Publications by authors named "Robert Hawkins"

444 Publications

Commentary: At the surgeon's discretion: Complete revascularization is best.

J Thorac Cardiovasc Surg 2021 Jul 14. Epub 2021 Jul 14.

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.07.008DOI Listing
July 2021

Commentary: Tricuspid repair for mild regurgitation: Should you put a ring on it?

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

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.2021.06.003DOI Listing
June 2021

Possible novel features of synaptic regulation during long-term facilitation in .

Learn Mem 2021 Jul 15;28(7):218-227. Epub 2021 Jun 15.

Department of Neuroscience, Columbia University, New York, New York 10032, USA.

Most studies of molecular mechanisms of synaptic plasticity have focused on the sequence of changes either at individual synapses or in the cell nucleus. However, studies of long-term facilitation at sensory neuron-motor neuron synapses in isolated cell culture suggest two additional features of facilitation. First, that there is also regulation of the number of synaptic contacts between two neurons, which may occur at the level of cell pair-specific branch points in the neuronal arbor. Branch points contain many molecules that are involved in protein synthesis-dependent long-term facilitation including neurotrophins and the RNA binding protein CPEB. Second, the regulation involves homeostatic feedback and tends to keep the total number of contacts between two neurons at a fairly constant level both at rest and following facilitation. That raises the question of how facilitation and homeostasis can coexist. A possible answer is suggested by the findings that they both involve spontaneous transmission and postsynaptic Ca, which can have bidirectional effects similar to LTP and LTD in hippocampus. In addition, long-term facilitation can involve a change in the set point of homeostasis, which could be encoded by plasticity molecules such as CPEB and/or PKM. A computational model based on these ideas can qualitatively simulate the basic features of both facilitation and homeostasis of the number of contacts.
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http://dx.doi.org/10.1101/lm.053124.120DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8212780PMC
July 2021

Optimization of hemolysis, icterus and lipemia interference thresholds for 35 clinical chemistry assays.

Pract Lab Med 2021 May 27;25:e00232. Epub 2021 Apr 27.

Department of Pathology and Laboratory Medicine, KK Women's & Children's Hospital, Singapore.

Objectives: Interference of chemistry assays by hemolysis, icterus and lipemia (HIL) was investigated on the Abbott Alinity c system. We sought to empirically establish optimized HIL index thresholds for the purposes of reporting HIL interference in a hospital laboratory and advising clinicians on the interpretation of laboratory results in the presence of hemolysis, icterus or lipemia.

Methods: HIL index values measured by spectrophotometry were compared with concentrations of hemoglobin, bilirubin and Intralipid. HIL interference of 35 Abbott Alinity chemistry assays was subsequently investigated by pairwise comparison of test results in pooled serum or plasma with those in test preparations spiked with hemolysate, bilirubin or Intralipid. Data generated from the interference experiments were critically assessed according to assay-specific acceptance criteria adapted from multiple sources, and optimized thresholds for HIL indices were established.

Results: Correlations between HIL index values and their corresponding concentrations of hemoglobin, bilirubin and Intralipid were, in general, very good within the ranges of interferent concentrations tested. Hemolysis significantly affected 12 of 35 assays, whereas bilirubin and Intralipid interfered with four and three assays, respectively. Both the direction and magnitude of Intralipid interference with the direct bilirubin assay were dependent on the concentrations of the analyte.

Conclusions: HIL interference of the Abbott Alinity clinical chemistry assays investigated in this study was not uncommon At present, there are no universally accepted criteria for defining significant assay interference for clinical practice. In establishing acceptance criteria for defining assay interference, each assay should be assessed according to both analytical criteria and clinical relevance.
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http://dx.doi.org/10.1016/j.plabm.2021.e00232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8145753PMC
May 2021

A Phase I/II Study to Assess the Safety and Efficacy of Pazopanib and Pembrolizumab Combination Therapy in Patients with Advanced Renal Cell Carcinoma.

Clin Genitourin Cancer 2021 Apr 20. Epub 2021 Apr 20.

Beth Israel Deaconess Medical Center, Boston, MA. Electronic address:

Background: This study assessed whether antiangiogenic treatment may potentiate immune checkpoint blockade in patients with advanced renal cell carcinoma.

Patients And Methods: This was an open-label, two-part, multicenter study involving treatment-naïve patients with advanced renal cell carcinoma. Part 1 consisted of a phase I dose escalation and expansion of pazopanib plus pembrolizumab (combination therapy). Cohorts A and B received pazopanib in combination with pembrolizumab, whereas Cohort C received pazopanib monotherapy for 9 weeks before receiving the combination therapy. Part 2 was planned as a randomized three-arm study but was not conducted.

Results: Overall, 42 patients were enrolled (10 each in Cohorts A and B, 22 in Cohort C). The maximum tolerated dose was not reached and the recommended phase II dose was not declared, as Cohort C was closed early because of safety concerns. The overall response rates were 60% and 20% in Cohorts A and B, respectively. In Cohort C, the overall response rates were 33%, 25%, and 0% in the combination therapy, pembrolizumab monotherapy, and pazopanib monotherapy groups, respectively. The median progression-free survival rates were 21.95 months and 41.40 months in Cohorts A and B, respectively. Grade 3 or 4 adverse events (AEs) were observed in 90% of patients in Cohorts A and B. In Cohort C, the frequencies of grade 3 or 4 AEs, serious adverse events, and AEs leading to dose reduction were typically high in the combination therapy group.

Conclusions: Despite preliminary signs of efficacy, significant hepatotoxicity was observed in Cohorts A and B. The sequential schedule of pazopanib followed by pazopanib plus pembrolizumab showed reduced hepatotoxicity; however, other safety issues emerged with this approach.
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http://dx.doi.org/10.1016/j.clgc.2021.04.007DOI Listing
April 2021

Commentary: Complexity and complications drive cost.

J Thorac Cardiovasc Surg 2021 Apr 1. Epub 2021 Apr 1.

Division of Thoracic and Cardiovascular Surgery and Center for Health Policy, University of Virginia, Charlottesville, Va.

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.090DOI Listing
April 2021

Commentary: The curse of missing long-term data in cardiac surgery.

J Thorac Cardiovasc Surg 2021 Mar 26. Epub 2021 Mar 26.

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

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.067DOI Listing
March 2021

Commentary: Less May Be More: Once You Get to Transplant.

Semin Thorac Cardiovasc Surg 2021 Apr 17. Epub 2021 Apr 17.

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

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http://dx.doi.org/10.1053/j.semtcvs.2021.03.022DOI Listing
April 2021

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

Minimally Invasive Versus Sternotomy for Mitral Surgery in the Elderly: A Systematic Review and Meta-Analysis.

Innovations (Phila) 2021 Mar 30:15569845211000332. Epub 2021 Mar 30.

622170384 Western University, London, ON, Canada.

Objective: The safety of minimally invasive mitral valve surgery (MIMVS) in elderly patients is still debated. Our objective was to perform a systematic review and meta-analysis of studies comparing MIMVS with conventional sternotomy (CS) in elderly patients (≥65 years old).

Methods: We searched PubMed, EMBASE, Web of Science, clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for trials and observational studies comparing MIMVS with CS in patients ≥65 years old presenting for mitral valve surgery. We performed a random-effects meta-analysis of all outcomes.

Results: The MIMVS group had lower odds of acute renal failure (odds ratio [OR] 0.27; 95% CI 0.10 to 0.78), prolonged intubation (>48 h; OR 0.47; 95% CI 0.31 to 0.70), less blood product transfusion (weighted mean difference [WMD] -0.82 units; 95% CI -1.29 to -0.34 units), shorter ICU length of stay (LOS; WMD -2.57 days; 95% CI -3.24 to -1.90 days) and hospital LOS (WMD -4.06 days; 95% CI -5.19 to -2.94 days). There were no significant differences in the odds of mortality, stroke, respiratory infection, reoperation for bleeding, and postoperative atrial fibrillation. MIMVS was associated with longer cross-clamp (WMD 11.8 min; 95% CI 3.5 to 20.1 min) and cardiopulmonary bypass times (WMD 23.0 min; 95% CI 10.4 to 35.6 min).

Conclusions: MIMVS in elderly patients is associated with lower postoperative complications, blood transfusion, shorter ICU, and hospital LOS, and longer cross-clamp and bypass times.
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http://dx.doi.org/10.1177/15569845211000332DOI Listing
March 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

The Division of Labor in Communication: Speakers Help Listeners Account for Asymmetries in Visual Perspective.

Cogn Sci 2021 Mar;45(3):e12926

Department of Psychology, Stanford University.

Recent debates over adults' theory of mind use have been fueled by surprising failures of perspective-taking in communication, suggesting that perspective-taking may be relatively effortful. Yet adults routinely engage in effortful processes when needed. How, then, should speakers and listeners allocate their resources to achieve successful communication? We begin with the observation that the shared goal of communication induces a natural division of labor: The resources one agent chooses to allocate toward perspective-taking should depend on their expectations about the other's allocation. We formalize this idea in a resource-rational model augmenting recent probabilistic weighting accounts with a mechanism for (costly) control over the degree of perspective-taking. In a series of simulations, we first derive an intermediate degree of perspective weighting as an optimal trade-off between expected costs and benefits of perspective-taking. We then present two behavioral experiments testing novel predictions of our model. In Experiment 1, we manipulated the presence or absence of occlusions in a director-matcher task. We found that speakers spontaneously modulated the informativeness of their descriptions to account for "known unknowns" in their partner's private view, reflecting a higher degree of speaker perspective-taking than previously acknowledged. In Experiment 2, we then compared the scripted utterances used by confederates in prior work with those produced in interactions with unscripted directors. We found that confederates were systematically less informative than listeners would initially expect given the presence of occlusions, but listeners used violations to adaptively make fewer errors over time. Taken together, our work suggests that people are not simply "mindblind"; they use contextually appropriate expectations to navigate the division of labor with their partner. We discuss how a resource-rational framework may provide a more deeply explanatory foundation for understanding flexible perspective-taking under processing constraints.
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http://dx.doi.org/10.1111/cogs.12926DOI 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 06;105(6):1381-1387

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

Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in >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 are 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 as 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 individuals, and the acuity was high, with 85% on extracorporeal membrane oxygenation preoperatively. There was a 95% early survival rate, with 1 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 with 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
June 2021

Angiokines Associated with Targeted Therapy Outcomes in Patients with Non-Clear Cell Renal Cell Carcinoma.

Clin Cancer Res 2021 Jun 16;27(12):3317-3328. Epub 2021 Feb 16.

Department of Biostatistics, Duke University, Durham, North Carolina.

Purpose: Biomarkers are needed in patients with non-clear cell renal cell carcinomas (NC-RCC) to inform treatment selection but also to identify novel therapeutic targets. We thus sought to profile circulating angiokines in the context of a randomized treatment trial of everolimus versus sunitinib.

Patients And Methods: ASPEN (NCT01108445) was an international, randomized, open-label phase II trial of patients with metastatic papillary, chromophobe, or unclassified NC-RCC with no prior systemic therapy. Patients were randomized to everolimus or sunitinib and treated until disease progression or unacceptable toxicity. The primary endpoint was radiographic progression-free survival (PFS) defined by RECIST 1.1. Plasma angiokines were collected at baseline, cycle 3, and progression and associated with PFS and overall survival (OS).

Results: We enrolled 108 patients, 51 received sunitinib and 57 everolimus; of these, 99 patients had evaluable plasma for 23 angiokines. At the final data cutoff, 94 PFS and 64 mortality events had occurred. Angiokines that were independently adversely prognostic for OS were osteopontin (OPN), TIMP-1, thrombospondin-2 (TSP-2), hepatocyte growth factor (HGF), and VCAM-1, and these were also associated with poor-risk disease. Stromal derived factor 1 (SDF-1) was associated with improved survival. OPN was also significantly associated with worse PFS. No statistically significant angiokine-treatment outcome interactions were observed for sunitinib or everolimus. Angiopoeitin-2 (Ang-2), CD-73, HER-3, HGF, IL6, OPN, PIGF, PDGF-AA, PDGF-BB, SDF-1, TGF-b1-b2, TGFb-R3, TIMP-1, TSP-2, VCAM-1, VEGF, and VEGF-R1 levels increased with progression on everolimus, while CD-73, ICAM-1, IL6, OPN, PlGF, SDF-1, TGF-b2, TGFb-R3, TIMP-1, TSP-2, VEGF, VEGF-D, and VCAM-1 increased with progression on sunitinib.

Conclusions: In patients with metastatic NC-RCC, we identified several poor prognosis angiokines and immunomodulatory chemokines during treatment with sunitinib or everolimus, particularly OPN.
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http://dx.doi.org/10.1158/1078-0432.CCR-20-4504DOI Listing
June 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

Black and Latino Persons Living with HIV Evidence Risk and Resilience in the Context of COVID-19: A Mixed-Methods Study of the Early Phase of the Pandemic.

AIDS Behav 2021 May 10;25(5):1340-1360. Epub 2021 Feb 10.

NYU Silver School of Social Work, New York University, 1 Washington Square North, Room 303, New York, NY, 10003, USA.

The COVID-19 pandemic has great potential to disrupt the lives of persons living with HIV (PLWH). The present convergent parallel design mixed-methods study explored the early effects of COVID-19 on African American/Black or Latino (AABL) long-term survivors of HIV in a pandemic epicenter, New York City. A total of 96 AABL PLWH were recruited from a larger study of PLWH with non-suppressed HIV viral load. They engaged in structured assessments focused on knowledge, testing, trust in information sources, and potential emotional, social, and behavioral impacts. Twenty-six of these participants were randomly selected for in-depth semi-structured interviews. Participants were mostly men (64%), African American/Black (75%), and had lived with HIV for 17 years, on average (SD=9 years). Quantitative results revealed high levels of concern about and the adoption of recommended COVID-19 prevention recommendations. HIV care visits were commonly canceled but, overall, engagement in HIV care and antiretroviral therapy use were not seriously disrupted. Trust in local sources of information was higher than trust in various federal sources. Qualitative findings complemented and enriched quantitative results and provided a multifaceted description of both risk factors (e.g., phones/internet access were inadequate for some forms of telehealth) and resilience (e.g., "hustling" for food supplies). Participants drew a direct line between structural racism and the disproportional adverse effects of COVID-19 on communities of color, and their knowledge gleaned from the HIV pandemic was applied to COVID-19. Implications for future crisis preparedness are provided, including how the National HIV/AIDS Strategy can serve as a model to prevent COVID-19 from becoming another pandemic of the poor.
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http://dx.doi.org/10.1007/s10461-021-03177-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873114PMC
May 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 the HVAD Left Ventricular Assist Device to the Centrimag Using a Customized Apical Plug.

Ann Thorac Surg 2021 05 17;111(5):e377-e379. Epub 2020 Dec 17.

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

Left ventricular assist device 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 left ventricular assist device complications from top priority to status 3. In this report we present a patient with recurrent left ventricular assist device thrombosis. Given no modifiable risk factors and recurrence of thrombosis, the HeartWare HVAD ((Medtronic, Minneapolis, MN)) was converted to a temporary Centrimag device device (Abbott, Abbott Park, IL) using a novel plug through the existing sewing ring. With status 2 listing the patient was successfully transplanted on postoperative day 3.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.067DOI Listing
May 2021

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 10. Epub 2020 Dec 10.

Department of Surgery, Washington University School of Medicine, St Louis, Missouri. 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 to 2017) were eligible for enrollment. Patient-reported outcomes were measured using the National Institutes of Health Patient-Reported Outcomes Measurement Information System preoperatively and 1 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 of 98) successful follow-up. The most common operation was coronary artery bypass graft surgery at 63.3% (62 of 98), with 60.2% (59 of 98) undergoing an elective operation. One-year all-cause mortality was 5.1% (5 of 98). Rate of major morbidity was 11.2% (11 of 98). Cardiac surgery significantly improved patient-reported outcomes at 1 year across four domains: mental health (preoperative 47.3 ± 7.7 vs postoperative 51.1 ± 8.9, P < .001), physical health (41.2 ± 8.2 vs 46.3 ± 9.3, P < .001), physical functioning (39.8 ± 8.6 vs 44.8 ± 8.5, P < .001), and social satisfaction (46.8 ± 10.9 vs 50.7 ± 10.8, P = .023). Hospital discharge to a facility did not affect 1-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 1 year postoperatively. Data collection with the National Institutes of Health Patient-Reported Outcomes Measurement Information System 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 03 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

An Outbreak of Covid-19 on an Aircraft Carrier.

N Engl J Med 2020 12 11;383(25):2417-2426. Epub 2020 Nov 11.

From the U.S. Navy Bureau of Medicine and Surgery, Falls Church (M.R.K., B.L.G.), and the Navy and Marine Corps Public Health Center, Portsmouth (J.R.G., A.J.R., T.L., A.M.V.T., G.D., R.J.H.) - both in Virginia; U.S. Navy Seventh Fleet, Yokosuka, Japan (C.L.S.); U.S. Pacific Fleet, Pearl Harbor, Hawaii (M.B.M.); the U.S. Naval Hospital Guam, Apra Harbor (N.O., D.H., R.F.); and the Uniformed Services University of the Health Sciences, Bethesda (T.H.B.), and the Naval Medical Research Center, Silver Spring (A.W.A.) - both in Maryland.

Background: An outbreak of coronavirus disease 2019 (Covid-19) occurred on the U.S.S. , a nuclear-powered aircraft carrier with a crew of 4779 personnel.

Methods: We obtained clinical and demographic data for all crew members, including results of testing by real-time reverse-transcriptase polymerase chain reaction (rRT-PCR). All crew members were followed up for a minimum of 10 weeks, regardless of test results or the absence of symptoms.

Results: The crew was predominantly young (mean age, 27 years) and was in general good health, meeting U.S. Navy standards for sea duty. Over the course of the outbreak, 1271 crew members (26.6% of the crew) tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection by rRT-PCR testing, and more than 1000 infections were identified within 5 weeks after the first laboratory-confirmed infection. An additional 60 crew members had suspected Covid-19 (i.e., illness that met Council of State and Territorial Epidemiologists clinical criteria for Covid-19 without a positive test result). Among the crew members with laboratory-confirmed infection, 76.9% (978 of 1271) had no symptoms at the time that they tested positive and 55.0% had symptoms develop at any time during the clinical course. Among the 1331 crew members with suspected or confirmed Covid-19, 23 (1.7%) were hospitalized, 4 (0.3%) received intensive care, and 1 died. Crew members who worked in confined spaces appeared more likely to become infected.

Conclusions: SARS-CoV-2 spread quickly among the crew of the U.S.S. . Transmission was facilitated by close-quarters conditions and by asymptomatic and presymptomatic infected crew members. Nearly half of those who tested positive for the virus never had symptoms.
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http://dx.doi.org/10.1056/NEJMoa2019375DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675688PMC
December 2020
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