Publications by authors named "Matthew D Bacchetta"

23 Publications

  • Page 1 of 1

Increasing Opportunity for Lung Transplant in Interstitial Lung Disease With Pulmonary Hypertension.

Ann Thorac Surg 2018 12 28;106(6):1812-1819. Epub 2018 May 28.

Section of Thoracic Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York. Electronic address:

Background: Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation for end-stage interstitial lung disease (ILD) and pulmonary hypertension (PH) has varying results based on ECMO configuration. We compare our experience using venovenous (VV) and venoarterial (VA) ECMO bridge to transplantation for ILD with PH on survival to successful transplantation.

Methods: A single-center retrospective review was done of patients with ILD and secondary PH who were placed on either VV or VA ECMO as bridge to transplantation from 2010 to 2016. Comparisons for factors associated with survival to transplantation between VV and VA ECMO strategies were made using Cox proportional hazards model. Subgroup analysis included comparisons of VV ECMO patients who remained on VV or were converted to VA ECMO.

Results: A total of 50 patients with ILD and PH were treated initially with either VV (n = 19) or VA (n = 31) ECMO as bridge to lung transplantation. Initial VA ECMO had a significantly higher survival to transplantation compared with initial VV ECMO (p = 0.03). Cox proportional hazards modeling showed a 59% reduction in risk of death for VA compared with VV ECMO (hazard reduction 0.41, 95% confidence interval: 0.18 to 0.92, p = 0.03). Patients converted from VV to VA ECMO had significantly longer survival awaiting transplant than patients who remained on VV ECMO (p = 0.03). Ambulation on ECMO before transplantation was associated with an 80% reduction in the risk of death (hazard reduction 0.20, 95% confidence interval: 0.08 to 0.48, p < 0.01).

Conclusions: Venoarterial ECMO upper body configuration for patients with end stage ILD and PH significantly improves overall survival to transplantation.
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http://dx.doi.org/10.1016/j.athoracsur.2018.04.068DOI Listing
December 2018

The Feasibility of Venovenous ECMO at Role-2 Facilities in Austere Military Environments.

Mil Med 2018 09;183(9-10):e644-e648

Department of Surgery, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL.

Introduction: Venovenous extracorporeal membrane oxygenation (VV-ECMO) has been gaining use to bridge the recovery from acute respiratory distress syndrome (ARDS) refractory to conventional treatment. However, these interventions are often limited to higher echelons of military care. We present a case of lung salvage from severe ARDS in an Afghani soldier with VV-ECMO at a Role-2 (R2) facility in an austere military environment in Afghanistan.

Case: A 25-year-old Afghani soldier presented to an R2 facility with blast lung injury and multiple penetrating injuries following an explosion. The patient underwent immediate damage control laparotomy. The abdomen was left open for subsequent washouts and ongoing resuscitation. Due to his ineligibility for evacuation and worsening ARDS, despite 5 d of conventional ventilation strategies, he was started on VV-ECMO. The patient had immediate improvements in oxygenation, which continued for 10 d. Moreover, he underwent three transportations to the operating room without accidental decannulation or disruption of the VV-ECMO device. Despite significant improvements, the patient expired on postoperative day 15, due to an overwhelming intra-abdominal sepsis.

Conclusion: As future advancements are sought, VV-ECMO may become a consideration for casualties with severe ARDS at the point of injury and at lower echelons of military care.
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http://dx.doi.org/10.1093/milmed/usx132DOI Listing
September 2018

Successful pulmonary thromboendarterectomy in a patient with sickle cell disease and associated resolution of a leg ulcer.

Lung India 2018 Jan-Feb;35(1):73-77

Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Hofstra Northwell School of Medicine, New York, NY, USA.

Pulmonary hypertension (PH) is a relatively frequent and severe complication of sickle cell disease (SCD). PH associated with SCD is classified as Group 5 PH. The exact pathogenesis of PH in SCD in not known. There are also very limited treatment options available at this time for such patients with Group 5 PH. Patients with SCD are predisposed to a hypercoagulable state and thus can also suffer from chronic thromboembolism. These patients can have associated chronic thromboembolic pulmonary hypertension (CTEPH), thus being classified as Group 4 PH. We present such a case of a patient with SCD diagnosed with severe PH who was found to have CTEPH and successfully underwent a thromboendarterectomy with resolution of his symptoms such as reduction of his oxygen requirements and healing of chronic leg ulcer. This case illustrates the importance of screening patients with SCD and elevated pulmonary artery pressures for CTEPH as this would offer possible treatment options such as pulmonary thromboendarterectomy and/or riociguat in this subset of patients.
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http://dx.doi.org/10.4103/lungindia.lungindia_47_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5760875PMC
January 2018

Anesthetic management of the patient with extracorporeal membrane oxygenator support.

Best Pract Res Clin Anaesthesiol 2017 Jun 18;31(2):227-236. Epub 2017 Jul 18.

Columbia University Medical Center, 622 W 168th Street, PH5, New York, NY 10032, USA. Electronic address:

The use of short-term mechanical circulatory support in the form of extracorporeal membrane oxygenation (ECMO) in adult patients has increased over the last decade. Cardiothoracic anesthesiologists may care for these patients during ECMO placement and for procedures while ECMO support is in place. An understanding of ECMO capabilities, indications, and complications is essential to the anesthesiologist caring for these patients. Below we review the anesthetic considerations for the implantation of ECMO and concerns when caring for patients on ECMO.
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http://dx.doi.org/10.1016/j.bpa.2017.07.005DOI Listing
June 2017

Chronic thromboembolic pulmonary hypertension, pregnancy, and a pulmonary endarterectomy: a rare challenge.

Pulm Circ 2016 Sep;6(3):384-8

Department of Thoracic Surgery, Columbia University Medical Center-New York Presbyterian Hospital, New York, New York, USA.

It is well described that patients with group 1 forms of pulmonary arterial hypertension have a high risk of mortality during pregnancy and in the early postpartum period. However, to the authors' knowledge, the diagnosis and management of group 4 pulmonary hypertension due to chronic thromboembolic pulmonary hypertension (CTEPH) during pregnancy with early postpartum pulmonary endarterectomy (PEA) has not been previously reported. We report the case of a 28-year-old woman who received a diagnosis of CTEPH during her pregnancy, was managed as an inpatient by a multidisciplinary team throughout the pregnancy and early postpartum period, and underwent PEA 6 weeks after delivery. While the management of acute pulmonary embolus in pregnancy is well described, this unique case of CTEPH diagnosed during pregnancy illustrates several challenging management issues.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5019092PMC
http://dx.doi.org/10.1086/687158DOI Listing
September 2016

Blood conservation in extracorporeal membrane oxygenation for acute respiratory distress syndrome.

Ann Thorac Surg 2015 Feb 10;99(2):590-5. Epub 2014 Dec 10.

Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York. Electronic address:

Background: Extracorporeal membrane oxygenation support (ECMO) typically requires multiple blood transfusions and is associated with frequent bleeding complications. Blood transfusions are known to increase morbidity and mortality in critically ill patients, which may extend to patients receiving ECMO. Aiming to reduce transfusion requirements, we implemented a blood conservation protocol in adults with severe acute respiratory distress syndrome (ARDS) receiving ECMO.

Methods: This was a retrospective study of adults receiving ECMO for ARDS after initiation of a blood conservation protocol that included a transfusion trigger of hemoglobin of less than 7.0 g/dL, use of low-dose anticoagulation targeting an activated partial thromboplastin time of 40 to 60 seconds, and autotransfusion of circuit blood during decannulation. The primary objective was to evaluate transfusion requirements during ECMO support. Clinical outcomes included survival, neurologic function, renal function, bleeding, and thrombotic complications.

Results: The analysis included 38 patients; of these, 24 (63.2%) received a transfusion while receiving ECMO. Median hemoglobin was 8.29 g/dL. A median of 1.0 units (range, 250 to 300 mL) was transfused during ECMO support over a median duration of 9.0 days, equivalent to 0.11 U/d (range, 27.5 to 33.3 mL/d). The median activated partial thromboplastin time was 46.5 seconds. Bleeding occurred in 10 patients (26.3%); severe bleeding occurred in 2 patients (5.3%). Twenty-eight patients (73.7%) survived to hospital discharge.

Conclusions: Implementation of a blood conservation protocol in adults receiving ECMO for ARDS resulted in lower transfusion requirements and bleeding complications than previously reported in the literature and was associated with comparable survival and organ recovery.
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http://dx.doi.org/10.1016/j.athoracsur.2014.08.039DOI Listing
February 2015

ECMO for adult respiratory failure: current use and evolving applications.

ASAIO J 2014 May-Jun;60(3):255-62

From the *Department of Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, New York; and †Department of Surgery, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, New York.

Extracorporeal membrane oxygenation (ECMO) is increasingly being used to support adults with severe forms of respiratory failure. Fueling the explosive growth is a combination of technological improvements and accumulating, although controversial, evidence. Current use of ECMO extends beyond its most familiar role in the support of patients with severe acute respiratory distress syndrome (ARDS) to treat patients with various forms of severe hypoxemic or hypercapnic respiratory failure, ranging from bridging patients to lung transplantation to managing pulmonary hypertensive crises. The role of ECMO used primarily for extracorporeal carbon dioxide removal (ECCO2R) in the support of patients with hypercapnic respiratory failure and less severe forms of ARDS is also evolving. Select patients with respiratory failure may be liberated from invasive mechanical ventilation altogether and some may undergo extensive physical therapy while receiving extracorporeal support. Current research may yield a true artificial lung with the potential to change the paradigm of treatment for adults with chronic respiratory failure.
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http://dx.doi.org/10.1097/MAT.0000000000000062DOI Listing
December 2014

Upper-body extracorporeal membrane oxygenation as a strategy in decompensated pulmonary arterial hypertension.

Pulm Circ 2013 Apr;3(2):432-5

Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Columbia University Medical Center/New York-Presbyterian Hospital, New York City, New York, USA.

Pulmonary arterial hypertension (PAH) is a disease with significant morbidity and mortality, particularly during an acute decompensation. We describe a single-center experience of three patients with severe Group 1 PAH, refractory to targeted medical therapy, in which an extubated, nonsedated, extracorporeal membrane oxygenation (ECMO) strategy with an upper-body configuration was used as a bridge to recovery or lung transplantation. All three patients were extubated within 24 hours of ECMO initiation. Two patients were successfully bridged to lung transplantation, and the other patient was optimized on targeted PAH therapy with subsequent recovery from an acute decompensation. The upper-body ECMO configuration allowed for daily physical therapy, including one patient, who would otherwise have been unsuitable for transplantation, ambulating over 850 meters daily. This series demonstrates the feasibility of using ECMO to bridge PAH patients to recovery or transplantation while avoiding the complications of immobility and invasive mechanical ventilation.
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http://dx.doi.org/10.4103/2045-8932.113178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3757840PMC
April 2013

Decellularization of human and porcine lung tissues for pulmonary tissue engineering.

Ann Thorac Surg 2013 Sep 18;96(3):1046-55; discussion 1055-6. Epub 2013 Jul 18.

Department of Biomedical Engineering, Columbia University, New York, New York 10032, USA.

Background: The only definitive treatment for end-stage organ failure is orthotopic transplantation. Lung extracellular matrix (LECM) holds great potential as a scaffold for lung tissue engineering because it retains the complex architecture, biomechanics, and topologic specificity of the lung. Decellularization of human lungs rejected from transplantation could provide "ideal" biologic scaffolds for lung tissue engineering, but the availability of such lungs remains limited. The present study was designed to determine whether porcine lung could serve as a suitable substitute for human lung to study tissue engineering therapies.

Methods: Human and porcine lungs were procured, sliced into sheets, and decellularized by three different methods. Compositional, ultrastructural, and biomechanical changes to the LECM were characterized. The suitability of LECM for cellular repopulation was evaluated by assessing the viability, growth, and metabolic activity of human lung fibroblasts, human small airway epithelial cells, and human adipose-derived mesenchymal stem cells over a period of 7 days.

Results: Decellularization with 3-[(3-Cholamidopropyl)dimethylammonio]-1-propanesulfonate (CHAPS) showed the best maintenance of both human and porcine LECM, with similar retention of LECM proteins except for elastin. Human and porcine LECM supported the cultivation of pulmonary cells in a similar way, except that the human LECM was stiffer and resulted in higher metabolic activity of the cells than porcine LECM.

Conclusions: Porcine lungs can be decellularized with CHAPS to produce LECM scaffolds with properties resembling those of human lungs, for pulmonary tissue engineering. We propose that porcine LECM can be an excellent screening platform for the envisioned human tissue engineering applications of decellularized lungs.
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http://dx.doi.org/10.1016/j.athoracsur.2013.04.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4033908PMC
September 2013

Pediatric trauma experience in a combat support hospital in eastern Afghanistan over 10 months, 2010 to 2011.

Am Surg 2013 Mar;79(3):257-60

Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA.

We reviewed the pediatric trauma experience of one Combat Support Hospital (CSH) in Afghanistan to focus on injuries, surgery, and outcomes in a war zone. We conducted a review of all pediatric patients over 10 months in an eastern Afghanistan CSH. We studied 41 children (1 to 18 years; mean, 8.5 years; median, 9 years), 28 (68.2%) with penetrating injuries. Blasts (13 patients) and burns (nine) were the most common mechanisms. At arrival 19 (46.3%) underwent endotracheal intubation, four (9.8%) had no palpable blood pressure, 10.6 per cent (four of 38) a Glasgow coma score of 5 or less, 30.6 per cent (11 of 36) base deficits of 6 or less, and 41.7 per cent (15 of 36) hematocrit 30 or less. Red cells were given in 14 (34.1%) and plasma in 11 (26.8%). Of 32 total nonburn patients, 12 (37.5%) had multiple system injuries. Three-fourths of injuries were severe (75.8% [47 of 62] Abbreviated Injury Score 3 or greater). Thirty-two patients (78.0%) required major operations: burn and wound care, orthopedic, chest, abdominal, vascular, and neurosurgical. Second operations were performed in 16 (39.0%), most often burn and orthopedic procedures. Six died (14.6%), 13 were transferred to other hospitals (31.7%), and 20 were discharged to home (48.8%; two not noted). Broad experience in operative trauma care, pediatric resuscitation, and critical care is a priority for military surgeons.
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March 2013

High lung allocation score is associated with increased morbidity and mortality following transplantation.

Chest 2010 Mar 9;137(3):651-7. Epub 2009 Oct 9.

Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, NY, USA.

Background: The lung allocation score (LAS) was initiated in May 2005 to allocate lungs based on medical urgency and posttransplant survival. The purpose of this study was to determine if there is an association between an elevated LAS at the time of transplantation and increased postoperative morbidity and mortality.

Methods: The United Network for Organ Sharing provided de-identified patient-level data. Analysis included lung transplant recipients aged >or= 12 years who received transplants between April 5, 2006, and December 31, 2007 (n = 3,836). Recipients were stratified into three groups: LAS < 50 (n = 3,161, 83.87%), LAS 50 to 75 (n = 411, 10.9%), and LAS >or= 75 (n = 197, 5.23%), referred to as low LAS (LLAS), intermediate LAS (ILAS), and high LAS (HLAS), respectively. The primary outcome was posttransplant graft survival at 1 year. Secondary outcomes included length of stay and in-hospital complications.

Results: HLAS recipients had significantly worse actuarial survival at 90 days and 1 year compared with LLAS recipients. When transplant recipients were stratified by disease etiology, a trend of decreased survival with elevated LAS was observed across all major causes of lung transplant. HLAS recipients were more likely to require dialysis or to have infections compared with LLAS recipients (P < .001). In addition, length of stay was higher in the HLAS group when compared with the LLAS group (P < .001).

Conclusions: HLAS is associated with decreased survival and increased complications during the transplant hospitalization. Whereas the LAS has improved organ allocation through decreased waiting list deaths and waiting list times, lower survival and higher morbidity among HLAS recipients suggests that continued review of LAS scoring is needed to ensure optimal long-term transplant survival.
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http://dx.doi.org/10.1378/chest.09-0319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2832864PMC
March 2010

Obesity and underweight are associated with an increased risk of death after lung transplantation.

Am J Respir Crit Care Med 2009 Nov 16;180(9):887-95. Epub 2009 Jul 16.

Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.

Rationale: Obesity is considered a relative contraindication to lung transplantation, based on studies that have not accounted for key confounders. Little is known about the risk of death for underweight candidates after transplantation.

Objectives: To examine the associations of pretransplant obesity and underweight with the risk of death after lung transplantation.

Methods: We examined 5,978 adults with cystic fibrosis, chronic obstructive pulmonary disease, and diffuse parenchymal lung disease who underwent lung transplantation in the United States between 1995 and 2003. We used Cox models and generalized additive models to examine the association between pretransplant body mass index and the risk of death after lung transplantation with adjustment for donor and recipient factors.

Measurements And Main Results: The median follow-up time was 4.2 years. Compared with normal weight recipients, the multivariable-adjusted rates of death were 15% higher for underweight recipients (95% confidence interval, 3 to 28%), 15% higher for overweight recipients (95% confidence interval, 6 to 26%), and 22% higher for obese recipients (95% confidence interval, 8 to 39%). These relationships persisted when stratified by diagnosis. The multivariable-adjusted population attributable fraction was 12% at 1 year and 8% at 5 years.

Conclusions: Both obesity and underweight are independent risk factors for death after lung transplantation, contributing to up to 12% of deaths in the first year after transplantation. Primary care providers and pulmonologists should promote a healthy weight for patients with lung disease long before transplantation is considered.
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http://dx.doi.org/10.1164/rccm.200903-0425OCDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2773915PMC
November 2009

Pulmonary lobectomy in a patient with a left ventricular assist device.

Ann Thorac Surg 2009 Jun;87(6):1934-6

Department of Surgery, New York Presbyterian Hospital, Columbia College of Physicians of Surgeons, New York, New York 10032, USA.

Left ventricular assist devices (LVADs) are increasingly being used as both bridge-to-transplantation and destination therapy in patients with severe congestive heart failure. Performing noncardiac surgical procedures in patients with LVADs represents a unique challenge given the anatomic, hemodynamic, and hematologic considerations in these patients. We present the case of a man with an LVAD who successfully underwent right upper lobectomy for a pulmonary nodule. The literature on thoracic surgery procedures in LVAD patients and the intraoperative and postoperative management of these patients are also reviewed.
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http://dx.doi.org/10.1016/j.athoracsur.2008.10.034DOI Listing
June 2009

Low-dose spironolactone: effects on artery-to-artery vein grafts and percutaneous coronary intervention sites.

Am J Ther 2009 May-Jun;16(3):204-14

Department of Cardiothoracic Surgery, Weill Cornell Medical College, Cornell University, New York, NY 10021, USA.

The efficacy of vein grafts used in coronary and peripheral artery bypass is limited by excessive hyperplasia and fibrosis that occur early after engraftment. In the present study, we sought to determine whether low-dose spironolactone alleviates maladaptive vein graft arterialization and alters intimal reaction to coronary artery stenting. Yorkshire pigs were randomized to treatment with oral spironolactone 25 mg daily or placebo. All animals underwent right carotid artery interposition grafting using a segment of external jugular vein and, 5 days later, underwent angiography of carotid and coronary arteries. At that time, a bare metal stent was placed in the left anterior descending artery and balloon angioplasty was performed on the circumflex coronary artery. Repeat carotid and coronary angiograms were performed before euthanasia and graft excision at 30 days. Angiography revealed that venous grafts of spironolactone-treated animals had lumen diameters twice the size of controls at 5 days, a finding that persisted at 30 days. However, neointima and total vessel wall areas also were 2- to 3-fold greater in spironolactone-treated animals, and there were no differences in vessel wall layer thicknesses or collagen and elastin densities. In the coronary circulation, there were no differences between treatment groups in any vessel wall parameters in either stented or unstented vessels. Taken together, these observations suggest that low-dose spironolactone may exert a novel protective effect on remodeling in venous arterial grafts that does not depend on the reduction of hyperplastic changes but may involve dilatation of the vessel wall.
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http://dx.doi.org/10.1097/MJT.0b013e31818bec62DOI Listing
July 2009

Despite decreased wait-list times for lung transplantation, lung allocation scores continue to increase.

Chest 2009 Apr 18;135(4):923-928. Epub 2008 Nov 18.

Division of Cardiothoracic Surgery, Department of Surgery, the Division of Pulmonary, Allergy. Electronic address:

Background: In May 2005, the lung allocation score (LAS) was introduced as a means of allocating donor lungs in order to decrease wait-list mortality and prioritize candidates based on medical urgency and posttransplant survival. The purpose of this study was to assess changes in recipient wait-list times and mean LAS since the introduction of the LAS model.

Methods: The United Network for Organ Sharing provided de-identified patient-level data. The study population consisted of all patients in the United States with a reported LAS (n = 3529) undergoing lung transplantation between May 7, 2005 and November 7, 2007. The study period was divided into 6-month intervals. The Kruskal-Wallis test was used to assess differences in variables with nonparametric distributions. The nonparametric trends test was used to determine significance of trends over time.

Results: There was a significant decrease in wait-list time during the study period, while LAS among transplant recipients increased (p < 0.001). There was no significant change in FVC (49.3 +/- 17.5%, p = 0.48) or pulmonary capillary wedge pressure (11.1 +/- 5.8 mm Hg, p = 0.23); however, there was a significant increase in age (51.5 +/- 13.9 years, p < 0.001) during the study period. When stratified by etiology, the LAS increased for both interstitial pulmonary fibrosis and COPD patients (p < 0.001). Moreover, the overall number of patients listed for transplantation as well as the LAS among transplant candidates increased (p < 0.001).

Conclusions: Two years after initiation of the LAS model, wait-list times continue to decrease while mean LAS continued to increase. This increase in LAS among transplant recipients was observed most notably in patients with interstitial pulmonary fibrosis and COPD, and reflected in an increased mean LAS at the time of listing.
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http://dx.doi.org/10.1378/chest.08-2052DOI Listing
April 2009

Factors influencing DNR decision-making in a surgical ICU.

J Am Coll Surg 2006 Jun;202(6):995-1000

Department of Surgery, Weill Medical College of Cornell University, New York, NY, USA.

Background: End-of-life decisions in the surgical ICU can be complicated by the unique characteristics of perioperative illness and the focus on life-extending interventions. We sought to determine whether illness severity correlated with the presence of DNR order in critically ill surgical patients.

Study Design: All surgical ICU patients who were given a DNR order from May 1, 1991 to May 31, 1998 were identified. Demographic data for all patients were collected prospectively. Patients who died without a DNR order were compared with patients with DNR orders. Variables in the analysis included date of DNR order, age, ICU, and hospital lengths of stay, APACHE II and III scores and maximum multiple organ dysfunction scores, past medical history, and mortality. ANOVA, multivariate ANOVA, and chi-square statistical tests were used to analyze the data, with p
Results: Mortality for DNR patients was 84.7%. Multiple organ dysfunction syndrome was ubiquitous in this group of patients. There were no differences between DNR and no-DNR groups on the basis of age or APACHE III score or multiple organ dysfunction score. ICU lengths of stay were substantially higher in the patients made DNR, 1.8 +/- 0.1 versus 1.0 +/- 0.1, p = 0.0001, and 16.9 +/- 0.2 versus 12.1 +/- 1.2, p = 0.011, respectively. Multivariate ANOVA revealed that only past medical history predicted a DNR order.

Conclusions: Although acuity of illness and organ dysfunction consistently predicted mortality in critically ill patient populations, only elements of the past medical history were positively associated with a DNR order in critically ill surgical patients. Additional prospective studies need to be performed to determine the relative influences of physiologic, demographic, and sociologic factors on the creation of DNR orders in critically ill surgical patients.
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http://dx.doi.org/10.1016/j.jamcollsurg.2006.02.027DOI Listing
June 2006

Comparison of open versus bedside percutaneous dilatational tracheostomy in the cardiothoracic surgical patient: outcomes and financial analysis.

Ann Thorac Surg 2005 Jun;79(6):1879-85

Department of Cardiothoracic Surgery, New York Presbyterian Hospital, Cornell University, New York, New York 10021, USA.

Background: The clinical and financial outcomes of a change in practice from traditional tracheostomy (open) to bedside percutaneous dilatational tracheostomies (PDT) was evaluated in patients who underwent cardiothoracic surgery.

Methods: During 3 years, 86 tracheostomies were performed in more than 4,000 patients who underwent cardiac surgery, 59 open and 27 PDT. A retrospective analysis was performed comparing clinical and financial outcomes of the two groups.

Results: There were no significant differences in demographics, medical histories, operations, or complications between open and PDT except the open group experienced more postoperative arrhythmias (70% [41 of 59] versus 44% [12 of 27], p < 0.05). Total savings associated with 1 year of PDT was $84,000, for a projected discounted savings of $283,000 during the study period. A sensitivity analysis of critical economic variables (number of tracheostomies per year, cost of operating room per minute, cost of intensive care unit bed per day) was included to evaluate the impact on cost savings. The net present value analysis, which discounts future savings by an appropriate interest rate, yielded a range of projected savings of PDT more than 5 years of $73,000 to $541,000 with a best estimate of $304,000 using figures established from our 3-year experience with PDT. Sensitivity analysis of the net present value for each critical variable was $227,000 per day of reduced intensive care unit length of stay, $180,000 per cost of operating room avoidance, $100,000 per intensive care unit bed cost per day, and $11,000 per additional tracheostomy per year.

Conclusions: There were no significant clinical differences between open and PDT in cardiac surgery patients during the 3-year study period; however, PDT offered significant cost savings.
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http://dx.doi.org/10.1016/j.athoracsur.2004.10.042DOI Listing
June 2005

Survival after a documented 19-story fall: a case report.

J Trauma 2003 Nov;55(5):869-72

Department of Surgery, New York-Presbyterian Hospital, Weill Medical College of Cornell University, 525 East 68th Street, New York, NY 10021, USA.

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http://dx.doi.org/10.1097/01.TA.0000075347.57152.B4DOI Listing
November 2003

Resection of a symptomatic pericardial cyst using the computer-enhanced da Vinci Surgical System.

Ann Thorac Surg 2003 Jun;75(6):1953-5

Department of Cardiothoracic Surgery, The New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York 10021, USA.

Traditionally, symptomatic pericardial cysts have been treated with thoracotomy and resection. More recently, video-assisted thoracoscopic procedures for pericardial cysts have been reported. We present the case of a 43-year-old man who was suffering from a symptomatic pericardial cyst. He underwent successful resection using a computer-enhanced robotic surgical system. This case is an example of the continued extension of robotic-assisted thoracic surgery.
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http://dx.doi.org/10.1016/s0003-4975(02)05008-7DOI Listing
June 2003

Outcomes of cardiac surgery in nonagenarians: a 10-year experience.

Ann Thorac Surg 2003 Apr;75(4):1215-20

Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Cornell University Medical College, New York, New York 10021, USA.

Background: With an increasing awareness of health issues and greater emphasis on preventive medicine, the general population is living longer and healthier lives than ever before. Physicians are taking care of older patients, many of whom may require cardiac surgical procedures. Improving cardiopulmonary bypass technology allows for safer procedures with reduced morbidity and mortality even in older patients.

Methods: We have performed a retrospective analysis of 42 consecutive nonagenarian patients who underwent open-heart procedures over a 10-year period (1993 to 2002) at our institution. Their demographic profiles, operative data, perioperative results, and long-term outcomes were recorded and analyzed.

Results: Twenty-two women and 20 men with an age range of 90 to 97 years (mean, 91.4 years) had open-heart surgery over the study period. The complication rate was 67% overall, consisting of 7% respiratory (pneumonia, respiratory failure, reintubation), 7% hemorrhagic or embolic (postoperative bleeding, cerebral vascular accident), 12% infectious (wound infection, sepsis), and 31% new arrhythmia (atrial fibrillation, atrial flutter, ventricular tachycardia, ventricular fibrillation). Despite these complication rates, average hospital stay was 17.5 days (median, 11 days), with an intensive care unit stay of 12.0 days (median, 5 days). Thirty-day survival was 95% and survival to discharge was 93% (three deaths total; one cardiac arrest at hospital day 134 and two perioperative deaths; one ventricular arrhythmia, one cerebral vascular accident). The only statistically significant risk factor of mortality was emergency surgery. Currently, 81% are still alive an average of 2.53 years since surgery (range, 0.16 to 7.1 years).

Conclusions: With improving techniques and greater attention to detail, the select nonagenarian can safely undergo cardiac surgery.
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http://dx.doi.org/10.1016/s0003-4975(02)04666-0DOI Listing
April 2003

Clinical pragmatism: bridging theory and practice.

Kennedy Inst Ethics J 1998 Mar;8(1):37-42

This response to Lynn Jansen's critique of clinical pragmatism concentrates on two themes: (1) contrasting approaches to moral epistemology and (2) the connection between theory and practice in clinical ethics. Particular attention is paid to the status of principles and the role of consensus, with some closing speculations on how Dewey might view the current state of bioethics.
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http://dx.doi.org/10.1353/ken.1998.0001DOI Listing
March 1998

Clinical pragmatism: a method of moral problem solving.

Kennedy Inst Ethics J 1997 Jun;7(2):129-45

This paper presents a method of moral problem solving in clinical practice that is inspired by the philosophy of John Dewey. This method, called "clinical pragmatism," integrates clinical and ethical decision making. Clinical pragmatism focuses on the interpersonal processes of assessment and consensus formation as well as the ethical analysis of relevant moral considerations. The steps in this method are delineated and then illustrated through a detailed case study. The implications of clinical pragmatism for the use of principles in moral problem solving are discussed.
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http://dx.doi.org/10.1353/ken.1997.0013DOI Listing
June 1997
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