Publications by authors named "Todd K Rosengart"

112 Publications

A Step in the Right Direction for Surgeon-Scientists.

J Am Coll Surg 2021 Mar;232(3):274-275

Houston, TX.

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http://dx.doi.org/10.1016/j.jamcollsurg.2020.12.019DOI Listing
March 2021

Commentary: NIH funding remains vital for cardiothoracic surgeon scientists.

Semin Thorac Cardiovasc Surg 2021 Feb 18. Epub 2021 Feb 18.

Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2021.01.055DOI Listing
February 2021

Consistent improvements in short- and long-term survival following heart transplantation over the past three decades.

Clin Transplant 2021 Feb 1:e14241. Epub 2021 Feb 1.

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

Background: Despite noted improvements in short-term survival outcomes following orthotopic heart transplantation (OHT), review of the relevant literature suggests little improvement in long-term outcomes for patients surviving beyond 1 year.

Methods: All OHT cases performed between 1989 and 2019 within the United Network for Organ Sharing (UNOS) database were reviewed. Adults who underwent isolated OHT were included in a 1-year survival analysis. Those who survived at least 1 year post-transplant were included in a long-term survival analysis. Demographic factors were assessed using Students' t test and chi-square analysis. Survival trends and risk factors were assessed using the Kaplan-Meier and the Cox regression analysis, respectively.

Results: A total of 53 265 and 46 372 recipients were included in the short-term and long-term cohorts, respectively. In an adjusted analysis, the reference implant era 2014-2019 had significantly better short-term survival outcomes when compared with earlier implant eras: 1989-1993 (HR: 2.92), 1994-1998 (HR: 1.53), 1999-2003 (HR: 1.27), 2004-2008 (HR: 1.11), and 2009-2013 (HR: 1.02). The same trend was recognized for long-term outcomes: 1989-1993 (HR: 1.87), 1994-1998 (HR: 1.27), 1999-2003 (HR: 1.09), and 2004-2008 (HR: 1.03).

Conclusions: Despite increases in multiple traditional risk factors, both short-term and long-term survival outcomes have consistently improved over the past 30 years, suggesting other factors are contributing to improved outcomes in recent eras.
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http://dx.doi.org/10.1111/ctr.14241DOI Listing
February 2021

Personalized Graduate Medical Education and the Global Surgeon: Training for Resource-Limited Settings.

Acad Med 2021 03;96(3):384-389

T.K. Rosengart is professor and chair, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.

Problem: The World Health Organization and the World Bank have identified improvement in access to surgical care as an urgent global health challenge and a cost-effective investment in public health. However, trainees in standard U.S. general surgery programs do not have adequate exposure to the procedures, technical skills, and foundational knowledge essential for providing surgical care in resource-limited settings.

Approach: The Michael E. DeBakey Department of Surgery at Baylor College of Medicine (BCM) created a 7-year global surgery track within its general surgery residency in 2014. Individualized rotations equip residents with the necessary skills, knowledge, and experience to operate in regions with low surgeon density and develop sustainable surgical infrastructures. BCM provides a formal, integrated global surgery curriculum-including 2 years dedicated to global surgery-with surgical specialty rotations in domestic and international settings. Residents tailor their individual experience to the needs of their future clinical practice, region of interest, and surgical specialty.

Outcomes: There have been 4 major outcomes of the BCM global surgery track: (1) increased exposure for trainees to a broad range of surgeries critical in resource-limited settings, (2) meaningful international partnerships, (3) contributions to global surgery scholarship, and (4) establishment of sustainable global surgery activities.

Next Steps: To better facilitate access to safe, timely, and affordable surgical care worldwide, global surgeons should pursue expertise in topics not currently included in U.S. general surgical curricula, such as setting-specific technical skills, capacity building, and organizational collaboration. Future evaluations of the BCM global surgery track will assess the effect of individualized education on trainees' professional identities, clinical practices, academic pursuits, global surgery leadership preparedness, and comfort with technical skills not encompassed in general surgery programs. Increasing availability of quality global surgery training programs would provide a critical next step toward contributing to the delivery of safe surgical care worldwide.
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http://dx.doi.org/10.1097/ACM.0000000000003898DOI Listing
March 2021

A steroid receptor coactivator stimulator (MCB-613) attenuates adverse remodeling after myocardial infarction.

Proc Natl Acad Sci U S A 2020 12 23;117(49):31353-31364. Epub 2020 Nov 23.

Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX 77030;

Progressive remodeling of the heart, resulting in cardiomyocyte (CM) loss and increased inflammation, fibrosis, and a progressive decrease in cardiac function, are hallmarks of myocardial infarction (MI)-induced heart failure. We show that MCB-613, a potent small molecule stimulator of steroid receptor coactivators (SRCs) attenuates pathological remodeling post-MI. MCB-613 decreases infarct size, apoptosis, hypertrophy, and fibrosis while maintaining significant cardiac function. MCB-613, when given within hours post MI, induces lasting protection from adverse remodeling concomitant with: 1) inhibition of macrophage inflammatory signaling and interleukin 1 (IL-1) signaling, which attenuates the acute inflammatory response, 2) attenuation of fibroblast differentiation, and 3) promotion of Tsc22d3-expressing macrophages-all of which may limit inflammatory damage. SRC stimulation with MCB-613 (and derivatives) is a potential therapeutic approach for inhibiting cardiac dysfunction after MI.
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http://dx.doi.org/10.1073/pnas.2011614117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733826PMC
December 2020

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

Ann Thorac Surg 2020 Nov 12. Epub 2020 Nov 12.

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 females and racial and ethnic minorities in cardiovascular trials is unclear. We evaluated these groups' inclusion in US 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 transplant. This yielded 178 US trials (159 completed, 19 active but not recruiting) started between September 1998 and May 2017, with 237,132 participants. To examine females' and racial and ethnic minorities' representation in these trials, we calculated participation-to-prevalence ratios (PPR). Values of 0.8-1.2 reflect similar representation.

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

Conclusions: Participation in cardiovascular trials by females and minorities (except Asians) remains low. Given that inherent differences among the abovementioned 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
November 2020

How to be an Innovator in Cardiothoracic Surgery.

Semin Thorac Cardiovasc Surg 2020 Nov 7. Epub 2020 Nov 7.

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

Cardiothoracic surgeons are uniquely and expertly positioned to be innovators. Innovation is an iterative process by which unmet needs are identified, a solution is invented, and the results are implemented. A team approach is required, with participation from a variety of experts including the surgeon-innovator. Innovation can be practiced on a multitude of pathways including basic science, clinical science, and commercialization. Economics realities are often the ultimate determinant in the success or failure of any innovative effort. In this manuscript, we aim to define innovation, describe the innovative process, and demonstrate how these principles can, and should, be enacted by cardiothoracic surgeon-innovators.
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http://dx.doi.org/10.1053/j.semtcvs.2020.10.004DOI Listing
November 2020

Commentary: Neonatal applications of cardiac cell therapy: It's good to be young!

J Thorac Cardiovasc Surg 2020 Oct 7. Epub 2020 Oct 7.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.09.107DOI Listing
October 2020

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

J Card Surg 2020 Sep 28. 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
September 2020

Commentary: Measure Twice, Cut Once.

Semin Thorac Cardiovasc Surg 2021 Spring;33(1):82-83. Epub 2020 Jun 29.

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

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http://dx.doi.org/10.1053/j.semtcvs.2020.06.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769994PMC
June 2020

Introduction: Great Institutions in Cardiothoracic Surgery, Adding to the List.

Semin Thorac Cardiovasc Surg 2020 29;32(4):605. Epub 2020 Jun 29.

Toronto General Hospital, Toronto, Ontario, Canada.

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http://dx.doi.org/10.1053/j.semtcvs.2020.06.042DOI Listing
March 2021

Development of a Risk Score to Predict 90-Day Readmission After Coronary Artery Bypass Graft.

Ann Thorac Surg 2021 02 23;111(2):488-494. Epub 2020 Jun 23.

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas. Electronic address:

Background: Readmission after coronary artery bypass grafting (CABG) is used for quality metrics and may negatively affect hospital reimbursement. Our objective was to develop a risk score system from a national cohort that can predict 90-day readmission risk for CABG patients.

Methods: Using the National Readmission Database between 2013 and 2014, we identified 104,930 patients discharged after CABG, for a total of 234,483 patients after weighted analysis. Using structured random sampling, patients were divided into a training set (60%) and test data set (40%). In the training data set, we used multivariable analysis to identify risk factors. A point system risk score was developed based on the odds ratios. Variables with odds ratio less than 1.3 were excluded from the final model to reduce noise. Performance was assessed in the test data set using receiver operator characteristics and accuracy.

Results: In the United States, overall 90-day readmission rate after CABG was 19% (n = 44,559 of 234,483). Nine demographic and clinical variables were identified as important in the training data set. The final risk score ranged from 0 to 52; the 2 largest risks were associated with length of stay greater than 10 days (score = +10) and Medicaid insurance (score = +7). The final model's C-statistic was 0.67. Using an optimal cutoff of 18 points, the accuracy of the risk score was 77%.

Conclusions: Ninety-day readmission after CABG surgery is frequent. A readmission risk score higher than 18 points predicts readmission in 77% of patients. Based on 9 demographic and clinical factors, this risk score can be used to target high-risk patients for additional postdischarge resources to reduce readmission.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.142DOI Listing
February 2021

Commentary: Culture trumps (transfusion) guidelines.

J Thorac Cardiovasc Surg 2020 May 11. Epub 2020 May 11.

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.04.129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655709PMC
May 2020

A Multifaceted Research Engagement Program Improved the Academic Productivity of General Surgery Residents.

J Surg Educ 2020 Sep - Oct;77(5):1082-1087. Epub 2020 Jun 3.

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey VA Medical Center, Houston, Texas; Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas. Electronic address:

Objective: Surgeon-scientists are becoming increasingly scarce, and therefore, engaging residents in research during their training is important. We evaluated whether a multifaceted research engagement program was associated with increased academic productivity of general surgery residents.

Design: Our research engagement program has 4 pillars: A research requirement, a structured research curriculum, infrastructure to support residents' research, and an annual resident research day to highlight trainees' work. We compared the number of manuscripts published per chief resident during the 4 years before and after program implementation in 2013. We performed subgroup analyses to examine productivity of research track residents and clinical track residents.

Setting: A general surgery residency program in an academic setting.

Participants: The participants were 57 general surgery residents (23 research track and 34 clinical track) graduating between 2010 and 2017.

Results: There was a significant increase in overall research productivity, with 28 chief residents publishing an average of 2.3 ± 1.0 manuscripts before and 29 chief residents publishing an average of 8.5 ± 3.2 manuscripts after program implementation (p = 0.01). Research track residents had a nonsignificant increase in publications from an average of 6.3 ± 3.1 before to 15.4 ± 8.9 after the new program (p = 0.10). Clinical track residents had a significant increase in publications from a median of 0.9 (interquartile range: 0.5, 1.0) before to a median of 1.3 (interquartile range: 1.2, 8.6) after the new program (p = 0.03).

Conclusions: Implementation of a multifaceted research engagement program was associated with a significant increase in manuscripts published by general surgery residents, including clinical track residents. Components of our program may be of use to other programs looking to improve resident research engagement and productivity.
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http://dx.doi.org/10.1016/j.jsurg.2020.03.028DOI Listing
June 2020

Enhanced Generation of Induced Cardiomyocytes Using a Small-Molecule Cocktail to Overcome Barriers to Cardiac Cellular Reprogramming.

J Am Heart Assoc 2020 06 5;9(12):e015686. Epub 2020 Jun 5.

Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston TX.

Background Given known inefficiencies in reprogramming of fibroblasts into mature induced cardiomyocytes (iCMs), we sought to identify small molecules that would overcome these barriers to cardiac cell transdifferentiation. Methods and Results We screened alternative combinations of compounds known to impact cell reprogramming using morphologic and functional cell differentiation assays in vitro. After screening 6 putative reprogramming factors, we found that a combination of the histone deacetylase inhibitor sodium butyrate, the WNT inhibitor ICG-001, and the cardiac growth regulator retinoic acid (RA) maximally enhanced iCM generation from primary rat cardiac fibroblasts when combined with administration of the cardiodifferentiating transcription factors Gata4, Mef2C, and Tbx5 (GMT) compared with GMT administration alone (23±1.5% versus 3.3±0.2%; <0.0001). Expression of the cardiac markers cardiac troponin T, Myh6, and Nkx2.5 was upregulated as early as 10 days after GMT-sodium butyrate, ICG-001, and RA treatment. Human iCM generation was likewise enhanced when administration of the human cardiac reprogramming factors GMT, Hand2, and Myocardin plus miR-590 was combined with sodium butyrate, ICG-001, and RA compared with GMT, Hand2, and Myocardin plus miR-590 treatment alone (25±1.3% versus 5.7±0.4%; <0.0001). Rat and human iCMs also more frequently demonstrated spontaneous beating in coculture with neonatal cardiomyocytes with the addition of sodium butyrate, ICG-001, and RA to transcription factor cocktails compared with transcription factor treatment alone. Conclusions The combined administration of histone deacetylase and WNT inhibitors with RA enhances rat and human iCM generation induced by transcription factor administration alone. These findings suggest opportunities for improved translational approaches for cardiac regeneration.
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http://dx.doi.org/10.1161/JAHA.119.015686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7429035PMC
June 2020

Cardiac Surgery During the Coronavirus Disease 2019 Pandemic: Perioperative Considerations and Triage Recommendations.

J Am Heart Assoc 2020 07 16;9(13):e017042. Epub 2020 May 16.

Cardiology Baylor College of Medicine Houston TX.

The coronavirus disease 2019 pandemic, caused by severe acute respiratory syndrome coronavirus-2, represents the third human affliction attributed to the highly pathogenic coronavirus in the current century. Because of its highly contagious nature and unprecedented global spread, its aggressive clinical presentation, and the lack of effective treatment, severe acute respiratory syndrome coronavirus-2 infection is causing the loss of thousands of lives and imparting unparalleled strain on healthcare systems around the world. In the current report, we discuss perioperative considerations for patients undergoing cardiac surgery and provide clinicians with recommendations to effectively triage and plan these procedures during the coronavirus disease 2019 outbreak. This will help reduce the risk of exposure to patients and healthcare workers and allocate resources appropriately to those in greatest need. We include an algorithm for preoperative testing for coronavirus disease 2019, personal protective equipment recommendations, and a classification system to categorize and prioritize common cardiac surgery procedures.
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http://dx.doi.org/10.1161/JAHA.120.017042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670528PMC
July 2020

Twelve Tips on enhancing global health education in graduate medical training programs.

Med Teach 2021 Feb 12;43(2):142-147. Epub 2020 May 12.

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

Investment in healthcare infrastructure in resource-limited settings is a vital and cost-effective approach for diminishing world-wide disease burden, increasing quality of life, and lengthening life expectancy. Graduate medical trainees enthusiastically express interest in supporting global health efforts that expand healthcare access and capacity in resource-limited settings. Academic institutions are responding by developing training programs to equip graduate medical trainees with the technical, interpersonal, scholastic, and ethical skillsets necessary for the pursuit of global health efforts. Drawn from real-world experience and current literature, the following twelve tips will strengthen a global health curriculum in graduate medical training programs with dedicated global health education.
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http://dx.doi.org/10.1080/0142159X.2020.1762033DOI Listing
February 2021

Mid-Term Efficacy of Subxiphoid Versus Transpleural Pericardial Window for Pericardial Effusion.

J Surg Res 2020 08 23;252:9-15. Epub 2020 Mar 23.

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

Background: The optimal surgical technique for drainage of pericardial effusions is frequently debated. Transpleural drainage via thoracotomy or thoracoscopy is hypothesized to provide more durable freedom from recurrent pericardial effusion than a subxiphoid pericardial window. We sought to compare operative outcomes and mid-term freedom from recurrent effusion between both approaches in patients with nontraumatic pericardial effusions.

Methods: All patients at our institution who underwent a pericardial window from 2001 to 2018 were identified. After excluding those who underwent recent cardiothoracic surgery or trauma, patients (n = 46) were stratified by surgical approach and presence of malignancy. Primary outcome was freedom from recurrent moderate or greater pericardial effusion. Secondary outcomes included operative mortality and morbidity and mid-term survival. Follow-up was determined by medical record review, with a follow-up of 67 patient-years. Fisher's exact test and Wilcoxon rank-sum test were used to compare groups. Mid-term survival and freedom from effusion recurrence were determined using Kaplan-Meier method.

Results: Subxiphoid windows (n = 31; 67%) were more frequently performed than transpleural windows (n = 15; 33%) and baseline characteristics were similar. Effusion etiologies included malignancy (n = 22; 48%), idiopathic (n = 12; 26%), uremia (n = 8; 17%), and collagen vascular disease (n = 4; 9%). Perioperative outcomes were comparable between the two surgical approaches, except for longer drain duration (7 versus 4 d, P = 0.029) in the subxiphoid group. Operative mortality was 19.6% overall and 36.4% in patients with malignancy. Mid-term survival and freedom from moderate or greater pericardial effusion recurrence was 37% (95% confidence interval [CI]: 19%-54%) and 69% (95% CI: 52%-86%) at 5 y, respectively. There was no difference in mid-term survival (P = 0.90) or freedom from pericardial effusion recurrence (P = 0.70) between surgical approaches. Although malignant etiology had worse late survival (P < 0.01), freedom from effusion recurrence was similar to nonmalignant etiology (P = 0.70).

Conclusions: Pericardial window provides effective mid-term relief of pericardial effusion. Subxiphoid and transpleural windows are equivalent in mid-term efficacy and both surgical approaches can be considered. Patients with malignancy have acceptable operative mortality with low incidence of recurrent effusion, supporting palliative indications.
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http://dx.doi.org/10.1016/j.jss.2020.01.014DOI Listing
August 2020

Lower Sugar, Sweeter Results.

J Am Heart Assoc 2020 03 10;9(6):e016029. Epub 2020 Mar 10.

Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston TX.

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http://dx.doi.org/10.1161/JAHA.120.016029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335510PMC
March 2020

Commentary: Alas, we are not yet zebrafish.

J Thorac Cardiovasc Surg 2020 06 7;159(6):2457-2458. Epub 2020 Jan 7.

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

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http://dx.doi.org/10.1016/j.jtcvs.2019.12.045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7577083PMC
June 2020

Commentary: The news of our demise….

Authors:
Todd K Rosengart

J Thorac Cardiovasc Surg 2020 06 21;159(6):2338-2339. Epub 2019 Sep 21.

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.08.126DOI Listing
June 2020

Discussion.

Authors:
Todd K Rosengart

J Thorac Cardiovasc Surg 2020 Aug 26;160(2):e24-e25. Epub 2019 Sep 26.

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http://dx.doi.org/10.1016/j.jtcvs.2019.06.116DOI Listing
August 2020

Inflammatory monocyte response due to altered wall shear stress in an isolated femoral artery model.

J Biol Methods 2019 20;6(1):e109. Epub 2019 Feb 20.

Department of Biomedical Engineering, Physiology and Biophysics, Stony Brook University, Stony Brook, NY 11794-5281, USA.

Arteriogenesis (collateral formation) is accompanied by a pro-inflammatory state that may be related to the wall shear stress (WSS) within the neo-collateral vessels. Examining the pro-inflammatory component or is complex. In an mouse femoral artery perfusion model, we examined the effect of wall shear stress on pro-arteriogenic inflammatory markers and monocyte adhesion. In a femoral artery model with defined pulsatile flow, WSS was controlled (at physiological stress, 1.4×, and 2× physiological stress) during a 24 h perfusion before gene expression levels and monocyte adhesion were assessed. Significant upregulation of expression was found for the cytokine TNFα, adhesion molecule ICAM-1, growth factor TGFβ, and the transcription factor Egr-1 at varying levels of increased WSS compared to physiological control. Further, trends toward upregulation were found for FGF-2, the cytokine MCP-1 and adhesion molecules VCAM-1 and P-selectin with increased WSS. Finally, monocytes adhesion increased in response to increased WSS. We have developed a murine femoral artery model for studying changes in WSS and show that the artery responds by upregulating inflammatory cytokines, adhesion molecules and growth factors consistent with previous findings.
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http://dx.doi.org/10.14440/jbm.2019.274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6706128PMC
February 2019

Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events.

JAMA Netw Open 2019 07 3;2(7):e198067. Epub 2019 Jul 3.

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

Importance: Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies.

Objective: To analyze and describe the incidence of human performance deficiencies (HPDs) during the provision of surgical care to identify opportunities to enhance patient safety.

Design, Setting, And Participants: This quality improvement study used a new taxonomy to inform the development and implementation of an HPD classifier tool to categorize HPDs into errors associated with cognitive, technical, and team dynamic functions. The HPD classifier tool was then used to concurrently analyze surgical adverse events in 3 adult hospital affiliates-a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital-from January 2, 2018, to June 30, 2018. Surgical trainees presented data describing all adverse events associated with surgical services at weekly hospital-based morbidity and mortality conferences. Adverse events and HPDs were classified in discussion with attending faculty and residents. Data were analyzed from July 9, 2018, to December 23, 2018.

Main Outcomes And Measures: The incidence and primary and secondary causes of HPDs were classified using an HPD classifier tool.

Results: A total of 188 adverse events were recorded, including 182 adverse events (96.8%) among 5365 patients who underwent surgical operations and 6 adverse events (3.2%) among patients undergoing nonoperative treatment. Among these 188 adverse events, 106 (56.4%) were associated with HPDs. Among these 106 HPD adverse events, a total of 192 HPDs (mean [SD], 1.8 [0.9] HPDs per HPD event) were identified. Human performance deficiencies were categorized as execution (98 HPDs [51.0%]), planning or problem solving (55 HPDs [28.6%]), communication (24 HPDs [12.5%]), teamwork (9 HPDs [4.7%]), and rules violation (6 HPDs [3.1%]). Human performance deficiencies most commonly presented as cognitive errors in execution of care or in case planning or problem solving (99 of 192 HPDs [51.6%]). In contrast, technical execution errors without other associated HPDs were observed in 20 of 192 HPDs (10.4%).

Conclusions And Relevance: Human performance deficiencies were identified in more than half of adverse events, most commonly associated with cognitive error in the execution of care. These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.8067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669897PMC
July 2019

Accuracy of Postoperative Risk Scores for Survival Prediction in Interagency Registry for Mechanically Assisted Circulatory Support Profile 1 Continuous-Flow Left Ventricular Assist Device Recipients.

ASAIO J 2020 05;66(5):539-546

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

In this study, we sought to determine the accuracy of several critical care risk scores for predicting survival of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Profile 1 patients after continuous-flow left ventricular assist device (CF-LVAD) placement. We retrospectively analyzed the records of 605 patients who underwent CF-LVAD implantation between 2003 and 2016. We calculated the preoperative HeartMate II Risk Score (HMRS) and preoperative Right Ventricular Failure Risk Score (RVFRS) and the following risk scores for postoperative days 1-5: HMRS, RVFRS, Model for End-stage Liver Disease (MELD), MELD-eXcluding International Normalized Ratio, Post Cardiac Surgery (POCAS) risk score, Sequential Organ Failure Assessment (SOFA) risk score, and Acute Physiology and Chronic Health Evaluation III. The preoperative scores and the postoperative day 1, 5-day mean, and 5-day maximum scores were entered into a receiver operating characteristic curve analysis to examine accuracy for predicting 30-day, 90-day, and 1-year survival. The mean POCAS score was the best predictor of 30-day and 90-day survival (area under the curve [AUC] = 0.869 and 0.816). The postoperative mean RVFRS was the best predictor of 1-year survival (AUC = 0.7908). The postoperative maximum and mean RVFRS and HMRS were more accurate than the preoperative scores. Both of these risk score measurements of acuity in the postoperative intensive care unit setting help predict early mortality after LVAD implantation.
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http://dx.doi.org/10.1097/MAT.0000000000001044DOI Listing
May 2020

Transition Planning for the Senior Surgeon: Guidance and Recommendations From the Society of Surgical Chairs.

JAMA Surg 2019 Jul;154(7):647-653

Department of Surgery, Rutgers New Jersey Medical School, Newark.

Importance: Aging is well documented to be associated with declines in cognitive function and psychomotor performance, but only limited guidance is currently available from medical professional societies or regulatory agencies on how to translate these observations into the appropriate monitoring of physician performance.

Observations: The Society of Surgical Chairs conducted a panel discussion at its 2017 annual meeting and a subsequent survey of its membership in 2018 to develop recommendations for the transitioning of the senior surgeon.

Conclusions And Relevance: Recommendations include mandatory cognitive and psychomotor testing of surgeons by at least age 65 years, potentially as a component of ongoing professional practice evaluation; career transition discussions with surgeons beginning early in their careers; respectful consideration of the potential financial needs, long-standing work commitments, and work-life concerns of retiring surgeons; and creation of teaching, mentoring or coaching, and/or administrative opportunities for senior surgeons in modified clinical or nonclinical roles. Ideally, these initiatives will catalyze a thoughtful and comprehensive new vista in supporting an aging workforce while ensuring the safety of patients, the efficient management of health care organizations, and the avoidance of unnecessary depletions to a sufficiently sized cadre of physicians with case-specific competencies.
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http://dx.doi.org/10.1001/jamasurg.2019.1159DOI Listing
July 2019

Gastrointestinal Bleeding After HeartMate II or HVAD Implantation: Incidence, Location, Etiology, and Effect on Survival.

ASAIO J 2020 03;66(3):283-290

From the Division of Cardiothoracic Transplantation and Circulatory Support, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.

The number of patients on destination therapy is increasing as long-term survival on continuous-flow left ventricular assist device (CF-LVAD) therapy has improved. Gastrointestinal bleeding (GIB) is a common complication after CF-LVAD implantation, and its risk correlates with longer support time, emphasizing the importance of GIB management. The lower pulsatility of CF-LVADs may promote arteriovenous malformations, which amplify the bleeding risk. Here, we retrospectively analyzed the location, incidence, and survival effect of GIB events in HeartMate II (HM-II) and HeartWare Ventricular Assist Device (HVAD) recipients to provide specific details regarding these complications. From November 2003 to March 2016, 526 patients with chronic heart failure underwent primary implantation of an HM-II (n = 403) or HVAD (n = 123) CF-LVAD at our center. Of the 526 patients, 140 (26.6%) had a GIB event (HM-II: n = 100; HVAD: n = 40), 92 (17.5%) had a single GIB event, and 48 (9.1%) had multiple GIB events (range: 2-9 events). HVAD recipients had a higher incidence of both upper and lower GIB events (p < 0.001 and P = 0.002, respectively) than HM-II recipients. Arteriovenous malformation was the most common etiology for GIB (50 patients/72 events); for this group, the average time-to-event was 300.4 days, the recurrence rate was 34%, and the 90-day and 1-year survival rates were 88.3% and 66.7%, respectively. Age at implantation was the only predictor of GIB. In conclusion, our study provides detailed information about GIB events associated with current CF-LVADs. Additional studies are required to evaluate strategies to reduce the incidence of GIB morbidity.
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http://dx.doi.org/10.1097/MAT.0000000000000998DOI Listing
March 2020

Concomitant valve procedures in patients undergoing continuous-flow left ventricular assist device implantation: A single-center experience.

J Thorac Cardiovasc Surg 2019 10 21;158(4):1083-1089.e1. Epub 2019 Feb 21.

Division of Cardiothoracic Transplant and Assist Devices, Baylor College of Medicine, Houston, Tex.

Objective: Long-term support with continuous-flow left ventricular assist devices (CF-LVADs) has improved the outcomes of patients with end-stage heart failure. However, valve disease management in patients who undergo CF-LVAD implantation remains controversial. The aim of this study was to assess our single-center experience with patients who underwent a concomitant valve procedure during implantation of a CF-LVAD.

Methods: From November 2003 through March 2016, 526 patients underwent primary CF-LVAD implantation with a HeartMate II (St Jude Inc, St Paul, Minn; n = 403) or HeartWare (Medtronic, Minneapolis, Minn; n = 123) device at our center. Of those, 91 underwent a concomitant valve procedure during implantation (CF-LVAD+valve procedure group), whereas 435 did not (CF-LVAD-only group). We compared preoperative characteristics and short-term and mid-term survival rates between these groups.

Results: The concomitant valve procedures performed included 13 tricuspid valve repairs, 19 aortic valve repairs or replacements, 30 mitral valve repairs or replacements, and 29 double valve repairs or replacements. Survival rates at 1 month, 6 months, 12 months, and 24 months were 90.3%, 81.4%, 74.9%, and 67.4%, respectively, for the CF-LVAD-only group and 89.0%, 75.8%, 70.3%, and 65.9%, respectively, for the CF-LVAD+valve procedure group (P = .55). The results of Cox regression multivariable modeling showed that performing a concomitant valve procedure was not an independent predictor of mortality (hazard ratio, 1.29; 95% confidence interval, 0.96-1.74; P = .08).

Conclusions: In our experience, performing a concomitant valve procedure during CF-LVAD implantation was not associated with an increased mortality rate. The decision to perform a concomitant valve procedure should be made primarily on the basis of clinical indications for the procedure.
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http://dx.doi.org/10.1016/j.jtcvs.2019.02.040DOI Listing
October 2019

Mitral Valve Repair Rate at a Veterans Affairs Hospital Utilizing a Multidisciplinary Heart Team.

Semin Thorac Cardiovasc Surg 2019 5;31(3):434-441. Epub 2019 Mar 5.

Department of Cardiothoracic Surgery, Baylor College of Medicine/Texas Heart Institute, Houston, Texas; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Hospital, Houston, Texas.

Between 2000 and 2008, the mitral valve (MV) repair rate in patients with severe mitral regurgitation at our low-volume Veterans Affairs hospital was 21%. After instituting a multidisciplinary valve team in 2009, we determined whether this rate increased and characterized the outcomes of patients with degenerative disease. We retrospectively reviewed data from 103 MV operations performed at our hospital between 1/2009 and 8/2016. MV pathology was categorized as degenerative, rheumatic, endocarditis, ischemic, hypertrophic cardiomyopathy, or failed prior MV repair. The surgical techniques used for MV repair were reviewed. For the patients with degenerative disease who underwent MV repair, we assessed leaflet involvement and postoperative valve function. For the full cohort, the MV repair rate was 67% and the 30-day mortality rate was 0.97%. Of the 74 patients with degenerative disease, 64 (86.5%) underwent MV repair (none required reoperation). For these patients, the MV repair rate was significantly higher when the surgical approach was sternotomy rather than minimally invasive right minithoracotomy (92.5% vs 71.4%, P = 0.03). After MV repair, 95.3% of the degenerative disease patients had mild or less mitral regurgitation; median echocardiography follow-up time was 555 days. Anatomic features associated with a reduced MV repair rate in patients with degenerative disease were dystrophic leaflet calcification and severe mitral annular calcification. In an institution with a low volume of MV operations, preoperative surgical planning with a multidisciplinary valve team was associated with improved MV repair rates and excellent repair quality in patients with degenerative valve disease.
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http://dx.doi.org/10.1053/j.semtcvs.2019.02.028DOI Listing
January 2020