Publications by authors named "J Hunter Mehaffey"

199 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

Commentary: The debate continues on optimal myocardial recovery assessment.

J Thorac Cardiovasc Surg 2021 Feb 22. Epub 2021 Feb 22.

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.2021.02.051DOI Listing
February 2021

Interviews During the Pandemic: A Thoracic Education Cooperative Group and Surgery Residents Project.

Ann Thorac Surg 2021 Mar 24. Epub 2021 Mar 24.

Division of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, TX. Electronic address:

Background: The 2020 interview cycle for cardiothoracic fellowships was affected by the coronavirus-19 pandemic. Many programs shifted from in-person to virtual interviews. We evaluated applicant perceptions of the various formats.

Methods: All 2019-2020 cardiothoracic fellowship applicants received an electronic survey after completion of the match process. The survey assessed number of in-person/virtual interviews completed, perception of efficacy and likelihood of ranking a program based on format, and strengths/inadequacies of virtual interviews.

Results: Response rate was 36% (48/133). Seventy-three percent (35/48) of respondents interviewed with more than 10 programs. Fifty-two percent (25/48) of respondents were able to schedule additional interviews once virtual formats were available. A slight majority (56%, 27/48) ranked a program at which they had an in-person interview as their first choice. Interviewing at more than 10 programs was associated with an increased likelihood of successfully matching at a program (p = 0.02). Overwhelmingly, respondents favored an in-person component to the interview process (96%, 46/48). Few respondents (29%, 14/48) felt they could adequately evaluate a program virtually. The factors which had the highest percentages of adequate portrayal during virtual interviews were the didactic schedule/curriculum (81%, 39/48) and case number/autonomy (58%, 28/48). The factors with the lowest percentages were culture/personality (19%, 9/48) and city/lifestyle (15%, 7/48).

Conclusions: Applicants strongly favored an in-person component to interviews, highlighting potential deficiencies in the virtual interview process. Programs should consider the addition of virtual tours of their hospitals, narrations from staff and vignettes from current fellows about lifestyle and well-being.
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http://dx.doi.org/10.1016/j.athoracsur.2021.02.089DOI Listing
March 2021

Secondary Burn Progression Mitigated by an Adenosine 2A Receptor Agonist.

J Burn Care Res 2021 Mar 26. Epub 2021 Mar 26.

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

Background: Current burn therapy is largely supportive with limited therapies to curb secondary burn progression. Adenosine 2A receptor (A2AR) agonists have anti-inflammatory effects with decreased inflammatory cell infiltrate and release of pro-inflammatory mediators. Using a porcine comb burn model, we examined whether A2AR agonists could mitigate burn progression.

Study Design: Eight full-thickness comb burns (4 prongs with 3 spaces per comb) per pig were generated with the following specifications: temperature 115° C, 3 kg force, and 30 second application time. In a randomized fashion, animals (4 per group) were then treated with A2AR agonist (ATL-1223, 3 ng/kg/min, intravenous infusion over 6 hours) or vehicle control. Necrotic interspace development was the primary outcome and additional histologic assessments were conducted.

Results: Analysis of unburned interspaces (72 per group) revealed that ATL-1223 treatment decreased the rate of necrotic interspace development over the first 4 days following injury (p<0.05). Treatment significantly decreased dermal neutrophil infiltration at 48 hours following burn (14.63±4.30 vs 29.71±10.76 neutrophils/high-power field, p=0.029). Additionally, ATL-1223 treatment was associated with fewer interspaces with evidence of microvascular thrombi through post-burn day 4 (18.8% vs 56.3%, p=0.002). Two weeks following insult, the depth of injury at distinct burn sites (adjacent to interspaces) was significantly reduced by ATL-1223 treatment (2.91±0.47 vs 3.28±0.58 mm, p=0.038).

Conclusion: This work demonstrates the ability of an A2AR agonist to mitigate burn progression through dampening local inflammatory processes. Extended dosing strategies may yield additional benefit and improve cosmetic outcome in those with severe injury.
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http://dx.doi.org/10.1093/jbcr/irab053DOI 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 10. Epub 2021 Mar 10.

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

Aortic Root Enlargement - Defining Risk and Reward.

Ann Thorac Surg 2021 Mar 9. Epub 2021 Mar 9.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, 409 Lane Road Charlottesville, VA 22903.

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http://dx.doi.org/10.1016/j.athoracsur.2021.03.005DOI 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

Breaking the Barriers not the Rules.

Ann Thorac Surg 2021 Mar 1. Epub 2021 Mar 1.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, 409 Lane Road, Charlottesville, VA 22903. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2021.02.025DOI Listing
March 2021

Commentary: Is heart failure with moderately reduced ejection fraction a useful classification for cardiac surgery?

J Thorac Cardiovasc Surg 2021 Jan 29. Epub 2021 Jan 29.

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.01.080DOI Listing
January 2021

Valve-sparing aortic root replacement after neonatal arterial switch operation.

J Card Surg 2021 Feb 27. Epub 2021 Feb 27.

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

Arterial switch operations (ASO) are lifesaving procedures performed on neonates to treat transposition of the great arteries. However, future operations on the neoaorta may be required due to dilation. We present a case of a 25-year-old female who presented with dilation of her neoaorta and required a David procedure. Her previous ASO resulted in an anterior lie of the pulmonary artery in front of the neoaorta, with both coronary arteries coming off anteriorly. We describe our approach to performing a David procedure on this patient with this unique anatomy.
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http://dx.doi.org/10.1111/jocs.15466DOI Listing
February 2021

Commentary: Building bridges to the future of heart transplantation.

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

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.08.106DOI Listing
September 2020

Commentary: Concomitant atrial fibrillation ablation: The juice is worth the squeeze.

J Thorac Cardiovasc Surg 2021 Jan 29. Epub 2021 Jan 29.

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.01.077DOI Listing
January 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

Commentary: Pathoanatomic differences in functional mitral regurgitation-a guide for future interventions?

J Thorac Cardiovasc Surg 2021 Jan 21. Epub 2021 Jan 21.

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.2021.01.054DOI Listing
January 2021

Female Surgeon Scientists: In Reply to Kibbe.

J Am Coll Surg 2021 Mar 29;232(3):339-340. Epub 2021 Jan 29.

Charlottesville, VA.

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http://dx.doi.org/10.1016/j.jamcollsurg.2020.12.011DOI Listing
March 2021

Commentary: Robotic mitral valve surgery selection criteria: Screening algorithm or quantifying selection bias?

J Thorac Cardiovasc Surg 2021 Jan 23. Epub 2021 Jan 23.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.12.053DOI Listing
January 2021

Aortic Annular Enlargement in the Elderly: Short and Long-Term Outcomes in the United States.

Ann Thorac Surg 2021 Jan 6. Epub 2021 Jan 6.

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

Background: Patient prosthesis mismatch (PPM) is associated with significant long-term morbidity and mortality after aortic valve replacement, but the role and outcomes of annular enlargement (AE) remains poorly defined. We hypothesized that increasing rates of AE may lead to improved outcomes for patients at risk for severe PPM.

Methods: Patients over age 65 undergoing surgical aortic valve replacement (SAVR) with or without coronary artery bypass grafting from 2008-2016 in the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD) with matching Center for Medicare Services data were included (n=189,268). Univariate, multivariate, and time-to-event analysis was used to evaluate the association between AE and early and late outcomes. Patients were stratified by projected degree of PPM based on calculated effective orifice area index (EOAi).

Results: A total of 5,412 (2.9%) patients underwent AE. STS predicted mortality was similar between AE and non-AE groups (2.97% vs 2.99%, p=0.052). Patients undergoing AE had higher risk-adjusted rates of 30-day complications and death (5.4% vs 3.4%, p<0.0001), but no differences in long-term rates of stroke, heart failure re-hospitalizations or aortic valve reoperation. Survival analysis demonstrated a higher risk of mortality with AE during the first 3 years after which the survival curves cross, favoring AE.

Conclusions: These data suggest annular enlargement during SAVR is associated with increased short-term risk in a Medicare population. Survival curves crossed after three years, which may portend a benefit in select patients. However, annular enlargement is still only done in the minority of patients who are at risk for PPM.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.023DOI Listing
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

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: Statistical methodology in cardiothoracic surgery: The devil is in the details.

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

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.102DOI Listing
November 2020

Socio-economic status and COVID-19-related cases and fatalities.

Public Health 2020 Dec 17;189:129-134. Epub 2020 Oct 17.

Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA, USA; Center for Health Policy, University of Virginia, Charlottesville, VA, USA.

Objectives: The United States has the highest number of coronavirus disease 2019 (COVID-19) in the world, with high variability in cases and mortality between communities. We aimed to quantify the associations between socio-economic status and COVID-19-related cases and mortality in the U.S.

Study Design: The study design includes nationwide COVID-19 data at the county level that were paired with the Distressed Communities Index (DCI) and its component metrics of socio-economic status.

Methods: Severely distressed communities were classified by DCI>75 for univariate analyses. Adjusted rate ratios were calculated for cases and fatalities per 100,000 persons using hierarchical linear mixed models.

Results: This cohort included 1,089,999 cases and 62,298 deaths in 3127 counties for a case fatality rate of 5.7%. Severely distressed counties had significantly fewer deaths from COVID-19 but higher number of deaths per 100,000 persons. In risk-adjusted analysis, the two socio-economic determinants of health with the strongest association with both higher cases per 100,000 persons and higher fatalities per 100,000 persons were the percentage of adults without a high school degree (cases: RR 1.10; fatalities: RR 1.08) and proportion of black residents (cases and fatalities: Relative risk(RR) 1.03). The percentage of the population aged older than 65 years was also highly predictive for fatalities per 100,000 persons (RR 1.07).

Conclusion: Lower education levels and greater percentages of black residents are strongly associated with higher rates of both COVID-19 cases and fatalities. Socio-economic factors should be considered when implementing public health interventions to ameliorate the disparities in the impact of COVID-19 on distressed communities.
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http://dx.doi.org/10.1016/j.puhe.2020.09.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7568122PMC
December 2020

Development and Evolution of the Thoracic Surgery Residents Association.

Ann Thorac Surg 2021 02 4;111(2):723-728. Epub 2020 Nov 4.

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

The Thoracic Surgery Residents Association (TSRA) was established in 1997 as a trainee-led organization under the guidance of the Thoracic Surgery Directors Association (TSDA) to represent the interests and meet the educational needs of cardiothoracic surgery residents across North America. Since its founding, the TSRA has continuously evolved and expanded to further its primary mission. In addition to now offering text- and audio-based educational resources, the TSRA acts to connect students, trainees, and faculty, with the ultimate goal of fostering relationships that will benefit not only individuals but also the field of cardiothoracic surgery as a whole.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.062DOI Listing
February 2021

Prolonged Opioid Use Associated With Reduced Survival After Lung Cancer Resection.

Ann Thorac Surg 2020 Oct 27. Epub 2020 Oct 27.

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

Background: Lung cancer remains the leading cause of cancer death worldwide and the search for modifiable risk factors to improve survival is ongoing. There is a growing appreciation for a biological relationship between opioids and lung cancer progression. Our goal was to evaluate the association between perioperative opioid use and long-term survival after lung cancer resection.

Methods: A retrospective analysis of 2006 to 2012 Surveillance, Epidemiology, and End Results Medicare datasets identified all patients undergoing pulmonary resection for non-small cell lung cancer stages I to III. Patients were stratified by filling opioid prescriptions only 30 days before or after surgery (standard group), filling opioid prescriptions greater than 30 days before surgery (chronic group), or filling opioid prescriptions greater than 90 days after surgery but not before surgery (prolonged group). Kaplan-Meier survival analysis compared each group; risk-adjusted survival analysis was performed using the Cox proportional hazards model.

Results: We identified 3273 patients, including 1385 in the standard group (42.3%), 1441 in the chronic group (44.0%), and 447 in the prolonged group (13.7%). Of previously opioid-naive patients, 447 of 1832 (24.4%) became new prolonged opioid users. Kaplan-Meier survival analysis illustrated lower overall and disease-specific survival in chronic and prolonged opioid groups (both P < .01). After risk adjustment, chronic (hazard ratio = 1.27; 95% confidence interval, 1.09-1.47; P < .01) and prolonged (hazard ratio = 1.42; 95% confidence interval, 1.17-1.73; P < .01) opioid use were independently associated with reduced long-term survival.

Conclusions: Chronic and prolonged opioid use were independently associated with reduced long-term, disease-specific survival after lung cancer resection. These findings provide epidemiologic support for a biological relationship between opioid use and lung cancer progression.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.015DOI Listing
October 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

The Thoracic Surgery Residents Association: Past contributions, current efforts, and future directions.

J Thorac Cardiovasc Surg 2020 Aug 31. Epub 2020 Aug 31.

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

Objective: The Thoracic Surgery Residents Association (TSRA) is a resident-led organization established in 1997 under the guidance of the Thoracic Surgery Directors Association to represent the interests and educational needs of cardiothoracic surgery residents. We aim to describe the past contributions, current efforts, and future directions of the TSRA within a conceptual framework of the TSRA mission.

Methods: Primary review of educational resources was performed to report goals and content of past contributions. TSRA Executive Committee input was used to describe current resources and activities, as well as the future goals of the TSRA. Podcast analytics were performed to report national and global usage.

Results: Since 2011, the TSRA has published 3 review textbooks, 5 reference guides, 3 test-preparation textbooks, 1 supplementary publication, and 1 multiple-choice question bank and mobile application, all written and developed by cardiothoracic surgery trainees. In total 108 podcasts have been recorded by mentored trainees, with more than 175,000 unique listens. Most recently, the TSRA has begun facilitating trainee submissions to Young Surgeon's Notes, fostered a trainee mentorship program, developed the monthly TSRA Newsletter, and established a wide-reaching presence on Facebook, Twitter, and Instagram to help disseminate educational resources and opportunities for trainees.

Conclusions: The TSRA continues to be the leading cardiothoracic surgery resident organization in North America, providing educational resources and networking opportunities for all trainees. Future directions include development of an integrated disease-based resource and continued collaboration within and beyond our specialty to enhance the educational opportunities and career development of cardiothoracic trainees.
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http://dx.doi.org/10.1016/j.jtcvs.2020.08.086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456949PMC
August 2020

Safety of Intravenous Heparin for Cardiac Surgery in Patients With Alpha-Gal Syndrome.

Ann Thorac Surg 2020 Oct 5. Epub 2020 Oct 5.

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

Background: Alpha-gal syndrome is a tick-acquired disease caused by immunoglobulin E (IgE) to the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal), causing allergic reactions to meat and products sourced from nonprimate mammals. As heparin is porcine-derived, we hypothesized that patients with alpha-gal syndrome who received high-dose heparin for cardiac surgery would have increased risk of anaphylaxis.

Methods: All cardiac surgery patients at an academic medical center from 2007 to 2019 were cross-referenced with research and clinical databases for the alpha-gal IgE blood test. Clinical data were obtained through the institutional Society of Thoracic Surgeons Adult Cardiac Database and chart review. Patients were stratified by development of an allergic reaction for univariate statistical analysis.

Results: Of the 8819 patients, 17 (0.19%) had a positive alpha-gal test before cardiac surgery. Of these 17 patients, 4 (24%) had a severe allergic reaction. The median alpha-gal titer was significantly higher in patients with a reaction (75 [interquartile range, 61-96] IU/mL vs 8 [interquartile range, 3-18] IU/mL; P = .006). There were no differences in median heparin loading dose, total dose, or maximum activated clotting time (all P > .05). In a subgroup of 8 patients with recent alpha-gal IgE level, 4 (50%) developed an allergic reaction.

Conclusions: Although alpha-gal is rare in patients undergoing cardiac surgery, there is up to a 50% risk of serious allergic reaction to heparin for cardiopulmonary bypass. Higher preoperative alpha-gal titers may confer a higher risk of severe allergic reaction. For patients with a clinical suspicion of alpha-gal syndrome, we recommend prescreening with IgE levels and premedicating before receiving high doses of intravenous heparin.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8019687PMC
October 2020

Mentorship Effectiveness in Cardiothoracic Surgical Training.

Ann Thorac Surg 2020 Oct 1. Epub 2020 Oct 1.

Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California. Electronic address:

Background: Mentoring is an essential component of cardiothoracic surgery training, yet trainees report varied experiences despite substantial efforts to enhance mentorship opportunities. This study aimed to evaluate mentorship effectiveness and identify gaps in mentorship education.

Methods: A survey was distributed to cardiothoracic surgical trainees in Accreditation Council for Graduate Medical Education-accredited programs (n = 531). Responses to 16 questions concerning trainee experiences, expectations, and perspectives on mentorship were collected. An 11-component mentorship effectiveness tool generated a composite score (0 to 55), with a score of 44 or lower indicating less effective mentorship.

Results: Sixty-seven residents completed the survey (12.6%), with most (83.6%) reporting a current mentor. Trainees with mentors cited "easy to work with and approachable" (44 of 58; 75.9%) as the major criterion for mentor selection, whereas trainees without a mentor reported an inability to identify one who truly reflected the resident's needs (6 of 11; 45.5%). Resident age, gender, race or ethnicity, marital status, family status, postgraduate year, and training program type or size were not associated with having a mentor (P = .15 to .73). The median mentorship effectiveness score was 51 (interquartile range, 44, 55). More than one-third of residents (25 of 67) had either no mentor (n = 6) or less effective mentorship (n = 16), or both (n = 3). Resident and program characteristics were not associated with mentorship effectiveness (P = .39 to .99). Finally, 61.2% of residents had not received education on effective mentorship, and 53.8% did not currently serve as a mentor.

Conclusions: Many resident respondents have either no mentor or less effective mentorship, and most reported not having received education on mentorship. Addressing these gaps in mentorship training and delivery should be prioritized.
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http://dx.doi.org/10.1016/j.athoracsur.2020.07.045DOI Listing
October 2020