Publications by authors named "Subhasis Chatterjee"

72 Publications

Continuous-Flow Left Ventricular Assist Device Support in Patients with Ischemic Versus Nonischemic Cardiomyopathy.

Tex Heart Inst J 2021 Sep;48(4)

Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas.

To determine whether the cause of cardiomyopathy affects outcomes in patients who undergo continuous-flow left ventricular assist device support, we compared postimplant adverse events and survival between patients with ischemic and nonischemic cardiomyopathy. The inclusion criteria for the ischemic group were a history of myocardial infarction or revascularization (coronary artery bypass grafting or percutaneous coronary intervention), ≥75% stenosis of the left main or proximal left anterior descending coronary artery, or ≥75% stenosis of ≥2 epicardial vessels. From November 2003 through March 2016, 526 patients underwent device support: 256 (48.7%) in the ischemic group and 270 (51.3%) in the nonischemic group. The ischemic group was older (60.0 vs 50.0 yr), included more men than women (84.0% vs 72.6%), and had more comorbidities. More patients in the nonischemic group were able to have their devices explanted after left ventricular recovery (5.9% vs 2.0%; P=0.02). More patients in the ischemic group had gastrointestinal bleeding (31.2% vs 22.6%; P=0.03), particularly from arteriovenous malformations (20.7% vs 11.9%; P=0.006) and ulcers (16.4% vs 9.3%; P=0.01). Kaplan-Meier analysis revealed no difference in overall survival between groups (P=0.24). Older age, previous sternotomy, higher total bilirubin level, and concomitant procedures during device implantation independently predicted death (P ≤0.03), whereas cause of heart failure did not (P=0.08). Despite the similarity in overall survival between groups, ischemic cardiomyopathy was associated with more frequent gastrointestinal bleeding. This information may help guide the care of patients with ischemic cardiomyopathy who receive continuous-flow left ventricular assist device support.
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http://dx.doi.org/10.14503/THIJ-20-7241DOI Listing
September 2021

Perioperative Coronavirus Vaccination-Timing and Implications: A Guidance Document.

Ann Thorac Surg 2021 Aug 8. Epub 2021 Aug 8.

Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.

Executive Summary: Cardiothoracic surgical patients are at risk of increased coronavirus disease severity. Several important factors influence the administration of the coronavirus disease vaccine in the perioperative period. This guidance statement outlines current information regarding vaccine types, summarizes recommendations regarding appropriate timing of administration, and provides information regarding side effects in the perioperative period for cardiac and thoracic surgical patients.
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http://dx.doi.org/10.1016/j.athoracsur.2021.07.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8349423PMC
August 2021

Ninety-Day Readmission After Open Surgical Repair of Stanford Type A Aortic Dissection.

Ann Thorac Surg 2021 Jul 28. Epub 2021 Jul 28.

Michael E. DeBakey Department of Surgery, Division of General Surgery, Baylor College of Medicine, Houston, Texas; Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas. Electronic address:

Background: Investigations into readmissions after surgical repair of acute Stanford Type A aortic dissection (TAAD) remain scarce. We analyzed potential risk factors for readmission after TAAD.

Methods: The 2013-2014 United States Nationwide Readmissions Database was queried for TAAD index hospitalizations and 90-day readmissions indicated by diagnostic and procedural codes. Multivariable analysis was completed to identify risk factors and the most common reasons for readmission.

Results: We identified 6,975 patients (65% male; age, 60.0±0.4 years) who underwent surgical repair for TAAD. Overall, 2,062 patients (29.6%) were readmitted within 90 days: 634 (30.7%) during the first 30 days, and 1,428 (69.3%) during days 31-90. Readmitted patients had a higher prevalence of chronic kidney disease at index admission (18.0% vs 11.6%, P=.002), greater overall index length of stay (17.8±0.6 vs 15.5±0.4 days; P=.0003), and greater index hospitalization cost ($90,637±$2,691 vs $80,082±$2,091; P=.0003). Mortality during readmission was 3.6% (n=74). Indications for readmission were most commonly cardiac (26.2%), infectious (17.8%), and pulmonary (11.7%). Multivariable analysis identified 2 independent risk factors for readmission: acute kidney injury (OR 1.49; 95% CI 1.24-1.78, P<.0001) and an Elixhauser Comorbidity Index >4 (OR 1.26; 95% CI 1.06-1.49, P=.009).

Conclusions: After surgical repair of TAAD, approximately 30% of patients were readmitted within 90 days, two thirds of them during the 31- to 90-day period. Targeted improvements in perioperative care and post-discharge follow-up of patients with multiple comorbidities could mitigate readmission rates. Efforts to reduce readmissions should be continued throughout the 90-day period.
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http://dx.doi.org/10.1016/j.athoracsur.2021.06.065DOI Listing
July 2021

Commentary: The aggregation of marginal gains for spinal cord protection.

JTCVS Tech 2021 Apr 26;6:9-10. Epub 2020 Dec 26.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Tex.

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http://dx.doi.org/10.1016/j.xjtc.2020.12.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8300903PMC
April 2021

Successful use of angiotensin II for vasoplegia after thoracoabdominal aortic aneurysm repair.

JTCVS Tech 2020 Dec 15;4:72-75. Epub 2020 Aug 15.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.

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http://dx.doi.org/10.1016/j.xjtc.2020.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8303085PMC
December 2020

Provisional extension to induce complete attachment of an endovascular repair for acute type A aortic dissection with visceral malperfusion.

JTCVS Tech 2020 Sep 2;3:61-63. Epub 2020 Jul 2.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.

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http://dx.doi.org/10.1016/j.xjtc.2020.06.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8303074PMC
September 2020

Commentary: Can we do better during a potential second wave of coronavirus disease 2019 (COVID-19)?

JTCVS Open 2020 Dec 2;4:115-116. Epub 2020 Nov 2.

Divisions of General Surgery and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Tex.

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http://dx.doi.org/10.1016/j.xjon.2020.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605862PMC
December 2020

Effect of sarcopenia on survival and spinal cord deficit outcomes after thoracoabdominal aortic aneurysm repair in patients 60 years of age and older.

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

Division of Cardiothoracic Surgery, Department of Surgery, Baylor College Medicine, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.

Objective: Sarcopenia (core muscle loss) has been used as a surrogate marker of frailty. We investigated whether sarcopenia would adversely affect survival after thoracoabdominal aortic aneurysm repair.

Methods: We retrospectively reviewed prospectively collected data from patients aged 60 years or older who underwent thoracoabdominal aortic aneurysm repairs from 2006 to 2016. Imaging was reviewed by 2 radiologists blinded to clinical outcomes. The total psoas index was derived from total psoas muscle cross-sectional area (cm) at the mid-L4 level, normalized for height (m). Patients were divided by sex-specific total psoas index values into sarcopenia (lower third) and nonsarcopenia (upper two-thirds) groups. Multivariable modeling identified operative mortality and spinal cord injury predictors. Unadjusted and adjusted survival curves were analyzed.

Results: Of 392 patients identified, those with sarcopenia (n = 131) were older than nonsarcopenic patients (n = 261) (70.0 years vs 68.0 years; P = .02) and more frequently presented with aortic rupture or required urgent/emergency operations. Operative mortality was comparable (sarcopenia 13.7% vs nonsarcopenia 10.0%; P = .3); sarcopenia was not associated with operative mortality in the multivariable model (odds ratio, 1.40; 95% confidence interval, 0.73-2.77; P = .3). Sarcopenic patients experienced more frequent delayed (13.0% vs 4.6%; P = .005) and persistent (10.7% vs 3.4%; P = .008) paraplegia. Sarcopenia independently predicted delayed paraplegia (odds ratio, 3.17; 95% confidence interval, 1.42-7.08; P = .005) and persistent paraplegia (odds ratio, 3.29; 95% confidence interval, 1.33-8.13; P = .01) in the multivariable model. Adjusted for preoperative/operative covariates, midterm survival was similar for sarcopenic and nonsarcopenic patients (P = .3).

Conclusions: Sarcopenia did not influence early mortality or midterm survival after thoracoabdominal aortic aneurysm repair but was associated with greater risk for delayed and persistent paraplegia.
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http://dx.doi.org/10.1016/j.jtcvs.2021.05.037DOI Listing
June 2021

Selecting Elements for a Cardiac Enhanced Recovery Protocol.

J Cardiothorac Vasc Anesth 2021 May 11. Epub 2021 May 11.

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

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http://dx.doi.org/10.1053/j.jvca.2021.05.006DOI Listing
May 2021

Extracorporeal membrane oxygenation as a bridge to durable left ventricular assist device implantation in INTERMACS-1 patients.

J Artif Organs 2021 May 13. Epub 2021 May 13.

Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, 77030, USA.

Left ventricular assist devices (LVADs) are increasingly used as destination therapy or as a bridge to future cardiac transplant in patients with end-stage heart failure. Extracorporeal membrane oxygenation (ECMO) can be used to bridge patients in cardiogenic shock or with decompensated heart failure to durable mechanical circulatory support. We assessed outcomes in patients in critical cardiogenic shock (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS] profile 1) who underwent implantation of a continuous-flow (CF)-LVAD, with or without preoperative ECMO bridging. For this retrospective study, we selected INTERMACS profile 1 patients who underwent CF-LVAD implantation at our institution between Sep 1, 2004 and Nov 30, 2018. Of 768 patients identified, 133 (17.3%) were INTERMACS profile 1; 26 (19.5%) received preoperative ECMO support, and 107 (80.5%) did not. Postimplantation outcomes were compared between the ECMO and no-ECMO groups. No significant differences were found in 30-day mortality (15.4 vs. 15.9%, P = 0.95) or survival at 1 year (53.8 vs. 60.9%, P = 0.51). Three patients who received ECMO before CF-LVAD implantation subsequently underwent cardiac transplant. In the ECMO group, the lactate level 1 day after ECMO initiation was lower in survivors than nonsurvivors (2.7 ± 2.2 vs. 7.4 ± 4.2 mmol/L, P = 0.02; area under the curve = 0.85, P = 0.01) after CF-LVAD implantation. Bridging with ECMO to CF-LVAD implantation in carefully selected INTERMACS profile 1 patients (those who are at the highest risk for critical cardiogenic shock and for whom palliation may be the only other option) produced acceptable postoperative outcomes.Field of research: Artificial lung/ECMO.
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http://dx.doi.org/10.1007/s10047-021-01275-3DOI Listing
May 2021

Sex Differences in Ascending Aortic and Arch Surgery: A Propensity-matched Comparison of 1153 Pairs.

Ann Thorac Surg 2021 May 7. Epub 2021 May 7.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas.

Background: We investigated the relationship of sex with clinical outcomes after proximal aortic (ascending and arch) operations, and whether sex-specific preoperative factors are associated with mortality.

Methods: Of 3745 patients who underwent elective, urgent, and emergency proximal aortic operations over a 20-year period, 1153 pairs of men and women were propensity-matched, and their early and long-term outcomes were compared. Kaplan-Meier survival analysis was used to estimate late survival.

Results: Women and men had similar operative mortality (9.1% vs 8.8%, P=0.8), stroke (5.7% vs 5.6%, P=0.9), and renal failure rates (7.0% vs 6.6%, P=0.7). Thirty-day mortality was 7.5% versus 5.6% (P=0.06), respectively. Results were less favorable for women than for men regarding respiratory failure (34.3% vs 29.2%, P=0.008) and intensive care unit length of stay (9.11±11.9 vs 7.87±12.48 days; P=0.023). Long-term survival was not significantly different between women and men: 66.3% (95%CI 62.8-69.5) versus 67.1% (95%CI 63.6-70.4) at 5 years, and 45.9% (95%CI 41.76-50.0) versus 46.2% (95%CI 41.7-50.6) at 10 years (P=0.4). Preoperative factors including diabetes, prior stroke, prior renal insufficiency, and peripheral vascular disease were associated with operative mortality in men, whereas chronic obstructive pulmonary disease was the main risk factor in women.

Conclusions: No differences were seen between the sexes in life-changing adverse outcomes after ascending aortic and arch procedures, although specific preoperative variables were associated with specific adverse events. Recognizing differences in preoperative risk factors for mortality between the sexes may facilitate targeted preoperative assessment, preparation, and counseling.
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http://dx.doi.org/10.1016/j.athoracsur.2021.04.069DOI Listing
May 2021

Commentary: After the train has left the station: The utility of a late biomarker for cardiac surgery-associated acute kidney injury.

J Thorac Cardiovasc Surg 2021 Apr 2. Epub 2021 Apr 2.

Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Mass. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.069DOI Listing
April 2021

Commentary: Is angiotensin II a game changer for vasoplegia after cardiac surgery, or is the jury still out?

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

Divisions of General Surgery and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.03.074DOI Listing
March 2021

Commentary: "How to Slay the Aortic Dissection Beast in a COVID-19 World".

Semin Thorac Cardiovasc Surg 2021 16;33(2):313-315. Epub 2021 Feb 16.

Heart and Vascular Program, Baystate Health, University of Massachusetts Medical School-Baystate, Springfield, Massachusetts. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2021.01.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885634PMC
May 2021

Predictors of renal replacement therapy in patients with continuous flow left ventricular assist devices.

J Artif Organs 2021 Jun 18;24(2):207-216. Epub 2021 Feb 18.

Division of Cardiothoracic Transplantation and Circulatory Support and Division of Cardiology, Baylor College of Medicine, 6720 Bertner Ave, Houston, TX, 77030, USA.

Renal replacement therapy (RRT) after continuous flow left ventricular assist device (CF-LVAD) implantation significantly affects patients' quality of life and survival. To identify preoperative prognostic markers in patients requiring RRT after CF-LVAD implantation, we retrospectively reviewed data from patients who underwent implantation of a CF-LVAD at our institution during 2012-2017. Patients who required preoperative RRT were excluded. Preoperative and operative characteristics, as well as survival and adverse events, were compared between 74 (22.2%) patients requiring any duration of postoperative RRT and 259 (77.8%) not requiring RRT. Patients requiring RRT experienced more postoperative complications than patients who did not, including respiratory failure necessitating tracheostomy (35.7% vs 2.5%, p < 0.001), reoperation for bleeding (34.3% vs 11.7%, p < 0.001), and right heart failure necessitating perioperative mechanical circulatory support (32.4% vs 6.9%, p < 0.001). Patients requiring postoperative RRT also had poorer survival at 30 days (74.7% vs 98.8%), 6 months (48.2% vs 95.1%), and 12 months (45.3% vs 90.2%) (p < 0.001). Significant predictors of RRT after CF-LVAD implantation included urine proteinuria (odds ratio [OR] 3.6, 95% confidence interval [CI] [1.7-7.6], p = 0.001), estimated glomerular filtration rate < 45 mL/min/1.73 m (OR 3.4, 95% CI [1.5-17.8], p = 0.004), and mean right atrial pressure to pulmonary capillary wedge pressure ratio ≥ 0.54 (OR 2.6, 95% CI [1.3-5.], p = 0.01). Of the 74 RRT patients, 11 (14.9%) recovered renal function before discharge, 36 (48.6%) still required RRT after discharge, and 27 (36.5%) died before discharge. We conclude that preoperative renal and right ventricular dysfunction significantly predict postoperative renal failure and mortality after CF-LVAD implantation.
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http://dx.doi.org/10.1007/s10047-020-01239-zDOI Listing
June 2021

Expert Consensus of Data Elements for Collection for Enhanced Recovery After Cardiac Surgery.

World J Surg 2021 Apr 31;45(4):917-925. Epub 2021 Jan 31.

Heart and Vascular Program, Baystate Health, Springfield, MA, USA.

Background: Despite the emergence of Enhanced Recovery Protocols (ERPs) in cardiac surgery, there is no consensus on the essential elements for data reporting for quality improvement efforts, as well as accountability and standardization of outcome reporting across institutions. The aim of this study was to establish a consensus on essential data elements for cardiac ERAS®.

Methods: A 2-round modified Delphi technique was utilized based on existing recommendations from the recently published ERAS® cardiac surgery consensus guidelines. Round 1 included a steering committee of 10 experts who oversaw formulation of a focused list of data elements into 3 main areas: Preoperative, intraoperative and postoperative. Round 2 consisted of a multidisciplinary, multinational, heterogenous group of 50 voting experts from across the United States and Europe. All participants evaluated their level of agreement with each data element using a 5-point Likert scale with consensus threshold of 70%.

Results: In round 1, 17 data elements were considered essential (consensus >  = 70%, either positive or negative) and 6 were considered marginal (consensus <  = 70%, either positive or negative). In round 2, positive consensus was achieved for 15/17 (88.2%) data elements in the essential category, and all six data elements (100%) in the marginal category, indicating a high level of overall agreement.

Conclusion: This initial study, which identified 21 key data elements for collection in an ERAS® cardiac program, will aid clinicians in establishing a framework for evaluating the quality of their contemporary ERP processes and will allow acquisition of data to help benchmark performance metrics between hospitals.
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http://dx.doi.org/10.1007/s00268-021-05964-1DOI Listing
April 2021

Propensity score analysis in patients with and without previous isolated coronary artery bypass grafting who require proximal aortic and arch surgery.

J Thorac Cardiovasc Surg 2020 Nov 30. Epub 2020 Nov 30.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.

Objective: The risk posed by previous isolated coronary artery bypass grafting (CABG) in patients who require proximal aortic or aortic arch surgery is unclear. We compared outcomes of ascending aortic and arch procedures in patients with and without previous CABG.

Methods: Using propensity scores, we created 2 matched groups of patients who underwent proximal aortic surgery, including total arch repairs, at our institution: 126 patients who underwent isolated CABG before the index operation and 126 without previous CABG. Forty-four percent of aortic operations were emergency procedures. Eighty-six patients had a patent previous left internal mammary graft. We compared outcomes between the 2 groups and calculated Kaplan-Meier survival curves.

Results: The following outcomes were recorded for the patients with previous isolated CABG versus no CABG: operative mortality, 15.9% versus 11.1% (P = .3); 30-day mortality, 13.5% versus 7.1% (P = .1); persistent stroke, 6.3% versus 4.8% (P = .6); and renal failure necessitating hemodialysis at discharge, 7.9% versus 4.0% (P = .2). Previous CABG did not independently predict any adverse outcome, even though patients who underwent previous CABG more frequently needed intra-aortic balloon support (P < .01). The P value for the overall intergroup difference in long-term survival was .06.

Conclusions: This is one of the largest studies yet reported to examine the impact of previous isolated CABG on proximal aortic or arch surgery outcomes. Although these results may be specific to aortic centers of excellence, in this complicated patient cohort, previous isolated CABG did not independently predict any adverse outcome. These results could serve as a benchmark for assessing future endovascular therapies.
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http://dx.doi.org/10.1016/j.jtcvs.2020.10.153DOI Listing
November 2020

Persistent Opioid Use After Open Aortic Surgery: Risk Factors, Costs and Consequences.

Ann Thorac Surg 2020 Dec 15. Epub 2020 Dec 15.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.

Background: The incidence and financial impact of persistent opioid use (POU) after open aortic surgery is undefined.

Methods: Insurance claim data from opioid-naïve patients who underwent aortic root replacement, ascending aortic replacement or transverse arch replacement from 2011 to 2017 were evaluated. Persistent opioid use was defined as filling an opioid prescription in the perioperative period and between 90 and 180 days after surgery. Postoperative opioid prescriptions, emergency room visits, readmissions and healthcare costs were quantified. Multivariable logistic regression identified risk factors for POU, and quantile regression quantified the impact of POU on postoperative healthcare costs.

Results: Among 3,240 opioid-naïve patients undergoing open aortic surgery, 169 (5.2%) of patients had POU. In the univariate analysis, patients with POU were prescribed more perioperative opioids (375 vs. 225 morphine milligram equivalents, p<0.001), had more emergency room visits (45.6% vs. 25.4%, p<0.001) and had significantly higher healthcare payments in the 6 months after surgery ($10,947 vs. $7,223, p<0.001). Independent risk factors for POU in the multivariable logistic regression included preoperative nicotine use and more opioids in the first perioperative prescription (all p<0.05). After risk adjustment, POU was associated with a $2,439 increase in total healthcare costs in the 6 months after surgery.

Conclusions: POU is a challenge after open aortic surgery and can have longer term impacts on healthcare payments and emergency room visits in the 6 months after surgery. Strategies to reduce outpatient opioid use after aortic surgery should be encouraged when feasible.
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http://dx.doi.org/10.1016/j.athoracsur.2020.11.021DOI Listing
December 2020

Critical care management after open thoracoabdominal aortic aneurysm repair.

J Cardiovasc Surg (Torino) 2021 Jun 14;62(3):220-229. Epub 2020 Dec 14.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.

Thoracoabdominal aortic aneurysm repair is technically demanding for the surgeon and physiologically demanding on the patient. As such, it requires diligent multidisciplinary perioperative care to maximize the likelihood of a successful outcome. In this article, we discuss key principles for managing patients after open thoracoabdominal aortic aneurysm repair, which we have learned over the course of performing more than 3500 of such procedures. These principles address patient handoff between the operating room and Intensive Care Unit, resuscitation, prevention and management of spinal cord deficits, and important neurological, respiratory, cardiovascular, renal, gastrointestinal, and hematological considerations. Understanding the expected postoperative course allows for earlier recognition of deviations from that course and increases the likelihood of successful rescue of patients from adverse outcomes. Achieving positive outcomes after thoracoabdominal aortic aneurysm repair requires attention to detail across the perioperative, intraoperative, and postoperative phases of care.
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http://dx.doi.org/10.23736/S0021-9509.20.11712-9DOI Listing
June 2021

Current Surgical Risk Scores Overestimate Risk in Minimally Invasive Aortic Valve Replacement.

Innovations (Phila) 2021 Jan-Feb;16(1):43-51. Epub 2020 Dec 3.

158424 Division of Cardiothoracic Surgery, University of Miami, FL, USA.

Objective: Risk-scoring systems for surgical aortic valve replacement (AVR) were largely derived from sternotomy cases. We evaluated the accuracy of current risk scores in predicting outcomes after minimally invasive AVR (mini-AVR). Because transcatheter AVR (TAVR) is being considered for use in low-risk patients with aortic stenosis, accurate mini-AVR risk assessment is necessary.

Methods: We reviewed 1,018 consecutive isolated mini-AVR cases (2009 to 2015). After excluding patients with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores ≥4, we calculated each patient's European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, TAVR Risk Score (TAVR-RS), and age, creatinine, and ejection fraction score (ACEF). We compared all 4 scores' accuracy in predicting mini-AVR 30-day mortality by computing each score's observed-to-expected mortality ratio (O:E). Area under the receiver operating characteristic (ROC) curves tested discrimination, and the Hosmer-Lemeshow goodness-of-fit tested calibration.

Results: Among 941 patients (mean age, 72 ± 12 years), 6 deaths occurred within 30 days (actual mortality rate, 0.6%). All 4 scoring systems overpredicted expected mortality after mini-AVR: ACEF (1.4%), EuroSCORE II (1.9%), STS-PROM (2.0%), and TAVR-RS (2.1%). STS-PROM best estimated risk for patients with STS-PROM scores 0 to <1 (0.6 O:E), ACEF for patients with STS-PROM scores 2 to <3 (0.6 O:E), and TAVR-RS for patients with STS-PROM scores 3 to <4 (0.7 O:E). ROC curves showed only fair discrimination and calibration across all risk scores.

Conclusions: In low-risk patients who underwent mini-AVR, current surgical scoring systems overpredicted mortality 2-to-3-fold. Alternative dedicated scoring systems for mini-AVR are needed for more accurate outcomes assessment.
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http://dx.doi.org/10.1177/1556984520971775DOI Listing
December 2020

Successful Treatment of Pregnant and Postpartum Women With Severe COVID-19 Associated Acute Respiratory Distress Syndrome With Extracorporeal Membrane Oxygenation.

ASAIO J 2021 02;67(2):132-136

Department of Pediatrics (Critical Care), Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.

There are limited data on the use of extracorporeal membrane oxygenation (ECMO) for pregnant and peripartum women with COVID-19 associated acute respiratory distress syndrome (ARDS). Pregnant women may exhibit more severe infections with COVID-19, requiring intensive care. We supported nine pregnant or peripartum women with COVID-19 ARDS with ECMO, all surviving and suffering no major complications from ECMO. Our case series demonstrates high-maternal survival rates with ECMO support in the management of COVID-19 associated severe ARDS, highlighting that these pregnant and postpartum patients should be supported with ECMO during this pandemic.
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http://dx.doi.org/10.1097/MAT.0000000000001357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7846250PMC
February 2021

Sex, Racial, and Ethnic Disparities in U.S. Cardiovascular Trials in More Than 230,000 Patients.

Ann Thorac Surg 2021 09 13;112(3):726-735. Epub 2020 Nov 13.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas.

Background: The current representation of female patients and racial and ethnic minorities in cardiovascular trials is unclear. We evaluated these groups' inclusion in U.S. cardiovascular trials.

Methods: Using publicly available data from ClinicalTrials.gov, we evaluated cardiovascular trials pertaining to coronary artery bypass grafting (CABG), heart valve disease, aortic aneurysm, ventricular assist devices, and heart transplantation. This yielded 178 U.S. trials (159 completed, 19 active but not recruiting) started between September 1998 and May 2017, with 237,132 participants. To examine female patients' and racial and ethnic minorities' representation in these trials, we calculated participation-to-prevalence ratios (PPRs). Values of 0.8 to 1.2 reflect similar representation.

Results: All 178 trials reported sex distribution, whereas only 76 (42.7%) trials reported racial distribution and 52 (29.2%) trials reported ethnic (Hispanic vs non-Hispanic) distribution. Among all trials, participants were 28.3% female, 11.2% were Hispanic/Latino, 4.0% were African American, 10.4% were Asian, and 2.3% were other. The CABG PPR for female patients was 0.64, for Hispanic patients was 0.72, for African American patients was 0.28, and for Asian patients was 3.20. Between 2008-2012 and 2013-2017, the CABG PPR decreased for female patients (0.67→0.50) and African American patients (0.37→0.17) but increased for Hispanic patients (0.38→1.32) and Asian patients (3.51→4.57).

Conclusions: Participation in cardiovascular trials by female patients and minorities (except Asian patients) remains low. Given that inherent differences among the previously mentioned groups could affect outcomes, balance is clearly needed. The engagement of our surgical leadership, community, and industry to address these disparities is vitally important.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.075DOI Listing
September 2021

Acute DeBakey Type II Dissection Mimics Left Ventricle Outflow Tract Obstruction.

Ann Thorac Surg 2021 02 4;111(2):e149. Epub 2020 Nov 4.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2020.07.101DOI Listing
February 2021

Cardiac surgery during the COVID-19 sine wave: Preparation once, preparation twice. A view from Houston.

J Card Surg 2021 May 28;36(5):1615-1623. Epub 2020 Sep 28.

Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas.

The novel coronavirus disease (COVID-19) pandemic has created major challenges and disruptions to hospitals throughout the world, with profound implications for cardiac surgery and cardiac surgeons. In this review, we highlight the hospital and cardiac surgical experience at Baylor St. Luke's Medical Center in the Texas Medical Center in Houston, Texas as of mid-July 2020. Our local experience has consisted of a spring surge (early March to early May), followed by a relative flattening and then a summer surge (early June to present day), similar to a sine wave. Throughout the entire pandemic, our simultaneous medical priorities have been treating the growing number of patients with COVID-19 while continuing to provide needed care for those without COVID-19. The current situation will be the "new normal" until a vaccine becomes available. It will be vital to stay attuned to epidemiologists, public health officials, and infection control experts, because what they see today, the intensive care units will see tomorrow. The lessons we have learned are outlined in this review but can be summarized most succinctly: preparation. We must prepare in advance, stockpile supplies and personal protective equipment, have rapid and vigorous testing protocols in place, utilize technology (eg, online meetings, videoconference "office visits"), and encourage hospital-wide and community protective efforts (social distancing, mask wearing, hand hygiene). Hopefully, the lessons learned through this challenging experience will prepare us for the next time.
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http://dx.doi.org/10.1111/jocs.14987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537308PMC
May 2021

Prevention of Acute Kidney Injury.

Crit Care Clin 2020 Oct 13;36(4):691-704. Epub 2020 Aug 13.

Department of Anesthesiology, Intensive Care and Pain Medicine, University of Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication after cardiac surgery and associated with a worse outcome. The pathogenesis of CSA-AKI is complex and multifactorial. Therapeutic options for severe CSA-AKI are limited to renal replacement therapy constituting a supportive measure. Therefore, risk identification, prevention, and early diagnosis are of utmost importance to improve patient outcomes. This review aims to provide an overview of the diagnosis, pathophysiologic mechanisms, and risk factors of CSA-AKI and delineates the strategies for AKI prevention available to improve patient outcomes after cardiac surgery.
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http://dx.doi.org/10.1016/j.ccc.2020.07.002DOI Listing
October 2020

Goal-Directed Therapy for Cardiac Surgery.

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

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

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

Differential presentation in acuity and outcomes based on socioeconomic status in patients who undergo thoracoabdominal aortic aneurysm repair.

J Thorac Cardiovasc Surg 2020 Jul 27. Epub 2020 Jul 27.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; CHI St Luke's Health - Baylor St Luke's Medical Center, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.

Objectives: Socioeconomic differences can lead to differences in how patients present with surgical conditions. We attempted to determine whether socioeconomic status (SES) affects survival outcomes after thoracoabdominal aortic aneurysm (TAAA) repair.

Methods: We retrospectively reviewed prospectively collected data from 981 TAAA repairs performed on domestic (noninternational) patients between 2006 and 2016. We excluded patients <18 years old (n = 3), those with no available US home address (n = 114), those not within the race and ethnicity categories assessed (n = 30), and those lost to follow-up (n = 6), leaving 832 repairs for analysis. We derived patient SES by using US Census Bureau data to estimate median household income according to patient home address. Patients were grouped into 3 SES groups: high (n = 283), middle (n = 274), and low (n = 275). Multivariable logistic regression modeling was used to identify predictors of operative mortality. Kaplan-Meier curves and Cox proportional hazards regression were used to analyze the association between SES and survival.

Results: Operative mortality occurred in 9% (n = 76) of patients. Patients of low SES had greater rates of acute symptoms, dissection, and urgent or emergency TAAA repair. However, lower SES was not an independent predictor of operative death. Kaplan-Meier analysis and Cox proportional hazards modeling did not show a significant difference in mid-term survival by SES.

Conclusions: In our TAAA series from a single, high-volume practice, SES differences did not appear to influence operative mortality rates. In addition, SES was not associated with a difference in mid-term survival. Efforts to understand and ameliorate the greater acuity of presentation in patients of low SES appear worthwhile.
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http://dx.doi.org/10.1016/j.jtcvs.2020.07.073DOI Listing
July 2020

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

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

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

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