Publications by authors named "Robert B Hawkins"

134 Publications

Commentary: The debate continues on optimal myocardial recovery assessment.

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

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.02.051DOI Listing
February 2021

Socioeconomic risk-adjustment with the Area Deprivation Index predicts surgical morbidity and cost.

Surgery 2021 Mar 12. Epub 2021 Mar 12.

Department of Surgery, University of Virginia Health, Charlottesville, VA. Electronic address:

Background: There is a strong association between socioeconomic status and surgical outcomes; however, the optimal method for socioeconomic risk-stratification remains elusive. We aimed to compare 2 metrics of socioeconomic ranking by ZIP code, the Distressed Communities Index, and the Area Deprivation Index and their association with surgical outcomes.

Methods: This retrospective study included all general surgery cases performed at a single institution from 2005 to 2015. Each patient was assigned Distressed Communities Index and Area Deprivation Index scores based on ZIP code. Both indices are normalized composite measures of socioeconomic status derived from census data. Primary outcome was 30-day morbidity; secondary outcomes included long-term mortality and cost, stratified by socioeconomic status. The utility of the addition of each metric to the American College of Surgeons National Surgical Quality Improvement Program risk calculator was assessed.

Results: The 9,843 patients had normally distributed Distressed Communities Index (47.3 ± 22.4) and Area Deprivation Index (35.4 ± 19.0). Patients who experienced any complication or readmission had significantly higher Distressed Communities Index (48.6 vs 47.1, P = .04) and Area Deprivation Index (37.2 vs 35.1, P = .002). Risk-adjusted models demonstrated that only Area Deprivation Index independently predicted postoperative complications (odds ratio 1.11, P = .02), improved the discrimination of risk-stratification when added to the American College of Surgeons National Surgical Quality Improvement Program risk calculator (area under curve 0.758-0.790, P = .02), and was associated with hospitalization cost ($1,811 ± 856/quartile, P = .03).

Conclusion: Area Deprivation Index provides improved socioeconomic risk-adjustment in this surgical population. The addition of Area Deprivation Index to risk-stratification tools would allow us to better inform our patients of their expected postoperative courses, more accurately account for the increased cost of providing their care, and identify patients and regions that are most in need of improvements in health and healthcare.
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http://dx.doi.org/10.1016/j.surg.2021.02.016DOI Listing
March 2021

Aortic Root Enlargement - Defining Risk and Reward.

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

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

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http://dx.doi.org/10.1016/j.athoracsur.2021.03.005DOI Listing
March 2021

Longitudinal analysis of National Institutes of Health funding for academic thoracic surgeons.

J Thorac Cardiovasc Surg 2021 Feb 3. Epub 2021 Feb 3.

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

Objective: National Institutes of Health (NIH) funding for academic (noncardiac) thoracic surgeons at the top-140 NIH-funded institutes in the United States was assessed. We hypothesized that thoracic surgeons have difficulty in obtaining NIH funding in a difficult funding climate.

Methods: The top-140 NIH-funded institutes' faculty pages were searched for noncardiac thoracic surgeons. Surgeon data, including gender, academic rank, and postfellowship training were recorded. These surgeons were then queried in NIH Research Portfolio Online Reporting Tools Expenditures and Results for their funding history. Analysis of the resulting grants (1980-2019) included grant type, funding amount, project start/end dates, publications, and a citation-based Grant Impact Metric to evaluate productivity.

Results: A total of 395 general thoracic surgeons were evaluated with 63 (16%) receiving NIH funding. These 63 surgeons received 136 grants totaling $228 million, resulting in 1772 publications, and generating more than 50,000 citations. Thoracic surgeons have obtained NIH funding at an increasing rate (1980-2019); however, they have a low percentage of R01 renewal (17.3%). NIH-funded thoracic surgeons were more likely to have a higher professorship level. Thoracic surgeons perform similarly to other physician-scientists in converting K-Awards into R01 funding.

Conclusions: Contrary to our hypothesis, thoracic surgeons have received more NIH funding over time. Thoracic surgeons are able to fill the roles of modern surgeon-scientists by obtaining NIH funding during an era of increasing clinical demands. The NIH should continue to support this mission.
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http://dx.doi.org/10.1016/j.jtcvs.2021.01.088DOI Listing
February 2021

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

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

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

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

Commentary: Building bridges to the future of heart transplantation.

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

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

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

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

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

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.01.077DOI Listing
January 2021

Lung Transplantation for Severe Post-Coronavirus Disease 2019 Respiratory Failure.

Transplantation 2021 Feb 16. Epub 2021 Feb 16.

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, VA.

Background: The COVID-19 pandemic has resulted in more than 72 million cases and 1.6 million deaths. End-stage lung disease from COVID-19 is a new and growing entity that may benefit from lung transplant, however there is limited data on the patient selection, perioperative management and expected outcomes of transplantation for this indication.

Methods: A systematic review of the literature was performed with searches of MEDLINE and Web of Science databases as well the gray literature. All manuscripts, editorials, commentaries and gray literature reports of lung transplantation for COVID related respiratory failure were included. A case from the University of Virginia is described and included in the review.

Results: A total of 27 studies were included; 11 manuscripts, 5 commentaries, and 11 gray literature reports. The total number of transplantations for COVID related lung disease was 21. The mean age was 55 ± 12 years, 16 (76%) were male, and the acuity was high with 85% on extracorporeal membrane oxygenation preoperatively. There was a 95% early survival rate, with one additional late death. There is growing histopathologic evidence for permanent structural damage with no replicating virus at the time of transplantation.

Conclusions: Bilateral lung transplantation is an effective treatment option with reasonable short-term outcomes for patients suffering from end-stage lung failure secondary to COVID-19. However, specific considerations in this new population require a multidisciplinary approach. As we move into the second wave of the COVID-19 global pandemic, lung transplantation will likely have a growing role in management of these complex patients.
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http://dx.doi.org/10.1097/TP.0000000000003706DOI Listing
February 2021

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

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

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.01.054DOI Listing
January 2021

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

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

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

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

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

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

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

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

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

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

Conclusions: These data suggest annular enlargement during SAVR is associated with increased short-term risk in a Medicare population. Survival curves crossed after three years, which may portend a benefit in select patients. However, annular enlargement is still only done in the minority of patients who are at risk for PPM.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.023DOI Listing
January 2021

Conversion of HVAD Left Ventricular Assist Device to Centrimag Using Customized Apical Plug.

Ann Thorac Surg 2020 Dec 17. Epub 2020 Dec 17.

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

Left ventricular assist device (LVAD) thrombosis is a potentially life-threatening complication often managed acutely with device exchange. In the absence of modifiable risk factors, recurrent thrombosis can occur. Recent changes in the heart allocation policy have reduced LVAD complications from top priority to Status 3. In this report, we present a patient with recurrent LVAD thrombosis. Given no modifiable risk factors and recurrence of thrombosis, the HeartWare HVAD was converted to a temporary Centrimag device using a novel plug through the existing sewing ring. With status 2 listing, she was successfully transplanted on postoperative day 3.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.067DOI Listing
December 2020

Commentary: Transplanting lungs during a global respiratory pandemic.

J Thorac Cardiovasc Surg 2020 Nov 23. Epub 2020 Nov 23.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.11.071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831649PMC
November 2020

Effect of Cardiac Surgery on One-Year Patient-Reported Outcomes: A Prospective Cohort Study.

Ann Thorac Surg 2020 Dec 9. Epub 2020 Dec 9.

Department of Surgery, Washington University School of Medicine, St. Louis, MO. Electronic address:

Background: Current cardiac surgery risk algorithms and quality measures focus on perioperative outcomes. However, delivering high-value, patient-centered cardiac care will require a better understanding of long-term patient-reported quality of life after surgery. Our objective was to prospectively assess the effect of cardiac surgery on long-term patient-reported outcomes.

Methods: Patients undergoing cardiac surgery at an academic medical center (2016-2017) were eligible for enrollment. Patient-reported outcomes were measured using the NIH Patient-Reported Outcomes Measurement Information System (PROMIS) preoperatively and one year postoperatively across five domains: mental health, physical health, physical functioning, social satisfaction, and applied cognition. Baseline data and perioperative outcomes were obtained from the Society of Thoracic Surgeons database. The effect of cardiac surgery on long-term patient-reported quality of life was assessed.

Results: Ninety-eight patients were enrolled and underwent cardiac surgery, with 92.9% (91/98) successful follow-up. The most common operation was CABG (63.3% [62/98]), with 60.2% (59/98) undergoing an elective operation. One-year all-cause mortality was 5.1% (5/98). Rate of major morbidity was 11.2% (11/98). Cardiac surgery significantly improved patient-reported outcomes at one year across four domains: mental health (Preop: 47.3±7.7 vs. Postop: 51.1±8.9, p=0.0004), physical health (41.2±8.2 vs. 46.3±9.3, p=0.0003), physical functioning (39.8±8.6 vs. 44.8±8.5, p<0.0001), and social satisfaction (46.8±10.9 vs. 50.7±10.8, p=0.023). Hospital discharge to a facility did not impact one-year patient-reported outcomes.

Conclusions: Cardiac surgery improves long-term patient-reported quality of life. Mental, physical, and social well-being scores were significantly higher one year postoperatively. Data collection with NIH PROMIS provides meaningful, quantifiable results that may improve delivery of patient-centered care.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.061DOI Listing
December 2020

Early Versus Delayed Pacemaker for Heart Block After Valve Surgery: A Cost-Effectiveness Analysis.

J Surg Res 2021 Mar 3;259:154-162. Epub 2020 Dec 3.

Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia.

Background: A significant percentage of patients who acutely develop high-grade atrioventricular block after valve surgery will ultimately recover, yet the ability to predict recovery is limited. The purpose of this analysis was to evaluate the cost-effectiveness of two different management strategies for the timing of permanent pacemaker implantation for new heart block after valve surgery.

Methods: A cost-effectiveness model was developed using costs and probabilities of short- and long-term complications of pacemaker placement, short-term atrioventricular node recovery, intensive care unit stays, and long-term follow-up. We aggregated the total expected cost and utility of each option over a 20-y period. Quality-adjusted survival with a pacemaker was estimated from the literature and institutional patient-reported outcomes. Primary decision analysis was based on an expected recovery rate of 36.7% at 12 d with timing of pacemaker implantation: early placement (5 d) versus watchful waiting for 12 d.

Results: A strategy of watchful waiting was more costly ($171,798 ± $45,695 versus $165,436 ± $52,923; P < 0.0001) but had a higher utility (9.05 ± 1.36 versus 8.55 ± 1.33 quality-adjusted life years; P < 0.0001) than an early pacemaker implantation strategy. The incremental cost-effectiveness ratio of watchful waiting was $12,724 per quality-adjusted life year. The results are sensitive to differences in quality-adjusted survival and rates of recovery of atrioventricular node function.

Conclusions: Watchful waiting for pacemaker insertion is a cost-effective management strategy compared with early placement for acute atrioventricular block after valve surgery. Although this is cost-effective from a population perspective, clinical risk scores predicting recovery will aid in personalized decision-making.
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http://dx.doi.org/10.1016/j.jss.2020.11.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897291PMC
March 2021

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

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

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

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

Outcomes of surgical mitral valve replacement: A benchmark to assess transcatheter technologies.

J Card Surg 2021 Jan 1;36(1):69-73. Epub 2020 Nov 1.

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

Background: Clinical trials are underway to evaluate the safety and efficacy of transcatheter mitral valve replacement in intermediate and high surgical risk patients. We analyzed outcomes of surgical mitral valve replacement in a regional consortium to provide benchmark data for emerging alternative therapies.

Methods: All patients undergoing mitral replacement with a Society of Thoracic Surgeons predicted risk of mortality (STS PROM) in a regional consortium from 2001 to 2017 were analyzed. Patients with endocarditis were excluded. Patients were stratified by STS PROM into low (<4%), moderate (4%-8%), and high risk (>8%) cohorts. Mortality, postoperative complications, and resource utilization were evaluated for each group.

Results: A total of 1611 patients were analyzed including 927 (58%) low, 370 (23%) moderate, and 314 (20%) high-risk patients. The mean STS PROM was 2%, 5.6%, and 15.4% for each group. Mortality was adequately predicted for all groups while the most common complications included prolonged ventilation, reoperation, and renal failure. Higher risk patients had longer intensive care unit and hospital lengths of stay (2 vs. 3 vs. 5 days, p < .0001 and 7 vs. 8 vs. 10 days, p < .0001) and higher total hospital costs ($38,029 vs. $45,075 vs. $59,171 p < .0001).

Conclusions: Mitral valve replacement is associated with acceptable morbidity and mortality, particularly for low and intermediate-risk patients. These outcomes also serve as a benchmark with which to compare forthcoming results of transcatheter mitral valve replacement trials.
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http://dx.doi.org/10.1111/jocs.15157DOI Listing
January 2021

Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery.

Am Surg 2020 Oct 29:3134820950685. Epub 2020 Oct 29.

2358 Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Virginia, USA.

Background: Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery.

Methods: All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs.

Results: A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL ( < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%.

Conclusion: Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.
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http://dx.doi.org/10.1177/0003134820950685DOI Listing
October 2020

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

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

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

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

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

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

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

Minimally Invasive vs Open Coronary Surgery: A Multiinstitutional Analysis of Cost and Outcomes.

Ann Thorac Surg 2020 Sep 19. Epub 2020 Sep 19.

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

Background: Limited multiinstitutional data evaluating minimally invasive cardiac surgery (MICS) coronary artery bypass surgery (CABG) outcomes have raised concern for increased resource utilization compared with standard sternotomy. The purpose of this study was to assess short-term outcomes and resource utilization with MICS CABG in a propensity-matched regional cohort.

Methods: Isolated CABG patients (2012-2019) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by MICS CABG vs open CABG via sternotomy, propensity-score matched 1:2 to balance baseline differences, and compared by univariate analysis.

Results: Of 26,255 isolated coronary artery bypass graft patients, 139 MICS CABG and 278 open CABG patients were well balanced after matching. There was no difference in the operative mortality rate (2.2% open vs 0.7% MICS CABG, P = .383) or major morbidity (7.9% open vs 7.2% MICS CABG, P = .795). However, open CABG patients received more blood products (22.2% vs 12.2%, P = .013), and had longer intensive care unit (45 vs 30 hours, P = .049) as well as hospital lengths of stay (7 vs 6 days, P = .005). Finally, median hospital cost was significantly higher in the open CABG group ($35,011 vs $27,906, P < .001) compared with MICS CABG.

Conclusions: Open CABG via sternotomy and MICS CABG approaches are associated with similar, excellent perioperative outcomes. However, MICS CABG was associated with fewer transfusions, shorter length of stay, and ∼$7000 lower hospital cost, a superior resource utilization profile that improves patient care and lowers cost.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.136DOI Listing
September 2020

Commentary: Spinal cord ischemia: It's the anatomy, stupid.

J Thorac Cardiovasc Surg 2020 Aug 25. Epub 2020 Aug 25.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.08.060DOI Listing
August 2020

Commentary: Regardless of how you divide it, socioeconomic status determines outcomes.

J Thorac Cardiovasc Surg 2020 Aug 15. Epub 2020 Aug 15.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.08.028DOI Listing
August 2020

Commentary: Socioeconomic impact on aortic surgery: Is it about the individual, the community, or the surgeon?

J Thorac Cardiovasc Surg 2020 Aug 3. Epub 2020 Aug 3.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.079DOI Listing
August 2020

Extracorporeal membrane oxygenation for management of iatrogenic distal tracheal tear.

JTCVS Tech 2020 Dec 4;4:389-391. Epub 2020 Aug 4.

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

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http://dx.doi.org/10.1016/j.xjtc.2020.07.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402207PMC
December 2020

Commentary: Trial sequential analysis: An upgrade to the meta-analysis worth learning.

J Thorac Cardiovasc Surg 2020 Jul 12. Epub 2020 Jul 12.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.013DOI Listing
July 2020

A 30-year analysis of National Institutes of Health-funded cardiac transplantation research: Surgeons lead the way.

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

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, Va. Electronic address:

Objectives: Obtaining National Institutes of Health funding for heart transplant research is becoming increasingly difficult, especially for surgeons. We sought to determine the impact of National Institutes of Health-funded cardiac transplantation research over the past 30 years.

Methods: National Institutes of Health Research Portfolio Online Reporting Tools Expenditures and Results was queried for R01s using 10 heart transplant-related terms. Principal Investigator, total grant funding amount, number of publications, and citations of manuscripts were collected. A citation-based Grant Impact Metric was assigned to each grant: sum of citations for each manuscript normalized by the funding of the respective grant (per $100K). The department and background degree(s) (MD, PhD, MD/PhD) for each funded Principal Investigator were identified from institutional faculty profiles.

Results: A total of 321 cardiac transplantation R01s totaling $723 million and resulting in 6513 publications were analyzed. Surgery departments received more grants and more funding dollars to study cardiac transplantation than any other department (n = 115, $249 million; Medicine: n = 93, $208 million; Pathology: 26, $55 million). Surgeons performed equally well compared with all other Principal Investigators with respect to Grant Impact Metric (15.1 vs 20.6; P = .19) and publications per $1 million (7.5 vs 6.8; P = .75). Finally, all physician-scientists (MDs) have a significantly higher Grant Impact Metric compared with nonclinician researchers (non-MDs) (22.3 vs 16.3; P = .028).

Conclusions: Surgeon-scientists are equally productive and impactful compared with nonsurgeons despite decreasing funding rates at the National Institutes of Health and greater pressure from administrators to increase clinical productivity.
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http://dx.doi.org/10.1016/j.jtcvs.2020.06.076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7782209PMC
July 2020

Incidence and Prognostic Impact of Incomplete Revascularization Documented by Coronary Angiography 1 Year After Coronary Artery Bypass Grafting.

Am J Cardiol 2020 09 30;131:7-11. Epub 2020 Jun 30.

Research and Development Office, Northport Veterans Affairs Medical Center, Northport, NY.

Complete revascularization (CR) at the time of coronary artery bypass graft (CABG) surgery improves long-term cardiac outcomes. No studies have previously reported angiographically confirmed CR rates post-CABG. This study's aim was to assess the impact upon long-term outcomes of CR versus incomplete revascularization (IR), confirmed by coronary angiography 1 year after CABG. Randomized On/Off Bypass Study patients who returned for protocol-specified 1-year post-CABG coronary angiograms were included. Patients with a widely patent graft supplying the major diseased artery within each diseased coronary territory were considered to have CR. Outcomes were all-cause mortality and major adverse cardiovascular events (MACE; all-cause mortality, nonfatal myocardial infarction, repeat revascularization) over the 4 years after angiography. Of the 1,276 patients, 756 (59%) had CR and 520 (41%) had IR. MACE was 13% CR versus 26% IR, p <0.001. This difference was driven by fewer repeat revascularizations (5% CR vs 18% IR; p <0.001). There were no differences in mortality (7.1% CR vs 8.1% IR, p = 0.13) or myocardial infarction (4% in both). Adjusted multivariable models confirmed CR was associated with reduced MACE (odds ratio 0.44, 95% confidence interval 0.33 to 0.58, p <0.01), but had no impact on mortality. In conclusion, CR confirmed by post-CABG angiography was associated with improved MACE but not mortality. Repeat revascularization of patients with IR, driven by knowledge of the research angiography results, may have ameliorated potential mortality differences.
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http://dx.doi.org/10.1016/j.amjcard.2020.06.047DOI Listing
September 2020

Variability and Utilization of Concomitant Atrial Fibrillation Ablation During Mitral Valve Surgery.

Ann Thorac Surg 2021 01 18;111(1):29-34. Epub 2020 Jul 18.

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

Background: Concomitant surgical ablation for atrial fibrillation (AF) at the time of mitral valve surgery is a Society of Thoracic Surgeons Class IA recommendation with evidence from randomized trial data. We hypothesized that concomitant AF ablation rates have increased over time with implementation of this evidence-based practice.

Methods: All patients (N = 7261) undergoing mitral valve operations (2011-2018) were queried from a regional Society of Thoracic Surgeons database. Patients with preoperative AF were stratified by concomitant AF ablation. Trends in concomitant ablation were evaluated over time as well as by center and surgeon mitral surgical volume. The associations between patient and center factors on implementation of concomitant ablation were assessed with multivariate regression.

Results: A total of 1675 patients with preoperative AF underwent isolated mitral valve operations, with 1044 (64.6%) undergoing concomitant ablation. The utilization of concomitant ablation decreased over the study period (-2.82%/year), and was strongly associated with surgeon mitral valve volume (high 78.2% vs medium 62.5% vs low 59.0%; P < .001). Multivariate regression demonstrated age and comorbidities were strong predictors, but high volume mitral surgeons (odds ratio [OR], 2.2; P < .001) were twice as likely to perform concomitant AF ablation. Finally, patients with preoperative AF undergoing ablation were significantly less likely to be in AF at discharge (10.1% vs 53.8%; P < .001).

Conclusions: Despite increasing evidence and societal recommendations, we demonstrate a persistent underutilization of concomitant AF ablation during isolated mitral surgery across a large number of low-volume and high-volume centers. These data suggest significant variability and may represent an opportunity for improvement.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.125DOI Listing
January 2021

Long-term Implications of Tracheostomy in Cardiac Surgery Patients: Decannulation and Mortality.

Ann Thorac Surg 2021 02 30;111(2):594-599. Epub 2020 Jun 30.

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

Background: The long-term implications of tracheostomy in cardiac surgical patients are largely unknown. We sought to investigate outcomes including decannulation and long-term mortality in a population of post-cardiac surgery patients.

Methods: All patients undergoing cardiac surgery at a single institution between 1997 and 2016 were evaluated for postoperative tracheostomy placement, time to decannulation, and mortality. Patients were stratified by tracheostomy placement, as well as by successful decannulation for comparison. Kaplan-Meier analysis identified time to decannulation and mortality and a Fine-Gray's competing risk regression, accounting for mortality, identified predictors of time to decannulation.

Results: Of 14,600 total cardiac surgery patients, only 309 required tracheostomy. Patients with tracheostomy had high rates of perioperative comorbidities, including 60% with heart failure and 24% with postoperative stroke. Tracheostomy patients had high short-term and long-term mortality, with a median survival of 152 days, 1-year survival of 41%, and 5-year survival of 29.1%. Patients remained with tracheostomy in place for a median of 59 days, with a 1-year decannulation rate of 80% in living patients. Patients with older age (hazard ratio 0.98, P = .01), chronic lung disease (hazard ratio 0.66, P = .03), and preoperative or postoperative dialysis (hazard ratio 0.45, P < .01) were less likely to have their tracheostomy removed.

Conclusions: Tracheostomy is associated with poor long-term survival of cardiac surgery patients. However, patients who do survive have a short duration of tracheostomy with almost all surviving patients eventually decannulated. This finding provides valuable information for pre-procedural counseling for these high-risk patients and their families.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.052DOI Listing
February 2021

History of Serious Mental Illness Is a Predictor of Morbidity and Mortality in Cardiac Surgery.

Ann Thorac Surg 2021 01 13;111(1):109-116. Epub 2020 Jun 13.

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

Background: Serious mental illness (SMI), defined as a mental disorder causing functional impairment, affects 9.8 million Americans. SMI correlates with earlier onset, more extensive cardiac disease, and reduced life expectancy by 25 years. The impact of SMI on patients undergoing cardiac surgery has not been extensively studied. We hypothesized that patients with SMI have worse cardiac surgery outcomes.

Methods: Using our institution's Society of Thoracic Surgeons database of 16,781 cardiac operations (2002-2017), a total of 1445 (8.7%) patients with SMI were identified and stratified into anxiety, mood disorders, and psychosis. The risk-adjusted impact on morbidity and mortality were evaluated using multivariable regression.

Results: Patients with SMI were more often female patients, were younger, and had more comorbid disease. SMI patients were more likely to have had previous cardiac surgery and require urgent or emergent procedures (both P < .05). Among specific SMI diagnoses, patients with psychosis had worse outcomes compared with the general population, with higher operative mortality (9.1% vs 4.2%; P = .001), major morbidity (30.4% vs 15.8%; P < .0001), and cost ($50,211 vs $38,820; P < .001). After multivariable risk adjustment, SMI and psychosis remained independently associated with composite mortality and major morbidity (odds ratio, 1.21; P = .012; and odds ratio, 1.68; P = .003, respectively).

Conclusions: SMI is independently associated with morbidity and mortality after cardiac surgery. SMI patients, especially the subset with psychosis, are complicated, high-risk, and resource-consuming. Refined strategies to reduce postoperative complications and improve care coordination are necessary in this population.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.118DOI Listing
January 2021