Publications by authors named "Robbin G Cohen"

27 Publications

  • Page 1 of 1

Lack of Awareness of Reimbursement and Compensation Models amongst Cardiothoracic Surgery Trainees.

Ann Thorac Surg 2021 Aug 26. Epub 2021 Aug 26.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA; Department of Population and Public Health Sciences, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA. Electronic address:

Background: The objective of this study was to identify trainee knowledge gaps in reimbursement and compensation, determine the perceived importance of understanding these topics, and to explore if the Thoracic Surgery Curriculum needs additional educational material.

Methods: The Thoracic Surgical Residents Association (TSRA) Executive committee selected the research proposal and distributed an anonymous electronic survey to 531 ACGME cardiothoracic surgery trainees. Standard descriptive statistics and regression analyses were performed.

Results: 114 responses were collected (response rate 21.5%). Most trainees understand little or not at all about how attending surgeons are reimbursed (n=74, 69%). Most trainees reported knowing little or nothing about pay-for-performance compensation (n=73, 67%), bundled care (n=82, 75%) or value-based reimbursement (n=84, 77%). Only approximately 20% of trainees were accurate in estimating surgeon reimbursement for three common cardiothoracic surgery procedures to within 20% of the true reimbursement value, while approximately 30% were accurate to within 50% of the true reimbursement value. No respondent characteristics were found to be associated with a more or less accurate reimbursement response. Additionally, 81% of trainees responded that by the conclusion of training, understanding surgeon reimbursement is very important or extremely important (n=87) and 90% of trainees either somewhat agree or strongly agree with including these topics in the Thoracic Surgical Curriculum (n=95).

Conclusions: Despite acknowledging the importance of understanding physician compensation and reimbursement, cardiothoracic surgery trainees do not understand how the current models work. This study exemplifies the need for a succinct curriculum in this domain for trainees nationwide.
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http://dx.doi.org/10.1016/j.athoracsur.2021.07.078DOI Listing
August 2021

Eliminating the Cardiothoracic Surgery Gender Gap: Not there yet.

Authors:
Robbin G Cohen

Ann Thorac Surg 2021 Aug 10. Epub 2021 Aug 10.

Department of Surgery, Keck/USC School of Medicine, Healthcare Consultation Center II, 1520 San Pablo Street #4300, Los Angeles, CA 90033. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2021.06.092DOI Listing
August 2021

Commentary: The Autonomy/Safety Dilemma in Cardiac Surgical Training.

Authors:
Robbin G Cohen

Semin Thorac Cardiovasc Surg 2021 Jun 2. Epub 2021 Jun 2.

Department of Surgery, Division of Cardiothoracic Surgery, Keck/USC School of Medicine, Los Angeles, California. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2021.05.007DOI Listing
June 2021

Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease.

J Card Surg 2021 Aug 28;36(8):2636-2643. Epub 2021 Apr 28.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California, USA.

Background: Debate continues in regard to the optimal surgical approach to the mitral valve for degenerative disease.

Methods: Between February 2004 and July 2015, 363 patients underwent mitral valve repair for degenerative mitral valve disease via either sternotomy (sternotomy, n = 109) or small right anterior thoracotomy (minimally invasive, n = 259). Survival, need for mitral valve reoperation, and progression of mitral regurgitation more than two grades were compared between cohorts using time-based statistical methods and inverse probability weighting.

Results: Survival at 1, 5, and 10 years were 99.2, 98.3, and 96.8 for the sternotomy group and 98.1, 94.9, and 94.9 for the minimally invasive group (hazard ratio: 0.39, 95% confidence interval [CI] 0.11-1.30, p = .14). The cumulative incidence of need for mitral valve reoperation with death as a competing outcome at 1, 3, and 5 years were 2.7%, 2.7%, and 2.7% in the sternotomy cohort and 1.5%, 3.3%, and 4.1% for the minimally invasive group (subhazard ratio (SHR) 1.17, 95% CI: 0.33-4.20, p = .81). Cumulative incidence of progression of mitral regurgitation more than two grades with death as a competing outcome at 1, 3, and 5 years were 5.5%, 14.4%, and 44.5% for the sternotomy cohort and 4.2%, 9.7%, and 20.5% for the minimally invasive cohort (SHR: 0.67, 95% CI: 0.28-1.63, p = .38). Inverse probability weighted time-based analyses based on preoperative cohort assignment also demonstrated equivalent outcomes between surgical approaches.

Conclusions: Minimally invasive and sternotomy mitral valve repair in patients with degenerative mitral valve disease is associated with equivalent survival and repair durability.
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http://dx.doi.org/10.1111/jocs.15586DOI Listing
August 2021

Long-term outcomes with the pulmonary autograft inclusion technique in adults with bicuspid aortic valves undergoing the Ross procedure.

J Thorac Cardiovasc Surg 2021 Feb 4. Epub 2021 Feb 4.

Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif; Department of Preventive Medicine, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif. Electronic address:

Objective: To compare outcomes with wrapped (pulmonary autograft inclusion) versus unwrapped techniques in adults with bicuspid aortic valves undergoing the Ross procedure.

Methods: Between 1992 and 2019, 129 adults with bicuspid aortic valves (aged ≥18 years) underwent the Ross procedure by a single surgeon. Patients were divided into those without autograft inclusion (unwrapped, n = 71) and those with autograft inclusion (wrapped, n = 58). Median follow-up was 10.3 years (interquartile range, 3.0-16.8 years). Need for autograft reintervention was analyzed using competing risks.

Results: Pre- and intraoperative characteristics as well as 30-day morbidity or mortality did not differ between cohorts. Survival at 1, 5, and 10 years, respectively, was 97.2%, 97.2%, and 95.6% in the unwrapped cohort and 100%, 100%, and 100% in the wrapped cohort (P = .15). Autograft valve failure occurred in 25 (35.2%) of the unwrapped and 3 (5.2%) of the wrapped patients. Competing risks analysis demonstrated the wrapped cohort to have a lower need for autograft reintervention (subhazard ratio, 0.28, 95% confidence interval, 0.08-0.91; P = .035). The cumulative incidence of autograft reintervention (death as a competing outcome) at 1, 5, and 10 years, respectively, was 10.2%, 14.9%, and 26.8% in the unwrapped cohort and 4.0%, 4.0%, and 4.0% in the wrapped cohort.

Conclusions: In adults with bicuspid aortic valves, the Ross procedure with pulmonary autograft inclusion stabilizes the aortic root preventing dilatation and reduces the need for reoperation. The autograft inclusion technique allows the Ross procedure to be performed in this population with excellent long-term outcomes.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.101DOI Listing
February 2021

No Informed Consent/No Mitral Valve Surgery.

Ann Thorac Surg 2019 12;108(6):1607

Huntington Hospital, Pasadena, California.

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http://dx.doi.org/10.1016/j.athoracsur.2019.08.011DOI Listing
December 2019

The Disparity Between Public Utilization and Surgeon Awareness of the STS Patient Education Website.

Ann Thorac Surg 2020 07 19;110(1):284-289. Epub 2019 Nov 19.

Society for Thoracic Surgeons Media Office, Chicago, Illinois.

Background: Many online resources currently provide healthcare information to the public. In 2015, the Society of Thoracic Surgeons (STS) created a multimedia web portal (ctsurgerypatients.org) to educate the public regarding cardiothoracic surgery and provide an informative tool to which cardiothoracic surgeons could refer patients.

Methods: A patient education task force was created, and disease-specific content was created for 25 pathological conditions. After launching the website online, a marketing campaign was initiated to make STS members aware of its availability. Website visits were monitored, and an online survey for public users was created. An email survey was sent to STS members to evaluate awareness and content. Surveys were analyzed for effectiveness and utilization by both public users and STS member surgeons.

Results: From 2016 to 2018, the website had more than 1 million visits, with visits increasing yearly. Surveyed user ratings of the website were positive regarding quality and utility of the information provided. STS member response was poor (379 responses of 6347 emails), and 78.3% of responders were unaware of the website. Surgeon responders were positive about the content, though many still refrain from referring patients.

Conclusions: Online education for cardiothoracic surgery is seeing increased public use, with high ratings for content and utility. Despite aggressive marketing to STS members, most remain unaware of this website's existence. Those who are aware approve of its content, but adoption of referring patients to it has been slow. Improved strategies are necessary to make surgeons aware of this STS-provided service and increase patient referrals to it.
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http://dx.doi.org/10.1016/j.athoracsur.2019.09.074DOI Listing
July 2020

Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection.

Ann Thorac Surg 2018 Feb 3;105(2):505-512. Epub 2017 Nov 3.

Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California. Electronic address:

Background: Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair.

Methods: Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality.

Results: Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p < 0.01).

Conclusions: A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.
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http://dx.doi.org/10.1016/j.athoracsur.2017.07.016DOI Listing
February 2018

When a Patient Dies: How I Teach It.

Ann Thorac Surg 2017 Oct;104(4):1108-1110

University of Southern California Keck School of Medicine, Los Angeles, California.

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http://dx.doi.org/10.1016/j.athoracsur.2017.06.008DOI Listing
October 2017

Early trifecta valve failure: Warning shot or unfair scrutiny?

Authors:
Robbin G Cohen

J Thorac Cardiovasc Surg 2017 10 21;154(4):1241-1242. Epub 2017 Jun 21.

Department of Surgery, Keck/USC School of Medicine, Los Angeles, Calif. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2017.06.033DOI Listing
October 2017

Acute Type A Aortic Dissection.

Cardiol Clin 2017 Aug 26;35(3):331-345. Epub 2017 May 26.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033, USA. Electronic address:

Type A aortic dissection is a surgical emergency occurring when an intimal tear in the aorta creates a false lumen in the ascending aorta. Prompt diagnosis and surgical treatment are imperative to optimize outcomes. Surgical repair requires replacement of the ascending aorta with or without aortic root or aortic arch replacement. Surgical outcomes for this highly lethal diagnosis have improved, with contemporary survival to discharge at Centers of Excellence of 85% to 90%. Survival is related to prompt treatment, preexisting medical comorbidities, presence or absence of end organ malperfusion, extent of aortic repair required, and the development of postoperative complications.
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http://dx.doi.org/10.1016/j.ccl.2017.03.004DOI Listing
August 2017

Surgery for Diseases of the Aortic Root.

Cardiol Clin 2017 Aug 26;35(3):321-329. Epub 2017 May 26.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, 1520 San Pablo Street, HCC II, Suite 4300, Los Angeles, CA 90033, USA.

The aortic root is the junction between the heart and aorta, containing the aortic valve and the coronary artery ostia. Various pathologic conditions arise in this region requiring complex surgical correction. These include aneurysmal dilatation with and without aortic regurgitation, acute aortic dissection extending below the sinotubular junction, and infective endocarditis with valve and periannular destruction. Multiple strategies for correction of these complex surgical issues exist, with excellent early results and long-term survival.
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http://dx.doi.org/10.1016/j.ccl.2017.03.002DOI Listing
August 2017

Outcomes after mitral valve repair: A single-center 16-year experience.

J Thorac Cardiovasc Surg 2017 09 9;154(3):822-830.e2. Epub 2017 Feb 9.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.

Objective: To evaluate outcomes after mitral valve repair.

Methods: Between May 1999 and June 2015, 446 patients underwent mitral valve repair. Isolated mitral valve annuloplasty was excluded. A total of 398 (89%) had degenerative valve disease. Mean follow-up was 5.5 ± 3.8 years. Postoperative echocardiograms were obtained in 334 patients (75%) at a mean of 24.3 ± 13.7 months.

Results: Survival was 97%, 96%, 95%, and 94% at 1, 3, 5, and 10 years. Risk factor analysis showed age >60 years and nondegenerative etiology predict death (hazard ratio, 2.91; 95% confidence interval, 1.06-8.02, P = .038; and hazard ratio, 1.87; 95% confidence interval, 1.16-3.02, P = .010, respectively). Considering competing risks due to mortality, the cumulative incidence of reoperation was 2.8%, 4.2%, 5.1%, and 9.6% at 1, 3, 5, and 10 years. Competing risk proportional hazard survival regression identified nondegenerative etiology and previous cardiac surgery as predictors of reoperation, and posterior repair was protective (all P < .05). Cumulative incidence of progression of mitral regurgitation (2 or more grades) with mortality as a competing risk was 4.7%, 10.5%, 21.0%, and 35.8% at 1, 3, 5, and 10 years. Patients with previous sternotomy, repair or coronary artery bypass grafting, and concurrent tricuspid valve procedure or isolated anterior leaflet repair were more likely to develop progression of mitral regurgitation (all P < .05), and posterior leaflet repair was protective (P = .038). On multivariate analysis diabetes, previous coronary artery bypass grafting and concurrent tricuspid valve intervention predicted MR progression.

Conclusions: Mitral valve repair has excellent outcomes. Our results demonstrate failures appear to occur less in those who undergo posterior leaflet repair.
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http://dx.doi.org/10.1016/j.jtcvs.2017.01.047DOI Listing
September 2017

Evaluation of Hemodynamic Performance of Aortic Valve Bioprostheses in a Model of Oversizing.

Ann Thorac Surg 2017 Jun 26;103(6):1866-1876. Epub 2017 Jan 26.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California. Electronic address:

Background: The risk of patient-prosthesis mismatch drives most surgeons to select the largest bioprosthesis possible during aortic valve replacement, but interactions between the native aortic annulus and valve prosthesis remain poorly defined. We examined the hemodynamic and functional consequences of oversizing contemporary bioprostheses in an in vitro model.

Methods: Three sizes each (21, 23, and 25 mm) of 5 aortic bioprostheses (Magna, Edwards Lifesciences, Irvine, CA; Trifecta and Epic, St. Jude, St. Paul, MN; and Mosaic and Hancock II, Medtronic, Minneapolis, MN) were tested on a mock annulus in a pulsatile aortic simulator. After the annulus was sized to match each valve, the annulus was decreased by 3 mm and then by 6 mm to simulate oversizing. We measured the effective orifice area and the mean pressure gradient. Changes in prosthetic leaflet behavior and geometric orifice area were assessed with slow-motion video. Statistical analysis used mixed-effects models for repeated-measures data, allowing comparison within and between groups.

Results: For each valve model and size, oversizing resulted in decreased effective orifice areas and geometric orifice areas and increased pressure gradients. This was more pronounced with smaller valve sizes and higher flow rates but varied between valve types. Slow-motion imaging revealed this change in geometric orifice area was a result of an inward shift of the valve leaflet hinge point.

Conclusions: Bioprosthetic oversizing impairs hemodynamic performance of aortic valve bioprostheses. The magnitude of this effect varies by valve model and size. Clinically, these data suggest that during aortic valve replacement, placing a valve whose internal orifice closely matches the aortic annulus will provide the optimal hemodynamic performance.
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http://dx.doi.org/10.1016/j.athoracsur.2016.10.019DOI Listing
June 2017

Type A Aortic Dissection Repair: How I Teach It.

Ann Thorac Surg 2017 Jan;103(1):14-17

Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1016/j.athoracsur.2016.10.048DOI Listing
January 2017

Value in cardiac surgery: The price of saving.

Authors:
Robbin G Cohen

J Thorac Cardiovasc Surg 2017 07 16;154(1):199. Epub 2016 Nov 16.

Division of Cardiothoracic Surgery, Department of Surgery, Keck/University of Southern California School of Medicine, Los Angeles, Calif. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2016.11.004DOI Listing
July 2017

The patent internal thoracic artery graft: Increased degree of difficulty for left-sided pulmonary resections.

Authors:
Robbin G Cohen

J Thorac Cardiovasc Surg 2015 Sep 30;150(3):536-7. Epub 2015 Jun 30.

Department of Surgery, Keck/USC School of Medicine, Healthcare Consultation Center II, Los Angeles, Calif. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2015.06.033DOI Listing
September 2015

A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients.

Eur J Cardiothorac Surg 2016 Feb 6;49(2):456-63. Epub 2015 Mar 6.

Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.

Objectives: Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy.

Methods: Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed.

Results: Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups.

Conclusion: Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted.
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http://dx.doi.org/10.1093/ejcts/ezv038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711701PMC
February 2016

Exercise Hemodynamics and Quality of Life after Aortic Valve Replacement for Aortic Stenosis in the Elderly Using the Hancock II Bioprosthesis.

Cardiol Res Pract 2014 2;2014:151282. Epub 2014 Dec 2.

Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA ; USC Healthcare Consultation Center II, 1520 San Pablo Street, Suite 4300, Los Angeles, CA 90033, USA.

Background and Aim. While aortic valve replacement for aortic stenosis can be performed safely in elderly patients, there is a need for hemodynamic and quality of life evaluation to determine the value of aortic valve replacement in older patients who may have age-related activity limitation. Materials and Methods. We conducted a prospective evaluation of patients who underwent aortic valve replacement for aortic stenosis with the Hancock II porcine bioprosthesis. All patients underwent transthoracic echocardiography (TTE) and completed the RAND 36-Item Health Survey (SF-36) preoperatively and six months postoperatively. Results. From 2004 to 2007, 33 patients were enrolled with an average age of 75.3 ± 5.3 years (24 men and 9 women). Preoperatively, 27/33 (82%) were New York Heart Association (NYHA) Functional Classification 3, and postoperatively 27/33 (82%) were NYHA Functional Classification 1. Patients had a mean predicted maximum V O2 (mL/kg/min) of 19.5 ± 4.3 and an actual max V O2 of 15.5 ± 3.9, which was 80% of the predicted V O2 . Patients were found to have significant improvements (P ≤ 0.01) in six of the nine SF-36 health parameters. Conclusions. In our sample of elderly patients with aortic stenosis, replacing the aortic valve with a Hancock II bioprosthesis resulted in improved hemodynamics and quality of life.
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http://dx.doi.org/10.1155/2014/151282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4269201PMC
December 2014

Percutaneous versus surgical drainage of malignant pericardial effusion: Still no tiebreaker.

Authors:
Robbin G Cohen

J Thorac Cardiovasc Surg 2014 Nov 19;148(5):2294-5. Epub 2014 Sep 19.

Division of Cardiothoracic Surgery, USC/Keck School of Medicine, Los Angeles, Calif. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2014.09.033DOI Listing
November 2014

Occult metastases in lymph nodes predict survival in resectable non-small-cell lung cancer: report of the ACOSOG Z0040 trial.

J Clin Oncol 2011 Nov 11;29(32):4313-9. Epub 2011 Oct 11.

Thoracic Surgery Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY 10065, USA.

Purpose: The survival of patients with non-small-cell lung cancer (NSCLC), even when resectable, remains poor. Several small studies suggest that occult metastases (OMs) in pleura, bone marrow (BM), or lymph nodes (LNs) are present in early-stage NSCLC and are associated with a poor outcome. We investigated the prevalence of OMs in resectable NSCLC and their relationship with survival.

Patients And Methods: Eligible patients had previously untreated, potentially resectable NSCLC. Saline lavage of the pleural space, performed before and after pulmonary resection, was examined cytologically. Rib BM and all histologically negative LNs (N0) were examined for OM, diagnosed by cytokeratin immunohistochemistry (IHC). Survival probabilities were estimated using the Kaplan-Meier method. The log-rank test and Cox proportional hazards regression model were used to compare survival of groups of patients. P < .05 was considered significant.

Results: From July 1999 to March 2004, 1,047 eligible patients (538 men and 509 women; median age, 67.2 years) were entered onto the study, of whom 50% had adenocarcinoma and 66% had stage I NSCLC. Pleural lavage was cytologically positive in only 29 patients. OMs were identified in 66 (8.0%) of 821 BM specimens and 130 (22.4%) of 580 LN specimens. In univariate and multivariable analyses OMs in LN but not BM were associated with significantly worse disease-free survival (hazard ratio [HR], 1.50; P = .031) and overall survival (HR, 1.58; P = .009).

Conclusion: In early-stage NSCLC, LN OMs detected by IHC identify patients with a worse prognosis. Future clinical trials should test the role of IHC in identifying patients for adjuvant therapy.
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http://dx.doi.org/10.1200/JCO.2011.35.2500DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3221530PMC
November 2011

Our "default future".

Authors:
Robbin G Cohen

J Thorac Cardiovasc Surg 2011 Nov 14;142(5):961-6. Epub 2011 Sep 14.

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http://dx.doi.org/10.1016/j.jtcvs.2011.07.062DOI Listing
November 2011

Arch and visceral/renal debranching combined with endovascular repair for thoracic and thoracoabdominal aortic aneurysms.

J Vasc Surg 2011 Jul 21;54(1):30-40; discussion 40-1. Epub 2011 Feb 21.

Aortic Center, Cardio-Vascular Thoracic Institute, University of Southern California, Los Angeles, Calif., USA.

Objective: We report a single-center experience using the hybrid procedure, consisting of open debranching, followed by endovascular aortic repair, for treatment of arch/proximal descending thoracic/thoracoabdominal aortic aneurysms (TAAA).

Methods: From 2005 to 2010, 51 patients (33 men; mean age, 70 years) underwent a hybrid procedure for arch/proximal descending thoracic/TAAA. The 30-day and in-hospital morbidity and mortality rates, and late endoleak, graft patency, and survival were analyzed. Graft patency was assessed by computed tomography, angiography, or duplex ultrasound imaging.

Results: Hybrid procedures were used to treat 27 thoracic (16 arch, 11 proximal descending thoracic) and 24 TAAA (Crawford/Safi types I to III: 3; type IV: 12; type V: 9). The hybrid procedure involved debranching 47 arch vessels or 77 visceral/renal vessels using bypass grafts, followed by endovascular repair. Seventy-five percent of debranching and endovascular repair procedures were staged, with an average interval of 28 days. Major 30-day and in-hospital complications occurred in 39% of patients and included bypass graft occlusion in four, endoleak reintervention in two, and paraplegia in one. Mortality was 3.9%. During a mean follow-up of 13 months, three additional type II endoleaks required intervention, and one bypass graft occluded. No aneurysm rupture occurred during follow-up. Primary bypass graft patency was 95.3%. Actuarial survival was 86% at 1 year and 67% at 3 years.

Conclusion: The hybrid procedure is associated with acceptable rates of mortality and paraplegia when used for treatment of arch/proximal descending thoracic/TAAA. These results support this procedure as a reasonable approach to a difficult surgical problem; however, longer follow-up is required to appraise its ultimate clinical utility.
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http://dx.doi.org/10.1016/j.jvs.2010.12.033DOI Listing
July 2011

Thoracic aortic stent-grafting for acute, complicated, type B aortic dissections.

Ann Vasc Surg 2011 Apr 28;25(3):333-9. Epub 2011 Jan 28.

Aortic Center, Cardio-Vascular Thoracic Institute, The University of Southern California, Department of Surgery, 1520 S. San Pablo St., Los Angeles, CA 90033, USA.

Background: To report a single-center experience of aortic stent-grafting for the treatment of acute, complicated, type B aortic dissections.

Methods: A retrospective review was conducted of the data obtained from all patients who underwent endovascular stent-grafting for acute, type B aortic dissection between 2006 and 2009. The primary and secondary endpoints were 30-day mortality and morbidity rates, respectively.

Results: In all, 104 thoracic endovascular aortic aneurysm repairs were performed during the study period. Nine (8.6%) patients (six men; mean age: 65 years) underwent thoracic endovascular aortic aneurysm repair for acute, complicated, type B aortic dissections. Seven (78%) patients had uncontrolled hypertension on presentation. Visceral branch vessel involvement of the dissection was limited to the celiac axis origin in one patient with no evidence of visceral malperfusion. The indication for repair was aortic rupture in five patients, renal malperfusion in two, and persistent pain in the remaining two. Average time taken from presentation to surgery was 5.5 days. Two patients presenting with aortic ruptures had retrograde extension of the dissection that required replacement of the aortic valve and ascending aorta. The mean length of thoracic aorta covered was 21 cm. Complete coverage of the left subclavian artery was required in three patients and partial coverage in two. On completion angiogram, two type I endoleaks were detected, one of which was resolved by postoperative day 5. The 30-day mortality rate was 22%. One mortality was secondary to aortic rupture. The other mortality was due to multiorgan system failure. Seven patients (78%) had one or more major complications. There were no strokes or paraplegia.

Conclusion: The association of morbidity and mortality with endovascular stent-grafting for acute, complicated, type B aortic dissections is significant, which most likely reflects the lethal nature of the disease. The precise role of endovascular treatment in these patients remains to be defined.
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http://dx.doi.org/10.1016/j.avsg.2010.09.017DOI Listing
April 2011

Pleural space problems after living lobar transplantation.

J Heart Lung Transplant 2005 Dec 28;24(12):2086-90. Epub 2005 Sep 28.

Department of Cardiothoracic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California 90003, USA.

Background: We reviewed our experience with adult living lobar lung transplant (LL) recipients to assess whether size and shape mismatch of the donor organ to the recipient pre-disposes to the development of pleural space problems (PSP).

Methods: Eighty-seven LL were performed on 84 adult recipients from 1993 through 2003. Seventy-six patients had cystic fibrosis. Patient records were examined for PSP, defined as air leak or bronchopleural fistula for more than 7 days; pneumothorax, loculated pleural effusions, or empyema in 68 patients for which complete data were available.

Results: There were 24 PSP identified for an overall incidence of 35%. The most common PSP was air leak/bronchopleural fistula, accounting for 38% of PSP. The second most common PSP was loculated pleural effusion (21% of PSP). Empyema was uncommon (2 patients, 3% of total patients) in our series of patients despite the large population of cystic fibrosis patients. In 4 of these patients, computed tomography-guided drainage was used for loculated effusions after chest tube removal. Three LL patients underwent surgery for persistent air leak and required muscle flap repair. One of these required subsequent omental transfer. Two LL patients required decortication for empyema. Many patients with PSP could be managed without further surgical intervention (14/24 patients). Donor-recipient height mismatch was not significantly different between PSP and non-PSP patients (p = 0.53).

Conclusions: The incidence of PSP in LL recipients is similar to that reported in the literature on cadaveric transplant recipients. The relatively small lobe in the potentially contaminated chest cavity of cystic fibrosis recipients does not significantly pre-dispose to development of empyema despite immunosuppression. Many PSP can be managed non-operatively, although early aggressive intervention for large air leaks and judicious chest tube management are essential for a good outcome.
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http://dx.doi.org/10.1016/j.healun.2005.06.013DOI Listing
December 2005

A decade of living lobar lung transplantation: recipient outcomes.

J Thorac Cardiovasc Surg 2004 Jan;127(1):114-22

University of Southern California Keck School of Medicine and Childrens Hospital Los Angeles, 90033, USA.

Objective: Living lobar lung transplantation was developed as a procedure for patients considered too ill to await cadaveric transplantation.

Methods: One hundred twenty-eight living lobar lung transplantations were performed in 123 patients between 1993 and 2003. Eighty-four patients were adults (age, 27 +/- 7.7 years), and 39 were pediatric patients (age, 13.9 +/- 2.9 years).

Results: The primary indication for transplantation was cystic fibrosis (84%). At the time of transplantation, 67.5% of patients were hospitalized, and 17.9% were intubated. One-, 3-, and 5-year actuarial survival among living lobar recipients was 70%, 54%, and 45%, respectively. There was no difference in actuarial survival between adult and pediatric living lobar recipients (P =.65). There were 63 deaths among living lobar recipients, with infection being the predominant cause (53.4%), followed by obliterative bronchiolitis (12.7%) and primary graft dysfunction (7.9%). The overall incidence of acute rejection was 0.8 episodes per patient. Seventy-eight percent of rejection episodes were unilateral. Age, sex, indication, donor relationship, preoperative hospitalization status, use of preoperative steroids, and HLA-A, HLA-B, and HLA-DR typing did not influence survival. However, patients on ventilators preoperatively had significantly worse outcomes (odds ratio, 3.06, P =.03; Kaplan-Meier P =.002), and those undergoing retransplantation had an increased risk of death (odds ratio, 2.50).

Conclusion: These results support the continued use of living lobar lung transplantation in patients deemed unable to await a cadaveric transplantation. We consider patients undergoing retransplantations and intubated patients to be at significantly high risk because of the poor outcomes in these populations.
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http://dx.doi.org/10.1016/j.jtcvs.2003.07.042DOI Listing
January 2004
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