Publications by authors named "Karen Kim"

142 Publications

Specialization in Acute Type A Aortic Dissection Repair: The Outcomes and Challenges.

Semin Thorac Cardiovasc Surg 2022 May 16. Epub 2022 May 16.

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

With increasing specialization within the field of cardiac surgery and a positive relationship between case volume and surgical outcomes in many areas, the concept of dedicated aortic surgeons performing acute type A aortic dissection (ATAAD) repair was investigated. From 1996 to 2014, 436 patients underwent open surgical repair of an ATAAD and were subsequently divided based on surgeon subspecialization, aortic-surgeon (AS, n=401) vs. non-aortic-surgeon (NAS, n=35). Each aortic surgeon performed an average of 13 ATAAD repair operations per year. Preoperative comorbidities were similar between groups. Intraoperatively, the AS group had 36% aortic root replacement vs. 23% in the NAS group, p=0.12, and 36% zone 1/2/3 arch replacement vs. 26% in the NAS group, p=0.20). Postoperatively, the AS group had significantly better outcomes, including intraoperative mortality (1.2% vs 5.7%), 30-day mortality (6.5% vs 17%), and composite outcomes (23% vs. 46%). Multivariable logistic regression showed NAS was a risk factor for 30-day mortality with an odds ratio (OR) of 4.4 (p=0.03), as were COPD (OR=4.0, p=0.046) and cardiogenic shock (OR=13.4, p<0.0001). The 10-year survival was 66% in the AS group vs. 46% in the NAS group, p=0.02. NAS (HR=2.2), Age (hazard ratio (HR)=1.05), COPD (HR=1.96), acute stroke (HR=3.0), and New York Heart Association class III or IV (HR=1.75) were significant risk factors for long-term mortality. Managing ATAAD by subspecialized aortic surgeons resulted in improved short- and long-term outcomes. Our specialty could consider ATAAD repair by high-volume aortic surgeons for better patient outcomes.
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http://dx.doi.org/10.1053/j.semtcvs.2022.05.005DOI Listing
May 2022

Perioperative Outcomes of Acute Type-A Aortic Dissection Repair was Unaffected by COVID-19 Testing Delay.

Cardiol Cardiovasc Med 2022 Apr 5;6(2):100-110. Epub 2022 Apr 5.

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

Background: This study assesses impact of COVID-19 testing delay on perioperative outcomes of Acute Type A Aortic Dissection (ATAAD) repair at a single institution.

Methods: From January 2010 - May 2021, 539 ATAAD patients underwent open aortic repair at our institution. Sixty-five of these patients had open aortic repair during COVID (March 2020 - May 2021) and 474 patients were pre-COVID (January 2010 - February 2020).

Results: Compared to the pre-COVID group, patients During-COVID had a higher proportion of previous myocardial ischemia [9/65 (14%) vs 28/474 (5.9%), p=0.03], chronic obstructive pulmonary disease [14/65 (22%) vs 55/474 (12%), p=0.02], and renal malperfusion syndrome [11/65 (17%) vs 30/474 (6.4%), p=0.01]. There was no significant difference in surgical outcomes between groups, including operative mortality (7.6% vs 9.2%, p=0.64). The median admission-to-Operating Room (OR) time was 107 minutes in the During-COVID group compared to 87 minutes in pre-COVID group, p=0.88. During COVID, the median admission-to-OR time was significantly longer in the Waiting group compared to the No-waiting group (209 min vs 75min, p=0.0009). Only one patient had positive COVID test. There were no aortic ruptures while awaiting COVID testing results. There was a total of 6 reported deaths in the During-COVID group: 1 patient died post-surgery due to ARDS caused by COVID, and others due to ischemic stroke (3 patients) and organ failure (2 patients).

Conclusions: Perioperative outcomes of ATAAD patients were similar during-COVID compared to pre-COVID. Waiting for COVID testing results did not significantly affect the perioperative outcomes among ATAAD patients after repair.
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http://dx.doi.org/10.26502/fccm.92920248DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9030690PMC
April 2022

Aortic and arch branch vessel cannulation in acute type A aortic dissection repair.

JTCVS Tech 2022 Apr 26;12:1-11. Epub 2022 Jan 26.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.

Objective: To evaluate central aortic cannulation and arch branch vessel (ABV) cannulation in acute type A aortic dissection repair.

Methods: From 2015 to April 2020, 298 patients underwent open repair of an acute type A aortic dissection. Patients undergoing femoral cannulation for cardiopulmonary bypass (n = 34) were excluded. Patients were then divided based on initial cannulation for cardiopulmonary bypass into central aortic cannulation (n = 72) and ABV cannulation (n = 192) groups. ABV sites included cannulation of the axillary, innominate, right/left common carotid, and intrathoracic right subclavian arteries.

Results: The aortic cannulation group was younger (59 vs 62 years;  = .02), more likely to be men (76% vs 60%;  = .02), and had more peripheral vascular disease (60% vs 37%;  = .0009). ABV dissection was similar between central and ABV cannulation groups (53% vs 60%;  = .51). The aortic cannulation group underwent less aggressive arch replacement, had shorter cardiopulmonary bypass times (200 vs 222 minutes;  = .01), less utilization of antegrade cerebral perfusion (93% vs 98%;  = .04), and received less blood transfusion (0 vs 1 U;  = .001). Postoperative outcomes were similar between aortic and ABV cannulation groups, including stroke (5.6% vs 5.2%;  = 1.0) and operative mortality (4.2% vs 6.3%;  = .77). In addition, postoperative strokes were similar in location (right-brain, left-brain, or bilateral), etiology (embolic vs hemorrhagic), and presence of permanent deficits. Aortic cannulation was not a risk factor for postoperative stroke (odds ratio, 0.94;  = .91) or operative mortality (odds ratio, 0.70;  = .64). Short-term survival was similar between central and ABV cannulation groups.

Conclusions: Both aortic and ABV cannulation were safe and effective cannulation strategies in acute type A aortic dissection repair.
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http://dx.doi.org/10.1016/j.xjtc.2022.01.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8987894PMC
April 2022

Parental socialization of mental health in Chinese American families: What parents say and do, and how youth make meaning.

Fam Process 2022 Mar 23. Epub 2022 Mar 23.

Medical Social Sciences, Northwestern University, Chicago, Illinois, USA.

Parental mental health socialization is a process by which parents shape how youth develop and maintain beliefs, attitudes, and behaviors regarding mental health and help-seeking behaviors. Although culture shapes parental mental health socialization, few studies have examined specific parental socialization practices regarding mental health and help-seeking, especially as a culturally anchored process. Using a qualitative approach, this study explores youth-reported parental socialization of mental health within Chinese American families by examining focus group data from 69 Chinese American high school and college students. Findings revealed that youth received parental messages that conveyed culturally anchored conceptualizations of mental health that included stigmatized views of mental illness and perceptions of mental distress as not a legitimate problem. Parents responded to youth distress in culturally consonant ways: by encouraging culturally specific coping methods, dismissing or minimizing distress, or responding with silence. Youth engaged in the active interpretation of parental messages through cultural brokering, bridging the gap between their parents' messages and mainstream notions of mental health and help-seeking. Overall, our findings point to the significant role of culture in parental mental health socialization in Chinese American families and the need to integrate culturally specific understandings of mental health into future interventions for Asian American youth.
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http://dx.doi.org/10.1111/famp.12766DOI Listing
March 2022

Prioritizing Asian Americans, Native Hawaiians, and Pacific Islanders in the U.S. Health Equity Agenda.

Acad Med 2022 Mar 22. Epub 2022 Mar 22.

H.K. Koh is Harvey V. Fineberg Professor of the Practice of Public Health Leadership, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations are growing rapidly in the United States, yet AANHPIs remain understudied, overlooked, and misunderstood. During the COVID-19 pandemic, themes from the tragic history of anti-Asian bias and marginalization have resurfaced in a surge of renewed bigotry and xenophobic violence against AANHPIs. In this commentary, the authors discuss the role of medical schools in combating anti-Asian sentiment as an important step toward achieving health equity. Based on their collective expertise in health disparities research, medical education, and policy, they offer suggestions about how to disrupt the pattern of invisibility and exclusion faced by AANHPI populations. They consider ways that representative data, leadership in medical education, research funding, national policies, and broad partnerships can help address AANHPI health disparities.
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http://dx.doi.org/10.1097/ACM.0000000000004673DOI Listing
March 2022

Progression of aortic root based on long-term imaging studies after acute type A dissection repair.

J Card Surg 2022 Jun 9;37(6):1674-1681. Epub 2022 Mar 9.

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

Background: To determine the progression of aortic root in acute type A aortic dissection (ATAAD) patients after aortic root repair (ARr) or replacement (ARR) based on long-term follow-up imaging studies.

Methods: From 1996 to 2019, 732 patients had ATAAD repair at our institution. Six hundred and seven of these patients had either ARr, (n = 383) or ARR (n = 224). Eighty-one patients were excluded due to a lack of postoperative imaging. Three hundred and thirty-two patients were included in the repair group and 194 patients in the replacement group for long-term follow-up imaging study.

Results: Compared to the ARR group, the ARr group was significantly older (60 years vs. 55 years) and had more patients with hypertension (79% vs. 63%) but less male patients (63% vs. 79%) and connective tissue disorder (1.8% vs 8%). The ARr group had more zone two arch replacement (22% vs. 11%), similar HCA time (35 min vs. 31 min), shorter cardiopulmonary bypass time (203 min vs. 266 min), aortic cross-clamp time (128 min vs. 214 min), and fewer concomitant coronary artery bypass (3.9% vs. 8.9%). The root growth rate over 12 years was similar between the repair and replacement group (0.20 mm/year vs. 0.18 mm/year, p = .75). Both the repair and replacement group had similar 15-year cumulative incidence of reoperation (6.9% vs. 5.9%; p = .67), operative mortality (7.8% vs. 8.5%; p = .78), and 15-year survival (51% vs. 52%; p = .40).

Conclusions: There was minimal growth of the aortic root after root repair or replacement for ATAAD patients. Both aortic root repair and replacement were acceptable techniques for ATAAD surgery in select patients.
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http://dx.doi.org/10.1111/jocs.16392DOI Listing
June 2022

Stentless Versus Stented Aortic Valve Replacement for Aortic Stenosis.

Ann Thorac Surg 2022 Feb 10. Epub 2022 Feb 10.

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

Background: The differences in long-term outcomes of aortic valve replacement for aortic stenosis between stentless and stented bioprostheses are controversial.

Methods: Between 2007 and 2018, 1173 patients underwent aortic valve replacement for aortic stenosis, including 559 treated with a stentless valve and 614 with a stented valve. A propensity score matched cohort with 348 pairs was generated by matching for age, sex, body surface area, bicuspid aortic valve, chronic lung disease, previous cardiac surgery, coronary artery disease, renal failure on dialysis, valve size, concomitant procedures, and surgeon. The primary endpoints of the study were long-term survival and incidence of reoperation.

Results: Immediate postoperative outcomes were similar between the stentless and stented groups with an overall operative mortality of 2.9% (P = .19). Kaplan-Meier estimation for long-term survival was comparable between the stentless and stented valves in both the whole cohort and the propensity score matched cohort (10-year survival 59% vs 55%, P = .20). The hazard ratio of stentless vs stented valve for risk of long-term mortality was 1.12 (P = .33). The 10-year cumulative incidence of reoperation due to valve degeneration was 5.5% in the stentless group and 4.7% in the stented group (P = .25). The transvalvular pressure gradient at 5-year follow-up was significantly lower in the stentless group (7 vs 11 mm Hg, P < .001).

Conclusions: Both stented and stentless valves could be used in aortic valve replacement for aortic stenosis. We recommend stented valves for aortic valve replacement in patients with aortic stenosis for their simplicity of implantation.
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http://dx.doi.org/10.1016/j.athoracsur.2022.01.029DOI Listing
February 2022

Stroke Following Thoracic Endovascular Aortic Repair: Determinants, Short and Long Term Impact.

Semin Thorac Cardiovasc Surg 2022 Jan 26. Epub 2022 Jan 26.

Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan. Electronic address:

We performed a contemporary assessment of clinical and radiographic factors of stroke after thoracic endovascular aortic repair (TEVAR). Patients undergoing TEVAR from 2006 to 2017 were identified. We assessed clinical and radiographic data, including preoperative head and neck computed tomography, Doppler ultrasonography, and intraoperative angiography. Our primary outcome was stroke after TEVAR. Four hundred seventy-nine patients underwent TEVAR, mean age 68.1 ± 19.5 years, 52.6% male. Indications for TEVAR included aneurysms (n = 238, 49.7%) or dissections (n = 152, 31.7%). Ishimaru landing zones were Zone 2 (n = 225, 47.0%), Zone 3 (n = 151, 31.5%), or Zone 4 (n = 103, 21.5%). Stroke occurred in 3.8% (n = 18) of patients, with 1.9% (8) major events (modified Rankin Scale >3). Pathophysiology was predominantly embolic (n = 14), and occurred in posterior (n = 6), anterior (n = 6), or combined circulation (n = 4), and in the left hemisphere (n = 10) or bilateral (n = 6). Univariate analysis suggested use of lumbar drain (33.3% versus 57.2%, P = 0.04), inability to revascularize the left subclavian artery (16.7% vs 5.2%, P = 0.04) and number of implanted components (2.5 ± 1.2 vs 2.0 ± 0.97, P = 0.03) were associated with stroke. Multivariable analysis identified number of implanted components (OR 1.7, 95%CI 1.17-2.67 P = 0.00) and inability to revascularize the left subclavian artery as independent predictors of stroke. Stroke was associated with a higher perioperative mortality (27.8% vs 3.9%, P < 0.01). Stroke after TEVAR is primarily embolic in nature and related to both anatomic and procedural factors. This may have important implications for device development in the era of endovascular arch repair.
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http://dx.doi.org/10.1053/j.semtcvs.2021.08.030DOI Listing
January 2022

Imaging features of renal malperfusion in aortic dissection.

Eur J Cardiothorac Surg 2022 03;61(4):805-813

Department of Radiology, University of Michigan, Ann Arbor, MI, USA.

Objectives: Malperfusion syndrome accompanying aortic dissection is an independent predictor of death with in-hospital mortality rates >60%. Asymmetrically decreased renal enhancement on computed tomography angiography is often considered evidence of renal malperfusion. We investigated the associations between renal enhancement, baseline laboratory values and the diagnosis of renal malperfusion, as defined by invasive manometry, among patients with aortic dissection.

Methods: In this retrospective cohort study, we included all patients who were referred to our institution with acute dissection and suspected visceral malperfusion between 2010 and 2020. We determined asymmetric renal enhancement by visual assessment and quantitative density measurements of the renal cortex. We collected invasive renal artery pressures during invasive angiography at the aortic root and in the renal arteries. Logistic regression was performed to evaluate independent predictors of renal malperfusion.

Results: Among the 161 patients analysed, the majority of patients were male (78%) and had type A dissection (52%). Invasive angiography confirmed suspected renal malperfusion in 83% of patients. Global asymmetric renal enhancement was seen in 42% of patients who did not have renal malperfusion during invasive angiography. Asymmetrically decreased renal enhancement was 65% sensitive and 58% specific for renal malperfusion. Both global [odds ratio (OR) 4.43; 1.20-16.41, P = 0.03] and focal (OR 11.23; 1.12-112.90, P = 0.04) enhancement defects were independent predictors for renal malperfusion.

Conclusions: In patients with aortic dissection, we found that differential enhancement of the kidney as seen on the computed tomography angiography is predictive, but not prescriptive for renal malperfusion. While detection of renal malperfusion is aided by computed tomography angiography, its diagnosis requires close monitoring and often invasive assessment.
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http://dx.doi.org/10.1093/ejcts/ezab555DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8947793PMC
March 2022

Teen With Rash, Testicular Pain, and Hallucinations.

Clin Pediatr (Phila) 2022 03 10;61(3):295-298. Epub 2022 Jan 10.

Ochsner Hospital for Children, New Orleans, LA, USA.

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http://dx.doi.org/10.1177/00099228211072635DOI Listing
March 2022

Should We Operate on Thoracic Aortic Aneurysm of 5-5.5cm in Bicuspid Aortic Valve Disease Patients?

Cardiol Cardiovasc Med 2021 3;5(6):651-662. Epub 2021 Dec 3.

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

Background: This study aims to determine the long-term outcomes and rate of reoperation among BAV patients with aortic diameter of 5-5.5cm who underwent immediate surgical repair versus surveillance.

Methods: A total of 148 BAV patients with aortic aneurysm measuring 5-5.5cm were identified between 1993 to 2019. Patients were categorized into two groups: immediately operated (n=89), versus watched group (n=59) i.e., monitored until either symptomatic, aortic diameter ≥ 5.5 cm or operated at surgeons' discretion/patient preference.

Results: Compared to the immediately operated group the watched group had significantly lower proportion of proximal aorta replacement (86% vs 100%). The mean size of proximal thoracic aorta at initial encounter, including aortic root, ascending, and arch, for the watched group was 52.1 ± 1.62mm and 52.6 ± 1.81mm in the immediately operated group, p=0.06. There was no significant difference in 10-year survival between the watched group 94% (95% CI: 79%, 99%) vs immediately operated group 96.5% (95% CI: 86%, 99%), p=0.90. Initial operation rate for the watched group during 10-year follow-up was 85%. The operative mortality in both groups was 0%. The 10-year reoperation rate between groups was similar: 3.5% (95% CI: 0.9%, 9.1%) in the immediately operated group vs 7.7% (95% CI: 2.4%, 17.1%) in the patients who eventually had surgery in the watched group, p= 0.30.

Conclusions: Our study showed that the rate of reoperation was similar between groups and survival outcomes were acceptable in observed asymptomatic BAV patients without significant family history and with proximal aortic diameter of 5-5.5cm.
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http://dx.doi.org/10.26502/fccm.92920230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8694044PMC
December 2021

Predictors of Discharge Home Without Opioids After Cardiac Surgery: A Multicenter Analysis.

Ann Thorac Surg 2021 Dec 9. Epub 2021 Dec 9.

Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan. Electronic address:

Background: Whether all patients will require an opioid prescription after cardiac surgery is unknown. We performed a multicenter analysis to identify patient predictors of not receiving an opioid prescription at the time of discharge home after cardiac surgery.

Methods: Opioid-naïve patients undergoing coronary artery bypass grafting and/or valve surgery through a sternotomy at 10 centers from January to December 2019 were identified retrospectively from a prospectively maintained data set. Opioid-naïve was defined as not taking opioids at the time of admission. The primary outcome was discharge without an opioid prescription. Mixed-effects logistic regression was performed to identify predictors of discharge without an opioid prescription, and postdischarge opioid prescribing was monitored to assess patient tolerance of discharge without an opioid prescription.

Results: Among 1924 eligible opioid-naïve patients, mean age was 64 ± 11 years, and 25% were women. In total, 28% of all patients were discharged without an opioid prescription. On multivariable analysis, older age, longer length of hospital stay, and undergoing surgery during the last 3 months of the study were independent predictors of discharge without an opioid prescription, whereas depression, non-Black and non-White race, and using more opioid pills on the day before discharge were independent predictors of receiving an opioid prescription. Among patients discharged without an opioid prescription, 1.8% (10 of 547) were subsequently prescribed an opioid.

Conclusions: Discharging select patients without an opioid prescription after cardiac surgery appears well tolerated, with a low incidence of postdischarge opioid prescriptions. Increasing the number of patients discharged without an opioid prescription may be an area for quality improvement.
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http://dx.doi.org/10.1016/j.athoracsur.2021.10.005DOI Listing
December 2021

Aberrant Subclavian Arteries and Associated Kommerell Diverticulum: Endovascular vs Open Repair.

Ann Thorac Surg 2021 Nov 10. Epub 2021 Nov 10.

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

Background: Various surgical options have been described for the treatment of aberrant subclavian arteries and an associated Kommerell diverticulum.

Methods: Between 1999 and 2019, 43 patients underwent a repair, comprising 26 (61%) endovascular and 17 (39%) open approaches. The endovascular approach consisted of initial subclavian revascularization followed by thoracic endovascular aortic repair. The open approach included total arch replacement (12%) and reverse hemiarch repair with left thoracotomy (53%) or right thoracotomy (35%). The perioperative and long-term outcomes were retrospectively reviewed.

Results: No mortality occurred in the endovascular group, whereas there was 1 (6%) in the open approach group. Patients in the endovascular group demonstrated a shorter hospital stay (3.5 days vs 10.0 days; P = .001) and less frequent prolonged mechanical ventilation (0% vs 24%; P = .019), with a lower occurrence of pneumonia (0% vs 24%; P = .019). Among patients who had the endovascular approach, shrinkage of Kommerell diverticulum or aberrant vessel origin was seen in 96%. Furthermore, relief of dysphagia was confirmed in 92% (12/13), including patients without Kommerell diverticulum (n = 3) after endovascular repair. The cumulative incidence of treatment failure or aortic reintervention at 7 years was 21% and 14 % in the endovascular and open approach groups, respectively (P = .62). Two (8%) patients in the endovascular group required an open reintervention. One reintervention was performed for persistent dysphagia in the setting of an untreated complete vascular ring, and the other was for persistent false lumen flow associated with aortic dissection.

Conclusions: The treatment approach should be individualized on the basis of the aortic disease and comorbidities. The endovascular approach is a viable and effective alternative in the presence of suitable landing zones.
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http://dx.doi.org/10.1016/j.athoracsur.2021.09.065DOI Listing
November 2021

Claviculectomy for exposure and redo repair of expanding, recurrent right subclavian aneurysm.

J Vasc Surg Cases Innov Tech 2021 Dec 29;7(4):694-697. Epub 2021 Sep 29.

Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich.

Subclavian artery aneurysms (SAAs) are rare, and their repair can be technically complex. We have reported the redo repair of a large, expanding, right SAA after primary repair consisting of total aortic arch replacement with bilateral subclavian artery ligation and bypass. The redo repair used claviculectomy to facilitate exposure, ligation of the right deep cervical and internal thoracic arteries from within the aneurysm sac, and revision of the previous axillary artery bypass that had thrombosed owing to the mass effect of the expanding SAA. Claviculectomy can facilitate repair of large SAAs that are poorly suited to more routine exposure approaches, with acceptable risk and functional outcomes.
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http://dx.doi.org/10.1016/j.jvscit.2021.08.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8556485PMC
December 2021

Prevalence of Depression Symptoms Before and During the COVID-19 Pandemic Among Two Asian American Ethnic Groups.

J Immigr Minor Health 2021 Oct 13. Epub 2021 Oct 13.

University of Chicago Center for Asian Health Equity, Chicago, IL, USA.

Asian Americans have experienced compounding stressors during the pandemic as a result of racial discrimination. We aim of to investigate the prevalence of depression symptoms among Asian Americans before and during the COVID-19 pandemic and examine differences based on socio-demographic factors. Data are from a cross-sectional study (N = 636) among Chinese and South Asian adults in Chicago collected between February and May 2020. One cohort of participants were surveyed from each ethnic group before the pandemic and a second cohort of participants were surveyed during the pandemic. Depression symptoms increased more than two-fold, from 9% pre-pandemic to 21% during the COVID-19 pandemic. We found an increase in depression symptoms during the pandemic for South Asians, men and adults older than 30 years. These findings call for public health education that effectively addresses anti-Asian harassment and violence and ensure that culturally competent mental health services are provided to Asian Americans from diverse ethnic backgrounds.
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http://dx.doi.org/10.1007/s10903-021-01287-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8511614PMC
October 2021

Evaluating for a correlation between osteopathic examination and ultrasonography on thoracic spine asymmetry.

J Osteopath Med 2021 Oct 13;122(1):31-43. Epub 2021 Oct 13.

Department of Anatomy, Midwesetern University, Arizona College of Osteopathic Medicine, Glendale, AZ, USA.

Context: The thoracic spine is a common area of focus in osteopathic manipulative medicine (OMM) for a variety of conditions. Thoracic spine somatic dysfunction diagnosis is achieved by palpating for asymmetry at the tips of the transverse processes (TPs). Previous studies reveal that instead of following the rule of threes, the TPs of a given thoracic vertebra generally align with the spinous process (SP) of the vertebra above. Ultrasonography has been widely utilized as a diagnostic tool to monitor musculoskeletal conditions; it does not utilize ionizing radiation, and it has comparable results to gold-standard modalities. In the case of thoracic somatic dysfunction, ultrasound (US) can be utilized to determine the location of each vertebral TP and its relationship with the SP. Previous studies have investigated the correlation between OMM and ultrasonography of the cervical, lumbar, and sacral regions. However, there has been no study yet that has compared osteopathic structural examination with ultrasonographic examination of the thoracic vertebral region.

Objectives: To examine the relationship between osteopathic palpation and ultrasonographic measurements of the thoracic spine by creating a study design that utilizes interexaminer agreement and correlation.

Methods: The ClinicalTrials.gov study identifier is NCT04823637. Subjects were student volunteers recruited from the Midwestern University (MWU)-Glendale campus. A nontoxic, nonpermanent marker was utilized to mark bony landmarks on the skin. Two neuromusculoskeletal board-certified physicians (OMM1, OMM2) separately performed structural exams by palpating T2-T5 TPs to determine vertebral rotation. Two sonographers (US1, US2) separately scanned and measured the distance from the tip of the SP to the adjacent TPs of the vertebral segment below. Demographic variables were summarized with mean and standard deviation. Interexaminer agreement was assessed with percent agreement, Cohen's Kappa, and Fleiss' Kappa. Correlation was measured by Spearman's rank correlation coefficient. Recruitment and protocols were approved by the MWU Institutional Review Board (IRB).

Results: US had fair interexaminer agreement for the overall most prominent segmental rotation of the T3-T5 thoracic spine, with Cohen's Kappa at 0.27 (0.09, 0.45), and a total agreement percentage at 51.5%. Osteopathic palpation revealed low interexaminer agreement for the overall most prominent vertebral rotation, with Cohen's Kappa at 0.05 (0.0, 0.27), and 31.8%. Segment-specific vertebral analysis revealed slight agreement between US examiners, with a correlation coefficient of 0.23, whereas all other pairwise comparisons showed low agreement and correlation. At T4, US had slight interexaminer agreement with 0.24 correlation coefficient, and osteopathic palpation showed low interexaminer (OMM1 vs. OMM2) agreement (0.17 correlation coefficient). At T5, there was moderate agreement between the two sonographers with 0.44 (0.27, 0.60) and 63.6%, with a correlation coefficient of 0.57, and slight agreement between OMM1 and OMM2 with 0.12 (0.0, 0.28) and 42.4%, with 0.23 correlation coefficient.

Conclusions: This preliminary study of an asymptomatic population revealed that there is a low-to-moderate interexaminer reliability between sonographers, low-to-slight interexaminer reliability between osteopathic physicians, and low interexaminer reliability between OMM palpatory examination and ultrasonographic evaluation of the thoracic spine.
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http://dx.doi.org/10.1515/jom-2021-0020DOI Listing
October 2021

Outcomes From the EXPLANT-TAVR Registry: Time to Change TAVR Informed Consent?

JACC Cardiovasc Interv 2021 09;14(18):1992-1994

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

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http://dx.doi.org/10.1016/j.jcin.2021.08.003DOI Listing
September 2021

Aortic septotomy to optimize landing zones during thoracic endovascular aortic repair for chronic type B aortic dissection.

J Thorac Cardiovasc Surg 2021 Aug 25. Epub 2021 Aug 25.

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

Objective: The role of thoracic endovascular aortic repair for chronic type B aortic dissection remains controversial. Clinical outcomes of thoracic endovascular aortic repair with recently implemented aortic septotomy strategy were compared with stand-alone thoracic endovascular aortic repair.

Methods: Between 2008 and 2020, 88 patients with chronic type B aortic dissection and degenerative aortic aneurysm underwent a thoracic endovascular aortic repair with or without adjunctive aortic septotomy, consisting of 36 (41%) with de novo chronic type B aortic dissection and 52 (59%) with residual chronic type B aortic dissection after type A aortic dissection repair.

Results: Aortic septotomy was performed in 31 patients (35%) to optimize the proximal (3/31;10%) and distal (31/31;100%) landing zones. The aortic septotomy techniques comprised laser aortic septotomy in 16 patients (52%) and cheese wire septotomy in 15 patients (48%) with a 97% overall technical success rate. The median time interval between aortic dissection occurrence and thoracic endovascular aortic repair was 1.2 years. During follow-up, there were 12 (21%) sudden deaths and 17 (30%) combined aorta-related and sudden deaths in the nonaortic septotomy group, whereas there were no deaths in the septotomy group (P < .001). Patients without aortic septotomy required aortic reinterventions more frequently than those with aortic septotomy (30% vs 7%; P = .014), and 77% of these procedures were related to residual retrograde false lumen flow. Positive aortic remodeling was confirmed in 90% and 37% in the aortic septotomy and nonseptotomy groups, respectively (P < .001).

Conclusions: Stand-alone thoracic endovascular aortic repair outcomes without adjunctive procedures for chronic type B aortic dissection remain unfavorable. In contrast, landing zone optimization using aortic septotomy resulted in a remarkably higher positive aortic remodeling rate. Routine aortic septotomy strategy may positively affect long-term chronic type B aortic dissection survival and expand thoracic endovascular aortic repair candidacy.
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http://dx.doi.org/10.1016/j.jtcvs.2021.07.049DOI Listing
August 2021

Endovascular Re-routing the Errant Aortic Endoprosthesis.

Ann Thorac Surg 2021 Sep 3. Epub 2021 Sep 3.

Department of Radiology; Division of Vascular and Interventional Radiology, University of Michigan, Ann Arbor, MI. Electronic address:

The anatomic complexity of aortic dissection remains a challenge in endovascular treatment. The dissection flap may contain defects allowing accidental guidewire passage from one lumen into the other, and inadvertent device placement into the false lumen can occur. The description of this complication and its bail-out maneuvers are sparse in the literature. Herein, we describe seven patients with errant endoprosthesis re-routed with minimally invasive intervention into the true lumen.
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http://dx.doi.org/10.1016/j.athoracsur.2021.08.006DOI Listing
September 2021

The STS Participant-Level, Multiprocedural Composite Measure for Adult Cardiac Surgery.

Ann Thorac Surg 2021 Aug 8. Epub 2021 Aug 8.

Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.

Background: Composite performance measures for the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database participants (typically hospital departments or practice groups) are currently available only for individual procedures. To assess overall participant performance, STS has developed a composite metric encompassing the most common adult cardiac procedures.

Methods: Analyses included 1-year (July 1, 2018 to June 30, 2019) and 3-year (July 1, 2016 to June 30, 2019) time windows. Operations included isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve repair (MVr) or replacement (MVR), AVR + CABG, MVr or MVR + CABG, AVR + MVr or MVR, and AVR + (MVr or MVR) + CABG. The composite was estimated using Bayesian hierarchical models with risk-adjusted mortality and morbidity end points. Star ratings were based upon whether the 95% credible interval of a participant's score was entirely lower than (1 star), overlapping (2 star), or higher than (3 star) the STS average composite score.

Results: The North American procedural mix in the 3-year study cohort was as follows: 448 569 CABG, 72 067 AVR, 35 708 MVr, 29 953 MVR, 45 254 AVR + CABG, 12 247 MVr + CABG, 10 118 MVR + CABG, 3743 AVR + MVr, 6846 AVR + MVR, and 3765 AVR + (MVr or MVR) + CABG. Mortality and morbidity weightings were similar for 1- and 3-year analyses (76% and 24% [3-year]), as were composite score distributions (median, 94.7%; interquartile range, 93.6% to 95.6% [3-year]). The 3-year time frame was selected for operational use because of higher model reliability (0.81 [0.78-0.83]) and better outlier discrimination (26%, 3 star; 16%, 1 star). Risk-adjusted outcomes for 1-, 2-, and 3-star programs were 4.3%, 3.0%, and 1.8% mortality and 18.4%, 13.4%, and 9.7% morbidity, respectively.

Conclusions: The STS participant-level, multiprocedural composite measure provides comprehensive, highly reliable, overall quality assessment of adult cardiac surgery practices.
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http://dx.doi.org/10.1016/j.athoracsur.2021.06.084DOI Listing
August 2021

Aortic valve reintervention after transcatheter aortic valve replacement.

J Thorac Cardiovasc Surg 2021 Jul 20. Epub 2021 Jul 20.

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

Background: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR), there are scant data regarding aortic valve reintervention after initial TAVR.

Methods: Between 2011 and 2019, 1487 patients underwent a TAVR at the University of Michigan. Among these, 24 (1.6%) patients required an aortic valve reintervention. Additionally, 4 patients who received a TAVR at another institution underwent a valve reintervention at our institution. We retrospectively reviewed these 28 patients.

Results: The median age was 72 years, 36% were female and 86% of implanted TAVR devices were self-expandable. The leading indications for reintervention were structural valve degeneration (39%) and paravalvular leak (36%). The cumulative incidence of aortic valve reintervention was 4.6% at 8 years. Most (71%) were deemed unsuitable for repeat TAVR because of the need for concurrent cardiac procedures (50%), unfavorable anatomy (45%), or endocarditis (10%). TAVR valve explant was associated with frequent concurrent procedures, consisting of aortic repair (35%), mitral repair/replacement (35%), tricuspid repair (25%), and coronary artery bypass graft (20%). Seventy-one percent of aortic procedures were unplanned but proved necessary because of severe adhesion of the devices to the contacting tissue. There were 3 (15%) in-hospital mortalities in the TAVR valve explant group, whereas there was no mortality in the repeat TAVR group.

Conclusions: Repeat TAVR procedure was frequently not feasible because of unfavorable anatomy and/or the need for concurrent cardiac procedures. Careful assessment of TAVR procedure repeatability should be weighed at the initial TAVR workup especially in younger patients who are expected to require a valve reintervention.
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http://dx.doi.org/10.1016/j.jtcvs.2021.03.130DOI Listing
July 2021

Early failure of the Trifecta GT bioprostheses.

JTCVS Tech 2020 Dec 12;4:106-108. Epub 2020 Aug 12.

Department of Cardiac Surgery, University of Michigan Health Systems, Ann Arbor, Mich.

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http://dx.doi.org/10.1016/j.xjtc.2020.08.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8303056PMC
December 2020

Regulatory variants in TCF7L2 are associated with thoracic aortic aneurysm.

Am J Hum Genet 2021 09 14;108(9):1578-1589. Epub 2021 Jul 14.

K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim 7030, Norway.

Thoracic aortic aneurysm (TAA) is characterized by dilation of the aortic root or ascending/descending aorta. TAA is a heritable disease that can be potentially life threatening. While 10%-20% of TAA cases are caused by rare, pathogenic variants in single genes, the origin of the majority of TAA cases remains unknown. A previous study implicated common variants in FBN1 with TAA disease risk. Here, we report a genome-wide scan of 1,351 TAA-affected individuals and 18,295 control individuals from the Cardiovascular Health Improvement Project and Michigan Genomics Initiative at the University of Michigan. We identified a genome-wide significant association with TAA for variants within the third intron of TCF7L2 following replication with meta-analysis of four additional independent cohorts. Common variants in this locus are the strongest known genetic risk factor for type 2 diabetes. Although evidence indicates the presence of different causal variants for TAA and type 2 diabetes at this locus, we observed an opposite direction of effect. The genetic association for TAA colocalizes with an aortic eQTL of TCF7L2, suggesting a functional relationship. These analyses predict an association of higher expression of TCF7L2 with TAA disease risk. In vitro, we show that upregulation of TCF7L2 is associated with BCL2 repression promoting vascular smooth muscle cell apoptosis, a key driver of TAA disease.
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http://dx.doi.org/10.1016/j.ajhg.2021.06.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8456156PMC
September 2021

Identifying actionable strategies: using Consolidated Framework for Implementation Research (CFIR)-informed interviews to evaluate the implementation of a multilevel intervention to improve colorectal cancer screening.

Implement Sci Commun 2021 May 31;2(1):57. Epub 2021 May 31.

Center for Asian Health Equity, University of Chicago, 5841 S Maryland Ave, Rm S406, MC 1140, Chicago, IL, 60637, USA.

Background: Many evidence-based interventions (EBIs) found to be effective in research studies often fail to translate into meaningful patient outcomes in practice. The purpose of this study was to identify facilitators and barriers that affect the implementation of three EBIs to improve colorectal cancer (CRC) screening in an urban federally qualified health center (FQHC) and offer actionable recommendations to improve future implementation efforts.

Methods: We conducted 16 semi-structured interviews guided by the Consolidation Framework for Implementation Research (CFIR) to describe diverse stakeholders' implementation experience. The interviews were conducted in the participant's clinic, audio-taped, and professionally transcribed for analysis.

Results: We used the five CFIR domains and 39 constructs and subconstructs as a coding template to conduct a template analysis. Based on experiences with the implementation of three EBIs, stakeholders described barriers and facilitators related to the intervention characteristics, outer setting, and inner setting. Implementation barriers included (1) perceived burden and provider fatigue with EHR (Electronic Health Record) provider reminders, (2) unreliable and ineffectual EHR provider reminders, (3) challenges to providing health care services to diverse patient populations, (4) lack of awareness about CRC screening among patients, (5) absence of CRC screening goals, (6) poor communication on goals and performance, and (7) absence of printed materials for frontline implementers to educate patients. Implementation facilitators included (1) quarterly provider assessment and feedback reports provided real-time data to motivate change, (2) integration with workflow processes, (3) pressure from funding requirement to report quality measures, (4) peer pressure to achieve high performance, and (5) a culture of teamwork and patient-centered mentality.

Conclusions: The CFIR can be used to conduct a post-implementation formative evaluation to identify barriers and facilitators that influenced the implementation. Furthermore, the CFIR can provide a template to organize research data and synthesize findings. With its clear terminology and meta-theoretical framework, the CFIR has the potential to promote knowledge-building for implementation. By identifying the contextual determinants, we can then determine implementation strategies to facilitate adoption and move EBIs to daily practice.
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http://dx.doi.org/10.1186/s43058-021-00150-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8167995PMC
May 2021

Where Do I Fit In? A Perspective on Challenges Faced by Asian American Medical Students.

Health Equity 2021 19;5(1):324-328. Epub 2021 May 19.

University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA.

Asian American medical students (AAMSs) face significant bias in the medical learning environment and are more likely than White students to perceive their school climate negatively. Little is known about the factors that contribute to AAMSs' negative experiences. This perspective aims to describe AAMSs' experiences with diversity and inclusion efforts using survey data from a midwest regional conference, Asians in Medicine: A Conference on Advocacy and Allyship. AAMS respondents reported feeling excluded from diversity and inclusion efforts and conference participants advocated for institutional culture and climate assessments stratified by race and disaggregated into Asian subgroups.
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http://dx.doi.org/10.1089/heq.2020.0158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140354PMC
May 2021

Differences among sexes in presentation and outcomes in acute type A aortic dissection repair.

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

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

Objective: Female sex is a known risk factor in most cardiac surgery, including coronary and valve surgery, but unknown in acute type A aortic dissection repair.

Methods: From 1996 to 2018, 650 patients underwent acute type A aortic dissection repair; 206 (32%) were female, and 444 (68%) were male. Data were collected through the Cardiac Surgery Data Warehouse, medical record review, and National Death Index database.

Results: Compared with men, women were significantly older (65 vs 57 years, P < .0001). The proportion of women and men inverted with increasing age, with 23% of patients aged less than 50 years and 65% of patients aged 80 years or older being female. Women had significantly less chronic renal failure (2.0% vs 5.4%, P = .04), acute myocardial infarction (1.0% vs 3.8%, P = .04), and severe aortic insufficiency. Women underwent significantly fewer aortic root replacements with similar aortic arch procedures, shorter cardiopulmonary bypass times (211 vs 229 minutes, P = .0001), and aortic crossclamp times (132 vs 164 minutes, P < .0001), but required more intraoperative blood transfusion (4 vs 3 units) compared with men. Women had significantly lower operative mortality (4.9% vs 9.5%, P = .04), especially in those aged more than 70 years (4.4% vs 16%, P = .02). The significant risk factors for operative mortality were male sex (odds ratio, 2.2), chronic renal failure (odds ratio, 3.4), and cardiogenic shock (odds ratio, 6.8). The 10-year survival was similar between sexes.

Conclusions: Physicians and women should be cognizant of the risk of acute type A aortic dissection later in life in women. Surgeons should strongly consider operations for acute type A aortic dissection in women, especially in patients aged 70 years or more.
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http://dx.doi.org/10.1016/j.jtcvs.2021.03.078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8478983PMC
March 2021

Multiple Emergency Department Presentations of COVID-19-Related Multisystem Inflammatory Syndrome in Children.

Clin Pediatr (Phila) 2021 05;60(4-5):214-220

Ochsner Medical Center, New Orleans, LA, USA.

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http://dx.doi.org/10.1177/00099228211005289DOI Listing
May 2021

The Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations.

Ann Thorac Surg 2022 Feb 5;113(2):511-518. Epub 2021 Aug 5.

Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.

Background: The Society of Thoracic Surgeons (STS) Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations ± CABG procedures.

Methods: Using July 2011 to June 2019 STS Adult Cardiac Surgery Database data, risk models for AVR+MVRR (n = 31,968) and AVR+MVRR+CABG (n = 12,650) were developed with the following endpoints: Operative Mortality, major morbidity (any 1 or more of the following: cardiac reoperation, deep sternal wound infection/mediastinitis, stroke, prolonged ventilation, and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 to June 2017; n = 35,109) and validation (July 2017 to June 2019; n = 9509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration.

Results: C-statistics for the overall population of multiple valve ± CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample.

Conclusions: New STS Adult Cardiac Surgery Database risk models have been developed for multiple valve ± CABG operations, and these models will be used in subsequent STS performance metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.089DOI Listing
February 2022

Primary care provider-led group visits for advance care planning in the safety net.

J Am Geriatr Soc 2021 05 2;69(5):1404-1406. Epub 2021 Apr 2.

Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA.

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http://dx.doi.org/10.1111/jgs.17098DOI Listing
May 2021

Another Tool in the Toolbox.

Authors:
Karen M Kim

Ann Thorac Surg 2021 09 16;112(3):754-755. Epub 2021 Feb 16.

Department of Cardiac Surgery, University of Michigan, 1500 E Medical Center Dr, 5164 CVC, SPC 5864, Ann Arbor, MI 48109. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2021.01.056DOI Listing
September 2021
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