Publications by authors named "Kevin Lobdell"

48 Publications

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

Ann Thorac Surg 2021 Apr 9. Epub 2021 Apr 9.

Duke University, Durham, North Carolina.

Background: The STS Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting surgery (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 (ACSD) 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 one 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 - June 2017, n=35,109) and validation (July 2017 - June 2019, n=9,509) 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-ACSD 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
April 2021

Goal-Directed Therapy for Cardiac Surgery.

Crit Care Clin 2020 Oct 12;36(4):653-662. Epub 2020 Aug 12.

Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Giessen, Justus-Liebig University Giessen, Rudolf-Buchheim-Strasse 7, Giessen 35392, Germany; Charity Medical University, Berlin, Germany. Electronic address: https://twitter.com/Mich_San_d.

Goal-directed therapy couples therapeutic interventions with physiologic and metabolic targets to mitigate a patient's modifiable risks for death and complications. Goal-directed therapy attempts to improve quality-of-care metrics, including length of stay, rate of readmission, and cost per case. Debate persists around specific parameters and goals, the risk profiles that may benefit, and associated therapeutic strategies. Goal-directed therapy has demonstrated reduced complication rates and lengths of stay in noncardiac surgery studies. Establishing goal-directed therapy's early promise and role in cardiac surgery-namely, producing fewer complications and deaths-will require larger studies, including those with greater focus on high-risk patients.
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http://dx.doi.org/10.1016/j.ccc.2020.06.004DOI Listing
October 2020

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

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

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

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

Digital Health Primer for Cardiothoracic Surgeons.

Ann Thorac Surg 2020 08 5;110(2):364-372. Epub 2020 Apr 5.

Sanger Heart and Vascular Institute, Atrium Health, Charlotte, North Carolina. Electronic address:

The burgeoning demands for quality, safety, and value in cardiothoracic surgery, in combination with the advancement and acceleration of digital health solutions and information technology, provide a unique opportunity to improve efficiency and effectiveness simultaneously in cardiothoracic surgery. This primer on digital health explores and reviews data integration, data processing, complex modeling, telehealth with remote monitoring, and cybersecurity as they shape the future of cardiothoracic surgery.
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http://dx.doi.org/10.1016/j.athoracsur.2020.02.072DOI Listing
August 2020

The Association between Cytokines and 365-Day Readmission or Mortality in Adult Cardiac Surgery.

J Extra Corpor Technol 2019 Dec;51(4):201-209

The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire.

Cardiac surgery results in a multifactorial systemic inflammatory response with inflammatory cytokines, such as interleukin-10 and 6 (IL-10 and IL-6), shown to have potential in the prediction of adverse outcomes including readmission or mortality. This study sought to measure the association between IL-6 and IL-10 levels and 1-year hospital readmission or mortality following cardiac surgery. Plasma biomarkers IL-6 and IL-10 were measured in 1,047 patients discharged alive after isolated coronary artery bypass graft surgery from eight medical centers participating in the Northern New England Cardiovascular Disease Study Group between 2004 and 2007. Readmission status and mortality were ascertained using Medicare, state all-payer claims, and the National Death Index. We evaluated the association between preoperative and postoperative cytokines and 1-year readmission or mortality using Kaplan-Meier estimates and Cox's proportional hazards modeling, adjusting for covariates used in the Society of Thoracic Surgeons 30-day readmission model. The median follow-up time was 1 year. After adjustment, patients in the highest tertile of postoperative IL-6 values had a significantly increased risk of readmission or death within 1 year (HR: 1.38; 95% CI: 1.03-1.85), and an increased risk of death within 1 year of discharge (HR: 4.88; 95% CI: 1.26-18.85) compared with patients in the lowest tertile. However, postoperative IL-10 levels, although increasing through tertiles, were not found to be significantly associated independently with 1-year readmission or mortality (HR: 1.25; 95% CI: .93-1.69). Pro-inflammatory cytokine IL-6 and anti-inflammatory cytokine IL-10 may be postoperative markers of cardiac injury, and IL-6, specifically, shows promise in predicting readmission and mortality following cardiac surgery.
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http://dx.doi.org/10.1182/JECT-1900014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6936301PMC
December 2019

Enhanced Recovery After Surgery: A Narrative Review of its Application in Cardiac Surgery.

Ann Thorac Surg 2020 06 23;109(6):1937-1944. Epub 2019 Dec 23.

Department of Surgery, Baylor Scott and White, The Heart Hospital, Plano, Texas. Electronic address:

Background: Enhanced Recovery After Surgery (ERAS) is a perioperative patient management strategy that is being adopted rapidly across surgical specialties worldwide. Components of ERAS work collaboratively throughout the perioperative course to achieve significant benefits for both the patient and the entire health care system. The use of ERAS in cardiac surgery (ERAS-C) could lead to similar improvements, but currently, use of ERAS-C programs is lacking and not well defined.

Methods: A literature search was performed of the Medline database to capture relevant studies discussing ERAS-C. Key concepts were extracted from these articles and grouped according to appropriate perioperative stages. Supporting literature was also included, briefly discussing the historical progression of cardiac surgery to enhanced recovery pathways, potential limitations to these pathways in cardiac surgery, and the first studies evaluating the use of an ERAS program with cardiac surgery patients.

Results: Initial results of ERAS-C studies have shown similar benefits to those of other surgical fields, including decreased hospital and intensive care unit lengths of stay (1-4 days and 4-20 hours, respectively), improved perioperative pain control (25%-60% decreased opioid usage), and improvements in early postoperative mobility and oral diets. Results especially beneficial to cardiac surgery have also been reported, such as an 8% to 14% decreased incidence of postoperative atrial fibrillation.

Conclusions: This review presents pertinent current research related to the implementation of ERAS programs in the field of cardiac surgery and provides a call to action for further investigation and adaption of ERAS in cardiac surgery.
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http://dx.doi.org/10.1016/j.athoracsur.2019.11.008DOI Listing
June 2020

The Society of Thoracic Surgeons General Thoracic Surgery Database: 2019 Update on Research.

Ann Thorac Surg 2019 11 11;108(5):1293-1298. Epub 2019 Sep 11.

Division of Thoracic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

The Society of Thoracic Surgeons (STS) Workforce on Research Development and the STS Research Center currently offer 3 outcomes research platforms using the STS General Thoracic Surgery Database: (1) the traditional Access and Publications Program supports STS-sponsored projects with data analysis conducted at an STS-approved data analytic center, (2) the STS Task Force for Funded Research supports STS investigators pursuing extramural research funding for projects incorporating STS National Database data linked to other data sets such as Centers for Medicare and Medicaid Services, and (3) the Participant User File (PUF) program that provides deidentified patient-level data files from the STS General Thoracic Surgery Database to investigators with approved projects to be analyzed at their institution. This report includes an updated review of each program in addition to an outline of 2019-based articles published or accepted.
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http://dx.doi.org/10.1016/j.athoracsur.2019.09.001DOI Listing
November 2019

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

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

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

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

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

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

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

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

Elevated preoperative Galectin-3 is associated with acute kidney injury after cardiac surgery.

BMC Nephrol 2018 10 20;19(1):280. Epub 2018 Oct 20.

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA.

Background: Previous research suggests that novel biomarkers may be used to identify patients at increased risk of acute kidney injury following cardiac surgery. The purpose of this study was to evaluate the relationship between preoperative levels of circulating Galectin-3 (Gal-3) and acute kidney injury after cardiac surgery.

Methods: Preoperative serum Gal-3 was measured in 1498 patients who underwent coronary artery bypass graft (CABG) surgery and/or valve surgery as part of the Northern New England Biomarker Study between 2004 and 2007. Preoperative Gal-3 levels were measured using multiplex assays and grouped into terciles. Univariate and multinomial logistic regression was used to assess the predictive ability of Gal-3 terciles and AKI occurrence and severity.

Results: Before adjustment, patients in the highest tercile of Gal-3 had a 2.86-greater odds of developing postoperative KDIGO Stage 2 or 3 (p < 0.001) and 1.70-greater odds of developing KDIGO Stage 1 (p = < 0.001), compared to the first tercile. After adjustment, patients in the highest tercile had 2.95-greater odds of developing KDIGO Stage 2 or 3 (p < 0.001) and 1.71-increased odds of developing KDIGO Stage 1 (p = 0.001), compared to the first tercile. Compared to the base model, the addition of Gal-3 terciles improved discriminatory power compared to without Gal-3 terciles (test of equality = 0.042).

Conclusion: Elevated preoperative Gal-3 levels significantly improves predictive ability over existing clinical models for postoperative AKI and may be used to augment risk information for patients at the highest risk of developing AKI and AKI severity after cardiac surgery.
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http://dx.doi.org/10.1186/s12882-018-1093-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6195960PMC
October 2018

Multiple arterial, minimally invasive coronary surgery (MA-MICS).

Ann Cardiothorac Surg 2018 Jul;7(4):564-566

Sanger Heart & Vascular Institute, Department of Cardiothoracic and Vascular Surgery, Atrium Health, Charlotte, NC, USA.

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http://dx.doi.org/10.21037/acs.2018.06.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082782PMC
July 2018

Utility of Biomarkers to Improve Prediction of Readmission or Mortality After Cardiac Surgery.

Ann Thorac Surg 2018 11 4;106(5):1294-1301. Epub 2018 Aug 4.

Department of Medicine, Johns Hopkins University, Baltimore, Maryland.

Background: Hospital readmission within 30 days is associated with higher risks of complications, death, and increased costs. Accurate statistical models to stratify the risk of 30-day readmission or death after cardiac surgery could help clinical teams focus care on those patients at highest risk. We hypothesized biomarkers could improve prediction for readmission or mortality.

Methods: Levels of ST2, galectin-3, N-terminal pro-brain natriuretic peptide, cystatin C, interleukin-6, and interleukin-10 were measured in samples from 1,046 patients discharged after isolated coronary artery bypass graft surgery from eight medical centers, with external validation in 1,194 patients from five medical centers. Thirty-day readmission or mortality were ascertained using Medicare, state all-payer claims, and the National Death Index. We tested and externally validated the clinical models and the biomarker panels using area under the receiver-operating characteristics (AUROC) statistics.

Results: There were 112 patients (10.7%) who were readmitted or died within 30 days after coronary artery bypass graft surgery. The Society of Thoracic Surgeons augmented clinical model resulted in an AUROC of 0.66 (95% confidence interval: 0.61 to 0.71). The biomarker panel with The Society of Thoracic Surgeons augmented clinical model resulted in an AUROC of 0.74 (bootstrapped 95% confidence interval: 0.69 to 0.79, p < 0.0001). External validation of the model showed limited improvement with the addition of a biomarker panel, with an AUROC of 0.51 (95% confidence interval: 0.45 to 0.56).

Conclusions: Although biomarkers significantly improved prediction of 30-day readmission or mortality in our derivation cohort, the external validation of the biomarker panel was poor. Biomarkers perform poorly, much like other efforts to improve prediction of readmission, suggesting there are many other factors yet to be explored to improve prediction of readmission.
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http://dx.doi.org/10.1016/j.athoracsur.2018.06.052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6668355PMC
November 2018

The Association Between Novel Biomarkers and 1-Year Readmission or Mortality After Cardiac Surgery.

Ann Thorac Surg 2018 10 1;106(4):1122-1128. Epub 2018 Jun 1.

Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire; Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire; Department of Epidemiology, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire. Electronic address:

Background: Novel cardiac biomarkers including soluble suppression of tumorigenicity 2, galectin-3, and the N-terminal prohormone of brain natriuretic peptide may be associated with long-term adverse outcomes after cardiac surgery. We sought to measure the association between cardiac biomarker levels and 1-year hospital readmission or mortality.

Methods: Plasma biomarkers from 1,047 patients discharged alive after isolated coronary artery bypass graft surgery from 8 medical centers were measured in a cohort from the Northern New England Cardiovascular Disease Study Group between 2004 and 2007. We evaluated the association between preoperative and postoperative biomarkers and 1-year readmission or mortality using Kaplan-Meier estimates and Cox proportional hazards modeling, adjusting for covariates used in The Society of Thoracic Surgeons 30-day readmission model.

Results: The median follow-up time was 365 days. After adjustment for established risk factors, above-median levels of postoperative galectin-3 (median 10.35 ng/mL; hazard ratio, 1.40; 95% confidence interval, 1.08 to 1.80; p = 0.010) and N-terminal prohormone of brain natriuretic peptide (median = 15.21 ng/mL, hazard ratio, 1.42; 95% confidence interval, 1.07 to 1.87; p = 0.014) were each significantly associated with 1-year readmission or mortality.

Conclusions: In patients undergoing cardiac surgery, novel cardiac biomarkers were associated with readmission or mortality independent of established risk factors. Measurement of these biomarkers may improve our ability to identify patients at highest risk for readmission or mortality before discharge. This will also allow resource allocation accordingly, while implementing strategies for personalized medicine based on the biomarker profile of the patient.
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http://dx.doi.org/10.1016/j.athoracsur.2018.04.084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6685203PMC
October 2018

Preoperative serum ST2 level predicts acute kidney injury after adult cardiac surgery.

J Thorac Cardiovasc Surg 2018 09 11;156(3):1114-1123.e2. Epub 2018 Apr 11.

The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH; Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH; Department of Community and Family Medicine, Geisel School of Medicine, Lebanon, NH. Electronic address:

Objective: The purpose of this study was to evaluate the relationship between preoperative levels of serum soluble ST2 (ST2) and acute kidney injury (AKI) after cardiac surgery. Previous research has shown that biomarkers facilitate the prediction of AKI and other complications after cardiac surgery.

Methods: Preoperative ST2 proteins were measured in 1498 patients undergoing isolated coronary artery bypass graft surgery at 8 hospitals participating in the Northern New England Biomarker Study from 2004 to 2007. AKI severity was defined using the Acute Kidney Injury Network (AKIN) definition. Preoperative ST2 levels were measured using multiplex assays. Ordered logistic regression was used to examine the relationship between ST2 levels and levels of AKI severity.

Results: Participants in this study showed a significant association between elevated preoperative ST2 levels and acute kidney risk. Before adjustment, the odds of patients developing AKIN stage 2 or 3, compared with AKIN stage 1, are 2.43 times higher (95% confidence interval, 1.86-3.16; P < .001) for patients in the highest tercile of preoperative ST2. After adjustment, patients in the highest tercile of preoperative ST2 had significantly greater odds of developing AKIN stage 2 or 3 AKI (odds ratio, 1.99; 95% confidence interval, 1.50-2.65; P < .001) compared with patients with AKIN stage 1.

Conclusions: Preoperative ST2 levels are associated with postoperative AKI risk and can be used to identify patients at higher risk of developing AKI after cardiac surgery.
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http://dx.doi.org/10.1016/j.jtcvs.2018.03.149DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6098731PMC
September 2018

The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery Risk Models: Part 1-Background, Design Considerations, and Model Development.

Ann Thorac Surg 2018 05 22;105(5):1411-1418. Epub 2018 Mar 22.

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

Background: The last published version of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) risk models were developed in 2008 based on patient data from 2002 to 2006 and have been periodically recalibrated. In response to evolving changes in patient characteristics, risk profiles, surgical practice, and outcomes, the STS has now developed a set of entirely new risk models for adult cardiac surgery.

Methods: New models were estimated for isolated coronary artery bypass grafting surgery (CABG [n = 439,092]), isolated aortic or mitral valve surgery (n = 150,150), and combined valve plus CABG procedures (n = 81,588). The development set was based on July 2011 to June 2014 STS ACSD data; validation was performed using July 2014 to December 2016 data. Separate models were developed for operative mortality, stroke, renal failure, prolonged ventilation, reoperation, composite major morbidity or mortality, and prolonged or short postoperative length of stay. Because of its low occurrence rate, a combined model incorporating all operative types was developed for deep sternal wound infection/mediastinitis.

Results: Calibration was excellent except for the deep sternal wound infection/mediastinitis model, which slightly underestimated risk because of higher rates of this endpoint in the more recent validation data; this will be recalibrated in each feedback report. Discrimination (c-index) of all models was superior to that of 2008 models except for the stroke model for valve patients.

Conclusions: Completely new STS ACSD risk models have been developed based on contemporary patient data; their performance is superior to that of previous STS ACSD models.
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http://dx.doi.org/10.1016/j.athoracsur.2018.03.002DOI Listing
May 2018

The Society of Thoracic Surgeons 2018 Adult Cardiac Surgery Risk Models: Part 2-Statistical Methods and Results.

Ann Thorac Surg 2018 05 22;105(5):1419-1428. Epub 2018 Mar 22.

Department of Surgery and Center for Quality and Safety, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: The Society of Thoracic Surgeons (STS) uses statistical models to create risk-adjusted performance metrics for Adult Cardiac Surgery Database (ACSD) participants. Because of temporal changes in patient characteristics and outcomes, evolution of surgical practice, and additional risk factors available in recent ACSD versions, completely new risk models have been developed.

Methods: Using July 2011 to June 2014 ACSD data, risk models were developed for operative mortality, stroke, renal failure, prolonged ventilation, mediastinitis/deep sternal wound infection, reoperation, major morbidity or mortality composite, prolonged postoperative length of stay, and short postoperative length of stay among patients who underwent isolated coronary artery bypass grafting surgery (n = 439,092), aortic or mitral valve surgery (n = 150,150), or combined valve plus coronary artery bypass grafting surgery (n = 81,588). Separate models were developed for each procedure and endpoint except mediastinitis/deep sternal wound infection, which was analyzed in a combined model because of its infrequency. A surgeon panel selected predictors by assessing model performance and clinical face validity of full and progressively more parsimonious models. The ACSD data (July 2014 to December 2016) were used to assess model calibration and to compare discrimination with previous STS risk models.

Results: Calibration in the validation sample was excellent for all models except mediastinitis/deep sternal wound infection, which slightly underestimated risk and will be recalibrated in feedback reports. The c-indices of new models exceeded those of the last published STS models for all populations and endpoints except stroke in valve patients.

Conclusions: New STS ACSD risk models have generally excellent calibration and discrimination and are well suited for risk adjustment of STS performance metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2018.03.003DOI Listing
May 2018

Decision Making, Evidence, and Practice.

Ann Thorac Surg 2018 04;105(4):994-999

Department of Cardiothoracic Surgery, Stanford University, Stanford, California.

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http://dx.doi.org/10.1016/j.athoracsur.2018.01.054DOI Listing
April 2018

The Society for Translational Medicine: clinical practice guidelines for the postoperative management of chest tube for patients undergoing lobectomy.

J Thorac Dis 2017 Sep;9(9):3255-3264

Charité Kompetenzzentrum für Thoraxchirurgie, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany.

The Society for Translational Medicine and The Chinese Society for Thoracic and Cardiovascular Surgery conducted a systematic review of the literature in an attempt to improve our understanding in the postoperative management of chest tubes of patients undergoing pulmonary lobectomy. Recommendations were produced and classified based on an internationally accepted GRADE system. The following recommendations were extracted in the present review: (I) chest tubes can be removed safely with daily pleural fluid of up to 450 mL (non-chylous and non-sanguinous), which may reduce chest tube duration and hospital length of stay (2B); (II) in rare instances, e.g., persistent abundant fluid production, the use of PrR <0.5 when evaluating fluid output to determine chest tube removal might be beneficial (2B); (III) it is recommended that one chest tube is adequate following pulmonary lobectomy, except for hemorrhage and space problems (2A); (IV) chest tube clearance by milking and stripping is not recommended after lung resection (2B); (V) chest tube suction is not necessary for patients undergoing lobectomy after first postoperative day (2A); (VI) regulated chest tube suction [-11 (-1.08 kPa) to -20 (1.96 kPa) cmHO depending upon the type of lobectomy] is not superior to regulated seal [-2 (0.196 kPa) cmHO] when electronic drainage systems are used after lobectomy by thoracotomy (2B); (VII) chest tube removal recommended at the end of expiration and may be slightly superior to removal at the end of inspiration (2A); (VIII) electronic drainage systems are recommended in the management of chest tube in patients undergoing lobectomy (2B).
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http://dx.doi.org/10.21037/jtd.2017.08.165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708414PMC
September 2017

Physician Burnout: Are We Treating the Symptoms Instead of the Disease?

Ann Thorac Surg 2017 Oct;104(4):1117-1122

Baylor Scott & White Research Institute, The Heart Hospital Baylor Plano, Plano, Texas; Department of Cardiothoracic Surgery, The Heart Hospital Baylor Plano, Plano, Texas. Electronic address:

Despite increasing recognition of physician burnout, its incidence has only increased in recent years, with nearly half of physicians suffering from symptoms of burnout in the most recent surveys. Unfortunately, most burnout research has focused on its profound prevalence rather than seeking to identify the root cause of the burnout epidemic. Health care organizations throughout the United States are implementing committees and support groups in an attempt to reduce burnout among their physicians, but these efforts are typically focused on increasing resilience and wellness among participants rather than combating problematic changes in how medicine is practiced by physicians in the current era. This report provides a brief review of the current literature on the syndrome of burnout, a summary of several institutional approaches to combating burnout, and a call for a shift in the focus of these efforts toward one proposed root cause of burnout.
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http://dx.doi.org/10.1016/j.athoracsur.2017.08.009DOI Listing
October 2017

Cardiothoracic Critical Care.

Surg Clin North Am 2017 Aug;97(4):811-834

Cardiovascular Critical Care, Boston Children's Hospital, Boston, MA, USA.

High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.
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http://dx.doi.org/10.1016/j.suc.2017.03.001DOI Listing
August 2017

Investigating the Causes of Adverse Events.

Ann Thorac Surg 2017 Jun;103(6):1693-1699

Department of Cardiothoracic Surgery, Stanford University, Stanford, California.

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http://dx.doi.org/10.1016/j.athoracsur.2017.04.001DOI Listing
June 2017

Invited Commentary.

Authors:
Kevin W Lobdell

Ann Thorac Surg 2017 04;103(4):1237-1238

Sanger Heart and Vascular Institute, Carolinas HealthCare System, PO Box 32861, Charlotte, NC 28232. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2016.07.058DOI Listing
April 2017

Axillary Versus Femoral Arterial Cannulation During Repair of Type A Aortic Dissection?: An Old Problem Seeking New Solutions.

Aorta (Stamford) 2016 Aug 1;4(4):115-123. Epub 2016 Aug 1.

Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut, USA.

Background: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute Type A aortic dissection with axillary or femoral artery cannulation.

Methods: A total of 305 patients from five academic medical centers underwent acute Type A aortic dissection repair via axillary ( = 107) or femoral ( = 198) artery cannulation between January 2000 and December 2010. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality, and Cox regression hazard ratios were calculated to determine predictors of long-term mortality.

Results: Operative mortality was not influenced by cannulation site (16% for axillary cannulation vs. 19% for femoral cannulation, p = 0.64). In multivariate logistic regression analysis, hemodynamic instability (p < 0.001) and prolonged cardiopulmonary bypass time (>200 min; p = 0.05) emerged as independent predictors of operative mortality. Stroke rates were comparable between the two techniques (14% for axillary and 17% for femoral cannulation, p = 0.52). Five-year actuarial survival was comparable between the groups (55.1% for axillary and 65.7% for femoral cannulation, p = 0.36). In Cox regression analysis, predictors of long-term mortality were: age (p < 0.001), stroke (p < 0.001), prolonged cardiopulmonary bypass time (p = 0.001), hemodynamic instability (p = 0.002), and renal failure (p = 0.001).

Conclusions: The outcomes of femoral versus axillary arterial cannulation in patients with acute Type A aortic dissection are comparable. The choice of arterial cannulation site should be individualized based on different patient risk profiles.
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http://dx.doi.org/10.12945/j.aorta.2016.16.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5217728PMC
August 2016

Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection.

Aorta (Stamford) 2016 Apr 1;4(2):33-41. Epub 2016 Apr 1.

Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut, USA.

Background: The goal of this study was to compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute Type A aortic dissection, including aortic valve (AV) resuspension, aortic valve replacement (AVR), and a root replacement procedure.

Methods: All patients who underwent acute Type A aortic dissection repair between January 2000 and October 2010 at four academic institutions were compiled from each institution's Society of Thoracic Surgeons Database. This included 189 patients who underwent a concomitant aortic valve (AV) procedure; 111, 21, and 57 patients underwent AV resuspension, AVR, and the Bentall procedure, respectively. The median age of patients undergoing a root replacement procedure was significantly younger than the other two groups. Early clinical outcomes and 10-year actuarial survival rates were compared. Trends in outcomes and surgical techniques throughout the duration of the study were also analyzed.

Results: The operative mortality rates were 17%, 29%, and 18%, for AV resuspension, AVR, and root replacement, respectively. Operative mortality ( = 0.459) was comparable between groups. Hemorrhage related re-exploration did not differ significantly between groups ( = 0.182); however, root replacement procedures tended to have decreased rates of bleeding when compared to AVR ( = 0.067). The 10-year actuarial survival rates for the AV resuspension, Bentall, and AVR groups were 72%, 56%, and 36%, respectively (log-rank = 0.035).

Conclusions: The 10-year actuarial survival was significantly lower in those receiving AVR compared to those receiving root replacement procedures or AV resuspension. Operative mortality was comparable between the three groups.
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http://dx.doi.org/10.12945/j.aorta.2016.14.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5054754PMC
April 2016

"What's the Risk?" Assessing and Mitigating Risk in Cardiothoracic Surgery.

Ann Thorac Surg 2016 Oct 2;102(4):1052-8. Epub 2016 Sep 2.

Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

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http://dx.doi.org/10.1016/j.athoracsur.2016.08.051DOI Listing
October 2016

Comparison between antegrade and retrograde cerebral perfusion or profound hypothermia as brain protection strategies during repair of type A aortic dissection.

Ann Cardiothorac Surg 2016 Jul;5(4):328-35

Department of Cardiac Surgery, Hartford Hospital, Hartford, CT, USA.

Background: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute type A aortic dissection by the method of cerebral perfusion used.

Methods: A total of 324 patients from five academic medical centers underwent repair of acute type A aortic dissection between January 2000 and December 2010. Of those, antegrade cerebral perfusion (ACP) was used for 84 patients, retrograde cerebral perfusion (RCP) was used for 55 patients, and deep hypothermic circulatory arrest (DHCA) was used for 184 patients during repair. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality and Cox Regression hazard ratios were calculated to determine the predictors of long term mortality.

Results: Operative mortality was not influenced by the type of cerebral protection (19% for ACP, 14.5% for RCP and 19.1% for DHCA, P=0.729). In multivariable logistic regression analysis, hemodynamic instability [odds ratio (OR) =19.6, 95% confidence intervals (CI), 0.102-0.414, P<0.001] and CPB time >200 min(OR =4.7, 95% CI, 1.962-1.072, P=0.029) emerged as independent predictors of operative mortality. Actuarial 5-year survival was unchanged by cerebral protection modality (48.8% for ACP, 61.8% for RCP and 66.8% for no cerebral protection, log-rank P=0.844).

Conclusions: During surgical repair of type A aortic dissection, ACP, RCP or DHCA are safe strategies for cerebral protection in selected patients with type A aortic dissection.
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http://dx.doi.org/10.21037/acs.2016.04.02DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4973129PMC
July 2016

Failure to Rescue Rates After Coronary Artery Bypass Grafting: An Analysis From The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

Ann Thorac Surg 2016 Aug 22;102(2):458-64. Epub 2016 Jun 22.

Department of Surgery/Center for Quality and Safety, Massachusetts General Hospital, Boston, Massachusetts.

Background: Failure to rescue (FTR) is increasingly recognized as an important quality indicator in surgery. The Society of Thoracic Surgeons National Database was used to develop FTR metrics and a predictive FTR model for coronary artery bypass grafting (CABG).

Methods: The study included 604,154 patients undergoing isolated CABG at 1,105 centers from January 2010 to January 2014. FTR was defined as death after four complications: stroke, renal failure, reoperation, and prolonged ventilation. FTR was determined for each complication and a composite of the four complications. A statistical model to predict FTR was developed.

Results: FTR rates were 22.3% for renal failure, 16.4% for stroke, 12.4% for reoperation, 12.1% for prolonged ventilation, and 10.5% for the composite. Mortality increased with multiple complications and with specific combinations of complications. The multivariate risk model for prediction of FTR demonstrated a C index of 0.792 and was well calibrated, with a 1.0% average difference between observed/expected (O/E) FTR rates. With centers grouped into mortality terciles, complication rates increased modestly (11.4% to 15.7%), but FTR rates more than doubled (6.8% to 13.9%) from the lowest to highest terciles. Centers in the lowest complication rate tercile had an FTR O/E of 1.14, whereas centers in the highest complication rate tercile had an FTR O/E of 0.91.

Conclusions: CABG mortality rates vary directly with FTR, but complication rates have little relation to death. FTR rates derived from The Society of Thoracic Surgeons data can serve as national benchmarks. Predicted FTR rates may facilitate patient counseling, and FTR O/E ratios have promise as valuable quality metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2016.04.051DOI Listing
August 2016

Effects of Gender on Outcomes and Survival Following Repair of Acute Type A Aortic Dissection.

Int J Angiol 2015 Jun;24(2):93-8

Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut.

Previous studies have demonstrated gender-related differences in early and late outcomes following type A dissection diagnosis. However, it is widely unknown whether gender affects early clinical outcomes and survival after repair of type A aortic dissection. The goal of this study was to compare the early and late clinical outcomes in women versus men after repair of acute type A aortic dissections. Between January 2000 and October 2010 a total of 251 patients from four academic medical centers underwent repair of acute type A aortic dissection. Of those, 79 were women and 172 were men with median ages of 67 (range, 20-87 years) and 58 years (range, 19-83 years), respectively (p < 0.001). Major morbidity, operative mortality, and 10-year actuarial survival were compared between the groups. Operative mortality was not significantly influenced by gender (19% for women vs. 17% for men, p = 0.695). There were similar rates of hemodynamic instability (12% for women vs. 13% men, p = 0.783) between the two groups. Actuarial 10-year survival rates were 58% for women versus 73% for men (p = 0.284). Gender does not significantly impact early clinical outcomes and actuarial survival following repair of acute type A aortic dissection.
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http://dx.doi.org/10.1055/s-0034-1396341DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4452609PMC
June 2015

Improved clinical outcomes and survival following repair of acute type A aortic dissection in the current era.

Interact Cardiovasc Thorac Surg 2014 Dec 21;19(6):971-6. Epub 2014 Aug 21.

Department of Cardiac Surgery, Hartford Hospital, Hartford, USA.

Objectives: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute type A aortic dissection during 2000-2005 and 2006-2010.

Methods: A total of 251 patients from four academic medical centres underwent repair of acute type A aortic dissection between January 2000 and October 2010. Of those, 111 patients underwent repair during 2000-2005, whereas 140 patients underwent repair during 2006-2010. Median ages were 62 years (range 20-83) and 58 years (range 30-80) for patients repaired from 2000-2005 compared with those repaired during 2006-2010, respectively (P = 0.180). Major morbidity, operative mortality and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality.

Results: Operative mortality was strongly influenced by surgical era (24% for 2000-2005 vs 12% for 2006-2010, P = 0.013). In multivariable logistic regression analysis, haemodynamic instability [odds ratio (OR) = 17.8, 95% confidence intervals (CIs) = 0.05-0.35, P <0.001], cardiopulmonary bypass time >200 min (OR = 9.5, 95% CI = 0.14-0.64, P = 0.002) and earlier date of surgery (OR = 5.8, 95% CI = 1.18-5.14, P = 0.016) emerged as independent predictors of operative mortality. Actuarial 5-year survival was worse for earlier compared with later date of surgery (64% for 2000-2005 vs 77% for 2006-2010, log-rank P <0.001).

Conclusions: Surgical era significantly impacts early outcomes and actuarial survival following repair of acute type A aortic dissection.
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http://dx.doi.org/10.1093/icvts/ivu268DOI Listing
December 2014