of mitral valve surgery is a Society of Thoracic Surgeons Class IA recommendation with evidence from randomized trial data. We hypothesized that concomitant AF ablation rates have increased over time with implementation of this evidence-based practice.

Methods: All patients (N = 7261) undergoing mitral valve operations (2011-2018) were queried from a regional Society of Thoracic Surgeons database. Patients with preoperative AF were stratified by concomitant AF ablation. Trends in concomitant ablation were evaluated over time as well as by center and surgeon mitral surgical volume. The associations between patient and center factors on implementation of concomitant ablation were assessed with multivariate regression.

Results: A total of 1675 patients with preoperative AF underwent isolated mitral valve operations, with 1044 (64.6%) undergoing concomitant ablation. The utilization of concomitant ablation decreased over the study period (-2.82%/year), and was strongly associated with surgeon mitral valve volume (high 78.2% vs medium 62.5% vs low 59.0%; P < .001). Multivariate regression demonstrated age and comorbidities were strong predictors, but high volume mitral surgeons (odds ratio [OR], 2.2; P < .001) were twice as likely to perform concomitant AF ablation. Finally, patients with preoperative AF undergoing ablation were significantly less likely to be in AF at discharge (10.1% vs 53.8%; P < .001).

Conclusions: Despite increasing evidence and societal recommendations, we demonstrate a persistent underutilization of concomitant AF ablation during isolated mitral surgery across a large number of low-volume and high-volume centers. These data suggest significant variability and may represent an opportunity for improvement.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.125DOI Listing
January 2021

Adenosine A2A receptor agonist (regadenoson) in human lung transplantation.

J Heart Lung Transplant 2020 06 13;39(6):563-570. Epub 2020 Feb 13.

Division of Developmental Immunology, La Jolla Institute for Immunology and Department of Pharmacology, University of California, San Diego, California.

Background: Currently, there are no clinically approved treatments for ischemia-reperfusion injury after lung transplantation. Pre-clinical animal models have demonstrated a promising efficacy of adenosine receptor (AR) agonists as a treatment option for reducing ischemia-reperfusion injury. The purpose of this human study, is to conduct a Phase I clinical trial for evaluating the safety of continuous infusion of an AR agonist in lung transplant recipients.

Methods: An adaptive, two-stage continual reassessment trial was designed to evaluate the safety of regadenoson (AR agonist) in the setting of lung transplantation. Continuous infusion of regadenoson was administered to lung transplant recipients that was started at the time of skin incision. Adverse events and dose-limiting toxicities, as pre-determined by a study team and assessed by a clinical team and an independent safety monitor, were the primary end-points for safety in this trial.

Results: Between January 2018 and March 2019, 14 recipients were enrolled in the trial. Of these, 10 received the maximum infused dose of 1.44 µg/kg/min for 12 hours. No dose-limiting toxicities were observed. The steady-state plasma regadenoson levels sampled before the reperfusion of the first lung were 0.98 ± 0.46 ng/ml. There were no mortalities within 30 days.

Conclusions: Regadenoson, an AR agonist, can be safely infused in the setting of lung transplantation with no dose-limiting toxicities or drug-related mortality. Although not powered for the evaluation of secondary end-points, the results of this trial and the outcome of pre-clinical studies warrant further investigation with a Phase II randomized controlled trial.
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http://dx.doi.org/10.1016/j.healun.2020.02.003DOI Listing
June 2020

Risk for non-home discharge following surgery for ischemic mitral valve disease.

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

Cardiovascular Medicine, Medicine, Vanderbilt University Medical Center, Nashville, Tenn.

Objectives: To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR).

Methods: Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.

Results: NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P < .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P < .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.

Conclusions: NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.
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http://dx.doi.org/10.1016/j.jtcvs.2020.02.084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874266PMC
March 2020

Commentary: Addressing tricuspid annular dilation: Cinch it down but not too tight.

J Thorac Cardiovasc Surg 2021 04 14;161(4):e288-e289. Epub 2019 Dec 14.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Va.

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http://dx.doi.org/10.1016/j.jtcvs.2019.11.117DOI Listing
April 2021

Hypoenergetic feeding does not improve outcomes in critically ill patients with premorbid obesity: a post hoc analysis of a randomized controlled trial.

Nutr Res 2020 02 30;74:71-77. Epub 2019 Nov 30.

Department of Surgery, University of Virginia, 1215 Lee St, Charlottesville, VA 22903, USA. Electronic address:

Optimal energy goals for adult, obese critically ill surgical patients are unclear. To date, there has been little data comparing feeding regimens for obese and non-obese critically ill surgical patients and the effect on outcomes. The objective was to compare the effect of hypoenergetic and euenergetic feeding goals in critically ill obese patients on outcomes, including infection, intensive care unit length of stay, and mortality. We hypothesized that hypoenergetic feeding of patients with premorbid obesity (body mass index ≥ 30 kg•m) during critical illness does not affect clinical outcomes. Post hoc analyses were performed on critically ill surgical patients enrolled in a randomized controlled trial. Patients were randomized to receive 25-30 kcal•kg•d (105-126 kJ.kg•d, euenergetic) or 12.5-15 kcal•kg•d (52-63 kJ.kg •d, hypoenergetic), with equal protein allocation (1.5 g•kg•d). The effect of feeding regimen on outcomes in obese and nonobese patients were assessed. Of the 83 patients, 30 (36.1%) were obese (body mass index ≥ 30 kg•m). Average energy intake differed based on feeding regimen (hypoenergetic: 982±61 vs euenergetic: 1338±92 kcal•d, P = .02). Comparing obese and nonobese patients, there was no difference in the percentage acquiring an infection (66.7% [20/30] vs 77.4% [41/53], P = .29), intensive care unit length of stay (16.4±3.7 vs 14.3±0.9 days, P = .39), or mortality (10% [3/30] vs 7.6% [4/53], P = .7). Within the subset of obese patients, the percentage acquiring an infection (hypoenergetic: 78.9% [15/19] vs euenergetic: 45.5% [5/11], P = .11) was not affected by the feeding regimen. Within the subset of nonobese patients, there was a trend toward more infections in the euenergetic group (hypoenergetic: 63.6% [14/22] vs euenergetic: 87.1% [27/31], P = .05). Hypoenergetic feeding does not appear to affect clinical outcomes positively or negatively in critically ill patients with premorbid obesity.
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http://dx.doi.org/10.1016/j.nutres.2019.11.011DOI Listing
February 2020

Pulsed ultrasound attenuates the hyperglycemic exacerbation of myocardial ischemia-reperfusion injury.

J Thorac Cardiovasc Surg 2021 04 2;161(4):e297-e306. Epub 2019 Nov 2.

Department of Surgery, University of Virginia, Charlottesville, Va. Electronic address:

Objective: Acute hyperglycemia during myocardial infarction worsens outcomes in part by inflammatory mechanisms. Pulsed ultrasound has anti-inflammatory potential in bone healing and neuromodulation. We hypothesized that pulsed ultrasound would attenuate the hyperglycemic exacerbation of myocardial ischemia-reperfusion injury via the cholinergic anti-inflammatory pathway.

Methods: Acute hyperglycemia was induced in wild-type C57BL6 or acetylcholine-receptor knockout (α7nAChR) mice by intraperitoneal injection of glucose. Pulsed ultrasound (frequency 7 MHz, bursting mechanical index 1.2, duration 1 second, repeated every 6 seconds for 2 minutes, 20-second total exposure) was performed at the spleen or neck after glucose injection. Separate mice underwent vagotomy before treatment. The left coronary artery was occluded for 20 minutes, followed by 60 minutes of reperfusion. The primary end point was infarct size in explanted hearts.

Results: Splenic pulsed ultrasound significantly decreased infarct size in wild-type C57BL6 mice exposed to acute hyperglycemia and myocardial ischemia-reperfusion injury (5.2% ± 4.4% vs 16.9% ± 12.5% of risk region, P = .013). Knockout of α7nAChR abrogated the beneficial effect of splenic pulsed ultrasound (22.2% ± 12.1%, P = .79 vs control). Neck pulsed ultrasound attenuated the hyperglycemic exacerbation of myocardial infarct size (3.5% ± 4.8%, P = .004 vs control); however, the cardioprotective effect disappeared in mice that underwent vagotomy. Plasma acetylcholine, β2 adrenergic receptor, and phosphorylated Akt levels were increased after splenic pulsed ultrasound treatment.

Conclusions: Pulsed ultrasound treatment of the spleen or neck attenuated the hyperglycemic exacerbation of myocardial ischemia-reperfusion injury leading to a 3-fold decrease in infarct size. Pulsed ultrasound may provide cardioprotection via the cholinergic anti-inflammatory pathway and could be a promising new nonpharmacologic, noninvasive therapy to reduce infarct size during acute myocardial infarction and improve patient outcomes.
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http://dx.doi.org/10.1016/j.jtcvs.2019.10.096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195241PMC
April 2021

SPECT imaging of lung ischemia-reperfusion injury using [Tc]cFLFLF for molecular targeting of formyl peptide receptor 1.

Am J Physiol Lung Cell Mol Physiol 2020 02 4;318(2):L304-L313. Epub 2019 Dec 4.

Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia.

Primary graft dysfunction after lung transplantation, a consequence of ischemia-reperfusion injury (IRI), is a major cause of morbidity and mortality. IRI involves acute inflammation and innate immune cell activation, leading to rapid infiltration of neutrophils. Formyl peptide receptor 1 (FPR1) expressed by phagocytic leukocytes plays an important role in neutrophil function. The cell surface expression of FPR1 is rapidly and robustly upregulated on neutrophils in response to inflammatory stimuli. Thus, we hypothesized that use of [Tc]cFLFLF, a selective FPR1 peptide ligand, would permit in vivo neutrophil labeling and noninvasive imaging of IRI using single-photon emission computed tomography (SPECT). A murine model of left lung IRI was utilized. Lung function, neutrophil infiltration, and SPECT imaging were assessed after 1 h of ischemia and 2, 12, or 24 h of reperfusion. [Tc]cFLFLF was injected 2 h before SPECT. Signal intensity by SPECT and total probe uptake by gamma counts were 3.9- and 2.3-fold higher, respectively, in left lungs after ischemia and 2 h of reperfusion versus sham. These values significantly decreased with longer reperfusion times, correlating with resolution of IRI as shown by improved lung function and decreased neutrophil infiltration. SPECT results were confirmed using Cy7-cFLFLF-based fluorescence imaging of lungs. Immunofluorescence microscopy confirmed cFLFLF binding primarily to activated neutrophils. These results demonstrate that [Tc]cFLFLF SPECT enables noninvasive detection of lung IRI and permits monitoring of resolution of injury over time. Clinical application of [Tc]cFLFLF SPECT may permit diagnosis of lung IRI for timely intervention to improve outcomes after transplantation.
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http://dx.doi.org/10.1152/ajplung.00220.2018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7052676PMC
February 2020

Socioeconomically Distressed Communities Index independently predicts major adverse limb events after infrainguinal bypass in a national cohort.

J Vasc Surg 2019 12;70(6):1985-1993.e8

Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, Va.

Background: Socioeconomic status is a major determinant of not only quality of life, but also mortality and health care-related outcomes. We hypothesized that patients coming from distressed communities would have worse short- and long-term limb related outcomes after infrainguinal bypass.

Methods: The infrainguinal bypass national Vascular Quality Initiative datasets for 2003 to 2018 were used. Clinical data were paired with the Distressed Communities Index (DCI) score before extraction. The DCI accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies at the zip code level, with a range of 0 (no distress) to 100 (severe distress). Severely distressed communities were defined as DCI greater than 75 for univariate analysis. Hierarchical multivariable modeling adjusted for baseline and operative risk factors, and clustering at the hospital level.

Results: The 9711 patients who underwent infrainguinal bypass from severely distressed communities (out of 40,109 total) were younger, more likely to smoke, disproportionately African American, with more comorbid disease (all P < .05). Patients from less distressed communities had lower rates of critical limb ischemia (56% DCI ≤ 75 vs 60% DCI > 75; P < .0001) and prior amputation (4.7 vs 6.3%; P < .0001). There was no difference in in-hospital mortality (1.3% vs 1.3%; P = .906) or major adverse cardiovascular events (4.1% vs 3.7%; P = .097). However, patients from distressed communities had higher rates of major adverse limb events (MALE; 11.7% vs 14.4%; P < .0001), and the components amputation, thrombectomy, and revision. After risk adjustment, DCI remained an independent predictor of in-hospital MALE (odds ratio, 1.05 per 25 DCI points; 95% confidence interval [CI], 1.02-1.08; P = .001) and long-term MALE (hazard ration [HR] 1.02; 95% CI, 1.00-1.04; P = .045). DCI is predictive of long-term graft occlusion (HR, 1.04; 95% CI, 1.00-1.07; P = .028) and amputation (HR, 1.09; 95% CI, 1.06-1.12; P < .0001).

Conclusions: The DCI is an independent predictor of MALE after infrainguinal bypass. Patients from distressed communities are at an increased risk of long-term graft occlusion, which is disproportionately treated with amputation instead of surgical limb-saving alternatives. Socioeconomic factors impact vascular disease and surgical outcomes with disparities that warrant further investigation.
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http://dx.doi.org/10.1016/j.jvs.2019.03.060DOI Listing
December 2019

Comprehensive National Institutes of Health funding analysis of academic cardiac surgeons.

J Thorac Cardiovasc Surg 2020 06 9;159(6):2326-2335.e3. Epub 2019 Sep 9.

Division of Cardiac Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va. Electronic address:

Objective: To determine trends in National Institutes of Health (NIH) funding for cardiac surgeons, hypothesizing they are at a disadvantage in obtaining funding owing to intensive clinical demands.

Methods: Cardiac surgeons (adult/congenital) currently at the top 141 NIH-funded institutions were identified using institutional websites. The NIH funding history for each cardiac surgeon was queried using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER). Total grant funding, publications, and type was collected. Academic rank, secondary degrees, and fellowship information was collected from faculty pages. Grant productivity was calculated using a validated grant impact metric.

Results: A total of 818 academic cardiac surgeons were identified, of whom 144 obtained 293 NIH grants totaling $458 million and resulting in 6694 publications. We identified strong associations between an institution's overall NIH funding rank and the number of cardiac surgeons, NIH grants to cardiac surgeons, and amount of NIH funding to cardiac surgeons (P < .0001 for all). The majority of NIH funding to cardiac surgeons is concentrated in the top quartile of institutions. Cardiac surgeons had a high conversion rates from K awards (mentored development awards) to R01s (6 of 14; 42.9%). Finally, we demonstrate that the rate of all NIH grants awarded to cardiac surgeons has increased, driven primarily by P and U (collaborative project) grants.

Conclusions: NIH-funded cardiac surgical research has had a significant impact over the last 3 decades. Aspiring cardiac surgeon-scientists may be more successful at top quartile institutions owing to better infrastructure and mentorship.
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http://dx.doi.org/10.1016/j.jtcvs.2019.08.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7546359PMC
June 2020

Distressed communities are associated with worse outcomes after coronary artery bypass surgery.

J Thorac Cardiovasc Surg 2020 Aug 22;160(2):425-432.e9. Epub 2019 Aug 22.

Department of Surgery, University of Virginia, Charlottesville, Va. Electronic address:

Objectives: Although low socioeconomic status has been associated with increased risk of complications after cardiac surgery, analyses have typically focused on insurance status, race, or median income. We sought to determine if the Distressed Communities Index, a composite socioeconomic metric, could predict operative mortality after coronary artery bypass grafting.

Methods: All patients who underwent isolated coronary artery bypass grafting (2011-2018) in the National Society of Thoracic Surgeons adult cardiac surgery database were analyzed. Clinical data were paired with the Distressed Communities Index, which accounts for unemployment, education level, poverty rate, median income, business growth, and housing vacancies by ZIP code. Developed by the Economic Innovation Group, Distressed Communities Index scores range from 0 (no distress) to 100 (severe distress). A distressed community was defined as one having a Distressed Communities Index of 75 or greater for univariate analyses.

Results: Of the 575,900 patients undergoing coronary artery bypass grafting with a Distressed Communities Index score, the median age was 65 years. The operative mortality rate was 2.0%, and the composite morbidity or mortality rate was 11.5%. Distressed communities were associated with increased Society of Thoracic Surgeons predicted risk of mortality (1.97% vs 1.85%, P < .0001) and risk of composite morbidity or mortality (12.8% vs 11.7%, P < .0001). After adjusting for Society of Thoracic Surgeons risk model, the Distressed Communities Index remained significantly associated with mortality (odds ratio, 1.12; P < .0001) and composite morbidity and mortality (odds ratio, 1.03; P = .002).

Conclusions: Patients from distressed communities are at increased risk for adverse events and death after coronary artery bypass grafting. The Distressed Communities Index is a useful, holistic measure of socioeconomic status that may help identify high-risk patients for quality improvement and should be considered when building risk models or comparing hospitals.
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http://dx.doi.org/10.1016/j.jtcvs.2019.06.104DOI Listing
August 2020

Community level socioeconomic status association with surgical outcomes and resource utilisation in a regional cohort: a prospective registry analysis.

BMJ Qual Saf 2020 03 20;29(3):232-237. Epub 2019 Sep 20.

Surgery, University of Virginia, Charlottesville, Virginia, USA.

Background: Socioeconomic status affects surgical outcomes, however these factors are not included in clinical quality improvement data and risk models. We performed a prospective registry analysis to determine if the Distressed Communities Index (DCI), a composite socioeconomic ranking by zip code, could predict risk-adjusted surgical outcomes and resource utilisation.

Methods: All patients undergoing surgery (n=44,451) in a regional quality improvement database (American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP) were paired with DCI, ranging from 0-100 (low to high distress) and accounting for unemployment, education level, poverty rate, median income, business growth and housing vacancies. The top quartile of distress was compared to the remainder of the cohort and a mixed effects modeling evaluated ACS-NSQIP risk-adjusted association between DCI and the primary outcomes of surgical complications and resource utilisation.

Results: A total of 9369 (21.1%) patients came from severely distressed communities (DCI >75), who had higher rates of most medical comorbidities as well as transfer status (8.4% vs 4.8%, p<0.0001) resulting in higher ACS-NSQIP predicted risk of any complication (8.0% vs 7.1%, p<0.0001). Patients from severely distressed communities had increased 30-day mortality (1.8% vs 1.4%, p=0.01), postoperative complications (9.8% vs 8.5%, p<0.0001), hospital readmission (7.7 vs 6.8, p<0.0001) and resource utilisation. DCI was independently associated with postoperative complications (OR 1.07, 95% CI 1.04 to 1.10, p<0.0001) as well as resource utilisation after adjusting for ACS-NSQIP predicted risk CONCLUSION: Increasing Distressed Communities Index is associated with increased postoperative complications and resource utilisation even after ACS-NSQIP risk adjustment. These findings demonstrate a disparity in surgical outcomes based on community level socioeconomic factors, highlighting the continued need for public health innovation and policy initiatives.
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http://dx.doi.org/10.1136/bmjqs-2019-009800DOI Listing
March 2020

Robotic compared with laparoscopic cholecystectomy: A propensity matched analysis.

Surgery 2020 02 3;167(2):432-435. Epub 2019 Sep 3.

Department of Surgery, University of Virginia, Charlottesville, VA. Electronic address:

Background: As robotic surgery becomes more ubiquitous, determining clinical benefit is necessary to justify the cost and time investment required to become proficient. We hypothesized that robotic cholecystectomy would be associated with improved clinical outcomes but also increased cost as compared with standard laparoscopic cholecystectomy.

Materials And Methods: All patients undergoing robotic or laparoscopic cholecystectomy at a single academic hospital between 2007 and 2017 were identified using an institutional clinical data repository. Patients were stratified by operative approach (robotic versus laparoscopic) for comparison and propensity score matched 1:10 based on relevant comorbidities and demographics. Categorical variables were analyzed by the χ test and continuous variables using the Mann-Whitney U test.

Results: A total of 3,255 patients underwent cholecystectomy during the study period. We observed no differences in demographics or body mass index, but greater rates of diabetes mellitus, hypertension, and gastroesophageal reflux disease were present in the laparoscopic group. After matching (n = 106 robotic, n = 1,060 laparoscopic), there were no differences in preoperative comorbidities. Patients who underwent robotic cholecystectomy had lesser durations of stay (robotic: 0.1 ± 0.7 versus laparoscopic: 0.8 ± 1.9, P < .0001) and lesser 90-day readmission rates (robotic: 0% [0], laparoscopic: 4.1% [43], P = 0.035); however, both operative and hospital costs were greater compared with laparoscopic cholecystectomy.

Conclusion: Robotic cholecystectomy is associated with lesser duration of stay and lesser readmission rate within 90 days of the index operation, but also greater operative duration and hospital cost compared with laparoscopic cholecystectomy. Hospitals and surgeons need to consider the improved clinical outcomes but also the monetary and time investment required before pursuing robotic cholecystectomy.
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http://dx.doi.org/10.1016/j.surg.2019.07.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6980975PMC
February 2020

Meaningful Patient-centered Outcomes 1 Year Following Cardiac Surgery.

Ann Surg 2019 May 2. Epub 2019 May 2.

Department of Surgery, Washington University School of Medicine, St. Louis, MO.

Objective: To evaluate meaningful, patient-centered outcomes including alive-at-home status and patient-reported quality of life 1 year after cardiac surgery.

Background: Long-term patient-reported quality of life after cardiac surgery is not well understood. Current operative risk models and quality metrics focus on short-term outcomes.

Methods: In this combined retrospective/prospective study, cardiac surgery patients at an academic institution (2014-2015) were followed to obtain vital status, living location, and patient-reported outcomes (PROs) at 1 year using the NIH Patient-Reported Outcomes Measurement Information System (PROMIS). We assessed the impact of cardiac surgery, discharge location, and Society of Thoracic Surgeons perioperative predicted risk of morbidity or mortality on 1-year outcomes.

Results: A total of 782 patients were enrolled; 84.1% (658/782) were alive-at-home at 1 year. One-year PROMIS scores were global physical health (GPH) = 48.8 ± 10.2, global mental health (GMH) = 51.2 ± 9.6, and physical functioning (PF) = 45.5 ± 10.2 (general population reference = 50 ± 10). All 3 PROMIS domains at 1 year were significantly higher compared with preoperative scores (GPH: 41.7 ± 8.5, GMH: 46.9 ± 7.9, PF: 39.6 ± 9.0; all P < 0.001). Eighty-two percent of patients discharged to a facility were alive-at-home at 1 year. These patients, however, had significantly lower 1-year scores (difference: GPH = -5.1, GMH = -5.1, PF = -7.9; all P < 0.001). Higher Society of Thoracic Surgeons perioperative predicted risk was associated with significantly lower PRO at 1 year (P < 0.001).

Conclusions: Cardiac surgery results in improved PROMIS scores at 1 year, whereas discharge to a facility and increasing perioperative risk correlate with worse long-term PRO. One-year alive-at-home status and 1-year PRO are meaningful, patient-centered metrics that help define long-term quality and the benefit of cardiac surgery.
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http://dx.doi.org/10.1097/SLA.0000000000003357DOI Listing
May 2019

Impact of Complications After Cardiac Operation on One-Year Patient-Reported Outcomes.

Ann Thorac Surg 2020 01 16;109(1):43-48. Epub 2019 Jul 16.

Division of Thoracic & Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Current reporting on cardiac surgical outcomes focuses on a patient's status at 30 days and lacks long-term meaningful data. The purpose of this study was to determine the impact of complications after cardiac operation on patient-reported outcomes (PROs) at 1 year after surgery.

Methods: All patients undergoing cardiac operation at an academic institution (2014-2015) were contacted 1 year after surgery to obtain vital status, location, and PROs using the validated National Institutes of Health Patient-Reported Outcomes Measurement Information System (NIH-PROMIS). Records were merged with Society of Thoracic Surgeons (STS) data, and multivariate linear regression evaluated the risk-adjusted effects of complications on 1-year PROs.

Results: A total of 782 eligible patients underwent cardiac operation, with PROs data available for 91% of patients alive at 1 year (648 of 716). Mean NIH-PROMIS scores were global physical health (GPH), 48.8 ± 10.2; global mental health (GMH), 51.3 ± 9.5; and physical functioning (PF), 45.5 ± 10.2 (reference score for general adult population, 50 ± 10). Occurrence of an STS Major Morbidity (prolonged ventilation, renal failure, reoperation, stroke, or deep sternal wound infection) significantly reduced 1-year PROs (GPH, 45.4 ± 8.9 [P < .001]; GMH, 48.6 ± 9.5 [P = .01]; PF, 40.9 ± 10.2 [P < .001]). After risk adjustment, incidence of a STS Major Morbidity, prolonged ventilation, or renal failure had a significant adverse effect on 1 or more PRO domains.

Conclusions: Although cardiac surgical patients have PROs scores similar to the general population, complications after cardiac operation continue to negatively influence patient quality of life 1 year after surgery. Use of NIH-PROMIS shows that prolonged ventilation and renal failure have the largest impact on 1-year patient-reported outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2019.05.067DOI Listing
January 2020

Incremental Risk of Annular Enlargement: A Multi-Institutional Cohort Study.

Ann Thorac Surg 2019 12 27;108(6):1752-1759. Epub 2019 Jun 27.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia. Electronic address:

Background: Annular enlargement (AE) is a critical technique to avoid patient-prosthesis mismatch and may help facilitate future valve-in-valve (ViV) transcatheter replacement. We hypothesized that the addition of annular enlargement would increase risk of morbidity and mortality and that the number of annular enlargement procedures is increasing to accommodate future ViV procedures.

Methods: Patients undergoing aortic valve replacement ± coronary surgery (2012 to 2017) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by annular enlargement and era, pre-ViV (2012 to 2014) vs ViV (2015 to 2017) for univariate analysis. Risk-adjusted outcomes were assessed by hierarchical regression modeling adjusting for predicted risk of mortality.

Results: Of 6045 patients, the 300 (5.0%) who received an annular enlargement were younger and more commonly female. Patients receiving an annular enlargement had higher complication rates including operative mortality (4.7% vs 2.5%, P = .024). After risk adjustment, AE was independently associated with increased mortality (odds ratio, 2.06, P = .016) and major morbidity (odds ratio, 1.41, P = .042). The rate of enlargement increased from 3.9% pre-ViV to 6.3% ViV (P < .001). The use of ViV capable valves (bioprosthetic ≥23 mm) from 61% to 67% (P = .001), and more in AE patients (30% vs 11% non-AE). Alternatively, the rate of patient prosthesis mismatch declined from 23% to 16%.

Conclusions: Increasing utilization of AE coincides with a decline in patient prosthesis mismatch and may facilitate future ViV transcatheter aortic valve replacement. However, AE was independently associated with increased morbidity and mortality. High variability in AE volume may be increasing risk and deserves further investigation.
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http://dx.doi.org/10.1016/j.athoracsur.2019.04.118DOI Listing
December 2019

Development and Validation of Procedure-Specific Risk Score for Predicting Postoperative Pulmonary Complication: A NSQIP Analysis.

J Am Coll Surg 2019 10 18;229(4):355-365.e3. Epub 2019 Jun 18.

Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA.

Background: Postoperative pulmonary complications (PPCs; unplanned reintubation, postoperative pneumonia, and failure to liberate from mechanical ventilation within 48 hours), contribute significantly to increased rates of morbidity and mortality. Procedure type is an important factor that contributes risk in generalized PPC prediction models. The objective of this study was to develop and validate procedure-specific risk scores for the 6 procedures with the highest rates of PPCs.

Study Design: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use File data (2005 to 2015) for patients undergoing pancreatectomy, hepatectomy, esophagectomy, abdominal aortic aneurysm repair, open aortoiliac repair, and lung resection were used for analysis. Multivariable logistic regression was used to develop pulmonary complications risk scores (PCRS) for each procedure. Youden indices were used to identify cutoff points within each PCRS and were further validated using a random selection of the original NSQIP dataset collected.

Results: Twenty-one variables were included in the initial analysis, which yielded unique relative risk score models for each procedure. Within all the risk score models, long operative time (within the last quartile) was a strong predictor of PPCs. An increased rate of PPCs was associated with increasing PCRS values in both the training and validation samples for all procedures.

Conclusions: Important variables were identified for 6 common procedures that yield an increased risk of PPCs. These variables differed by procedure type, outlining the importance of procedure-specific risk scores. Each procedure-specific PCRS developed in this study can be used by health care professionals to better predict the risk of PPCs and to optimize patient outcomes.
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http://dx.doi.org/10.1016/j.jamcollsurg.2019.05.028DOI Listing
October 2019