Publications by authors named "Vaughn A Starnes"

105 Publications

Intercostal Cryo Nerve Block in Minimally Invasive Cardiac Surgery: The Prospective Randomized FROST Trial.

Pain Ther 2021 Sep 20. Epub 2021 Sep 20.

United Heart and Vascular Institute-Allina, Saint Paul, MN, USA.

Introduction: Intercostal cryo nerve block has been shown to enhance pulmonary function recovery and pain management in post-thoracotomy procedures. However, its benefit have never been demonstrated in minimal invasive thoracotomy heart valve surgery (Mini-HVS). The purpose of the study was to determine whether intraoperative intercostal cryo nerve block in conjunction with standard of care (collectively referred to hereafter as CryoNB) provided superior analgesic efficacy in patients undergoing Mini-HVS compared to standard-of-care (SOC).

Methods: FROST was a prospective, 3:1 randomized (CryoNB vs. SOC), multicenter trial in patients undergoing Mini-HVS. The primary endpoint was the 48-h postoperative forced expiratory volume in 1 s (FEV1) result. Secondary endpoints were visual analog scale (VAS) scores for pain at the surgical site and general pain, intensive care unit and hospital length-of-stay, total opioid consumption, and allodynia at 6 months postoperatively.

Results: A total of 84 patients were randomized to the two arms of the trial CryoNB (n = 65) and SOC (n = 19). Baseline Society of Thoracic Surgeons Predictive Risk of Mortality (STS PROM) score, ejection fraction, and FEV1 were similar between cohorts. A higher 48-h postoperative FEV1 result was demonstrated in the CryoNB cohort versus the SOC cohort (1.20 ± 0.46 vs. 0.93 ± 0.43 L; P = 0.02, one-sided two-sample t test). Surgical site VAS scores were similar between the CryoNB and SOC cohorts at all postoperative timepoints evaluated, but VAS scores not related to the surgical site were lower in the SOC group at 72, 94, and 120 h postoperatively. The SOC cohort had a 13% higher opioid consumption than the CryoNB cohort. One of 64 CryoNB patients reported allodynia that did not require pain medication at 10 months.

Conclusions: The results of FROST demonstrated that intercostal CryoNB provided enhanced FEV1 score at 48 h postoperatively with optimized analgesic effectiveness versus SOC. Future larger prospective randomized trials are warranted to determine whether intercostal CryoNB has an opioid-sparing effect in patients undergoing Mini-HVS.

Trial Registration: Clinicaltrials.gov identifier: NCT02922153.
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http://dx.doi.org/10.1007/s40122-021-00318-0DOI Listing
September 2021

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

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

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

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

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

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

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

The Ross Procedure in Children: The Gold Standard?

Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021 ;24:62-66

Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California.

The management of aortic valve disease in the pediatric population is complex and requires an individualized approach and opportune application of techniques focused on each individual patient's specific anatomy, pathology, and clinical presentation. Though some patients may require variations in the approach to management, the ultimate goal should be to perform a Ross procedure when aortic valve replacement is indicated.
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http://dx.doi.org/10.1053/j.pcsu.2021.03.002DOI Listing
January 2021

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Resident education in congenital heart surgery does not compromise outcomes.

J Thorac Cardiovasc Surg 2021 Jan 11. Epub 2021 Jan 11.

Division of Cardiac Surgery, Children's Hospital Los Angeles, Los Angeles, Calif; Division of Cardiac Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.

Objective: Most of all congenital cardiac surgical programs participate in public outcomes reporting. The primary end point is transparency. In this era, academic programs with surgical residents face the challenge of producing outstanding results while allowing residents to learn by doing. We sought to understand the effect of education on our surgical outcomes.

Methods: We collected data for all American Board of Thoracic Surgery index cases done at our institution over a 10-year period. We identified 3406 cases and categorized them into 2 groups according to primary surgeon: attending (2269) versus resident (1137). In a multivariable logistic regression model we examined the effect of operating surgeon on in-hospital mortality, major morbidity, and length of stay. We used propensity score matching subsequently to balance differences between cohorts, and multivariable logistic regression was repeated.

Results: Using the entire cohort, multivariable logistic regression model adjusted for age, sex, weight, lack of preoperative comorbidity, presence of preoperative respiratory failure, The Society of Thoracic Surgeons--European Association for Cardio-Thoracic Surgery category, and need for deep hypothermic circulatory arrest, showed a higher odds of survival in the resident cohort (odds ratio, 1.484; 95% confidence interval, 0.998-2.206; P = .05). Propensity score matching identified 1137 pairs of attending and resident cases with well-balanced preoperative variables. Logistic regression modeling using the matched cohort showed equivalent 30-day mortality, 30-day major morbidity, and length of stay.

Conclusions: There was no difference in mortality, major morbidity, or length of stay when similar cases were compared that were operated on by attendings versus those by a resident. Effectively educating congenital heart surgeons without compromising an operation's quality requires thoughtful approach, including case selection and graded responsibility.
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http://dx.doi.org/10.1016/j.jtcvs.2020.12.112DOI Listing
January 2021

Gender representation among leadership at national and regional cardiothoracic surgery organizational annual meetings.

J Thorac Cardiovasc Surg 2021 Mar 11;161(3):733-744. Epub 2020 Dec 11.

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

Background: Increased attention has been dedicated to gender inequity at scientific meetings. This study evaluated the gender distribution of session leaders at cardiothoracic surgery national and regional meetings.

Methods: This is a descriptive study of the gender of peer-selected session leaders at 4 cardiothoracic surgery organizations' annual meetings from 2015 to 2019. Session leaders included moderators, panelists, and invited discussants. Data from publicly available programs were used to generate a list of session leaders and organization leaders. The primary outcome measure was the proportion of female session leaders at annual meetings. Descriptive analyses were performed, including the Cochran-Armitage trend test for linear trends of proportions.

Results: A total of 679 sessions over 20 meetings were examined. Of the 3662 session leaders, 480 (13.1%) were women. The proportion of total female session leaders trended positively over time from 9.6% (56 of 581) in 2015 to 15.9% (169 of 1060) in 2019 (P = .001). Among specialty topic sessions, female session leaders were distributed as follows: adult cardiac, 6.9% (81 of 1172); congenital cardiac, 10.8% (47 of 437); and thoracic, 23.2% (155 of 668). The proportion of female session leaders trended significantly only for thoracic sessions (20.6% [21 of 102] in 2015 to 29.2% [58 of 199] in 2019; P = .02). More than one-half of the sessions (57.4%; 390 of 679) featured all-male session leadership.

Conclusions: Women remain underrepresented in leadership roles at cardiothoracic surgery organizational meetings. This may deter female applicants and has implications for female surgeons' career trajectories; therefore, attention must be given to the potential for unconscious bias in leadership in cardiothoracic surgery.
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http://dx.doi.org/10.1016/j.jtcvs.2020.11.157DOI Listing
March 2021

Clinical Importance of Concomitant Cleft Lip/Palate in the Surgical Management of Patients With Congenital Heart Disease.

World J Pediatr Congenit Heart Surg 2021 Jan;12(1):35-42

Division of Cardiothoracic Surgery, Department of Surgery, Keck School of Medicine of USC, 12223University of Southern California, Los Angeles, CA, USA.

Background: Congenital heart disease (CHD) frequently occurs in conjunction with extracardiac developmental anomalies, including cleft malformations. The clinical impact of concomitant cleft disease on the surgical management of CHD has not been studied. We evaluated cardiac surgical outcomes in patients with concomitant CHD and cleft lip and/or palate (CL/P).

Methods: Patients with CHD + CL/P managed at our institution between January 2004 and December 2018 were included. Demographic, operative, and follow-up data were retrospectively collected and analyzed using SAS 9.4. Chi-square tests were used for categorical variables and test or Wilcoxon rank sum tests for continuous variables. Significance of < .05 was used.

Results: There were 127 patients with CHD + CL/P; 63 (50%) were boys. Compared to the general CHD population, patients with CHD + CL/P demonstrated an enrichment of atrial septal defects (10.5% vs 34%), tetralogy of Fallot/double outlet right ventricle (6.4% vs 15.7%), arch defects (4.5% vs 10.2%), truncus arteriosus (1.2% vs 3.1%), and total anomalous pulmonary venous return (1.0% vs 2.4%). Of 63 patients who underwent CHD repair, 58 (92%) did so prior to CL/P repair at 21.5 (6-114) days of age. Compared to CHD lesion-matched patients undergoing cardiac surgical repair at our institution, patients with CL/P had a 2- to 3.7-fold longer intensive care stay, 1.8- to 2.6-fold longer hospital stay, and 6- to 13.5-fold increase in major morbidity, without a significant difference in mortality.

Conclusions: Cardiac outflow tract defects are particularly overrepresented in CL/P patients. The presence of CL/P increases the complexity of postoperative care after CHD surgery, without a significant impact on mortality.
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http://dx.doi.org/10.1177/2150135120954814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8138941PMC
January 2021

Commentary: Expanding the utility of the Ross procedure-Proceed with caution.

J Thorac Cardiovasc Surg 2020 Oct 22. Epub 2020 Oct 22.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.10.058DOI Listing
October 2020

Brave New World: Virtual conferencing and surgical education in the Coronavirus Disease 2019 era.

J Thorac Cardiovasc Surg 2021 03 6;161(3):748-752. Epub 2020 Aug 6.

Department of Cardiothoracic and Vascular Surgery, University of Texas Health Science Center Houston, McGovern Medical School, Houston, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.07.094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409975PMC
March 2021

Thoracic surgical education in a changing paradigm.

Authors:
Vaughn A Starnes

J Thorac Cardiovasc Surg 2021 Mar 17;161(3):713-722. Epub 2020 May 17.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.05.023DOI Listing
March 2021

Impact of prior diaphragm plication on subsequent stages of single ventricle palliation.

J Thorac Cardiovasc Surg 2020 Nov 20;160(5):1291-1296.e1. Epub 2020 Jun 20.

Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Surgery, University of Southern California, Los Angeles, Calif.

Background: Phrenic nerve injury is a known cause of morbidity after single ventricle palliation. Previous studies have shown that hemidiaphragm plication improves short-term outcomes. The effect of plication on the outcomes of subsequent stages of single ventricle palliation is unknown.

Methods: From 1997 to 2015, 1146 patients underwent surgical management of single ventricle physiology at our institution. We reviewed the records of 30 patients who had undergone diaphragm plication for phrenic nerve injury before Fontan completion. Each patient was compared with 2 propensity-matched controls identified from patients who underwent the Glenn or Fontan procedure during the same period without diaphragm plication. Propensity matching was achieved for each test subject using the nearest neighbor algorithm. Data are presented as the median and quartiles or numbers and percentages.

Results: The cohort included 18 boys (60%). Of the 30 patients, 19 (63%) had undergone plication after first-stage palliation. Of these, 13 have undergone completion Fontan, 5 were awaiting Fontan at the last follow-up, and 1 had died. An additional 11 patients had undergone plication after Glenn and proceeded to Fontan completion. Thus, 24 patients with diaphragm plication have undergone Fontan completion. No difference was found in pulmonary pressure or resistance between the plicated patients and their propensity-matched controls. Both groups had comparable chest tube output and hospital lengths of stay. Equal proportions of patients in both groups required pulmonary vasodilator therapy and/or supplemental oxygen at hospital discharge.

Conclusions: Prior diaphragm plication does not adversely affect Fontan completion in children with single ventricle physiology. The hospital course during subsequent stages of palliation for plicated patients was no different than that of matched controls.
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http://dx.doi.org/10.1016/j.jtcvs.2020.06.007DOI Listing
November 2020

Biventricular Repair in Interrupted Aortic Arch and Ventricular Septal Defect With a Small Left Ventricular Outflow Tract.

Ann Thorac Surg 2021 02 26;111(2):637-644. Epub 2020 Jun 26.

Division of Cardiothoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital, Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California. Electronic address:

Background: In patients with interrupted aortic arch and ventricular septal defect (VSD) with a small left ventricular outflow tract (LVOT), either aortopulmonary amalgamation or a Ross-Konno type procedure can be performed to create stable systemic outflow. We sought to analyze factors associated with these different surgical approaches.

Methods: We retrospectively identified patients who underwent surgical repair for interrupted aortic arch/VSD at our institution between 1998 and 2017. Of these, 43 patients had a small, native LVOT that was unsuitable for systemic outflow. Patient data were retrospectively collected for this cohort and analyzed.

Results: Aortopulmonary amalgamation was performed at 7 days (interquartile range [IQR], 5-10) in 30 patients (group I). Within group I a primary Yasui repair with ventricular septation was performed in 3 patients and a Norwood-type repair in the other 27. Of these 27, 19 underwent subsequent biventricular conversion at 9 months (IQR, 7-11). In contrast 13 patients underwent a Ross procedure at 12 days (IQR, 6-27) (group II). Compared with group I, group II patients had a smaller VSD (3.5 vs 5.1 mm, P < .001) that was more often remote from the semilunar valves (38% vs 13%, P = .02). Operative mortality occurred in 1 group I patient (4%) at the time of biventricular conversion and 2 group II patients (15%) during the Ross procedure. After a 5.2-year (IQR, 3.2-7.4) follow-up there were 2 additional mortalities in each group, all unrelated to cardiac disease.

Conclusions: When native LVOT in interrupted aortic arch/VSD is unsuitable for systemic outflow, size and location of the VSD can be used to tailor the surgical approach to establish biventricular circulation with favorable intermediate-term outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.045DOI Listing
February 2021

Penetrating injury to the cardiac box.

J Trauma Acute Care Surg 2020 09;89(3):482-487

From the Division of Trauma and Critical Care (J.S.K., K.I., L.A.D.L., C.R., D.D.), University of Southern California, Los Angeles, California; Department of Surgery (J.B.H.), The University of Texas Medical School at Houston, Houston, Texas; Anesthesiology and Critical Care Medicine Department (J.S.D.), Hospices Civils de Lyon, Lyon, France; and Department of Surgery (V.A.S.), Keck School of Medicine, University of Southern California, Los Angeles, California.

Background: A penetrating injury to the "cardiac box" is thought to be predictive of an injury to the heart; however, there is very little evidence available to support this association. This study aims to evaluate the relationship between penetrating trauma to the cardiac box and a clinically significant injury.

Methods: All patients presenting to a Level I trauma center from January 2009 to June 2015 who sustained a penetrating injury isolated to the thorax were retrospectively identified. Patients were categorized according to the location of injury: within or outside the historical cardiac box. Patients with concurrent injuries both inside and outside the cardiac box were excluded. Clinical demographics, injuries, procedures, and outcomes were compared.

Results: During this 7-year period, 330 patients (92% male; median age, 28 years) sustained penetrating injuries isolated to the thorax: 138 (42%) within the cardiac box and 192 (58%) outside the cardiac box. By mechanism, 105 (76%) were stab wounds (SW) and 33 (24%) were gunshot wounds (GSW) inside the cardiac box, and 125 (65%) SW and 67 (35%) GSW outside the cardiac box. The overall rate of thoracotomy or sternotomy (35/138 [25.4%] vs. 15/192 [7.8%], p < 0.001) and the incidence of cardiac injury (18/138 [13%] vs. 5/192 [2.6%], p < 0.001) were significantly higher in patients with penetrating trauma within the cardiac box. This was, however, dependent on mechanism with SW demonstrating a higher incidence of cardiac injury (15/105 [14.3%] vs. 3/125 [2.4%], p = 0.001) and GSW showing no significant difference (3/33 [9.1%] vs. 2/67 [3%], p = 0.328]. There was no difference in overall mortality (9/138 [6.5%] vs. 6/192 [3.1%], p = 0.144).

Conclusion: The role of the cardiac box in the clinical evaluation of a patient with a penetrating injury to the thorax has remained unclear. In this analysis, mechanism is important. Stab wounds to the cardiac box were associated with a higher risk of cardiac injury. However, for GSW, injury to the cardiac box was not associated with a higher incidence of injury. The diagnostic interaction between clinical examination and ultrasound, for the diagnosis of clinically significant cardiac injuries, warrants further investigation.

Level Of Evidence: Prognostic study, Level IV, Therapeutic V.
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http://dx.doi.org/10.1097/TA.0000000000002808DOI Listing
September 2020

American Association for Thoracic Surgery: Maintaining the mission during the coronavirus disease 2019 (COVID-19) pandemic.

J Thorac Cardiovasc Surg 2020 09 16;160(3):737-739. Epub 2020 May 16.

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

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http://dx.doi.org/10.1016/j.jtcvs.2020.05.022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229448PMC
September 2020

Invited Commentary.

Ann Thorac Surg 2019 11 27;108(5):1381-1382. Epub 2019 Jun 27.

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

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http://dx.doi.org/10.1016/j.athoracsur.2019.05.017DOI Listing
November 2019

The ring of fire: Nuances in the surgical management of mitral annular calcification.

J Thorac Cardiovasc Surg 2019 02 10;157(2):570-571. Epub 2018 Oct 10.

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

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http://dx.doi.org/10.1016/j.jtcvs.2018.09.090DOI Listing
February 2019

Simultaneous Systemic to Pulmonary Shunt and Pulmonary Artery Banding is a Viable Option for Neonatal Palliation of Single Ventricle Physiology.

Semin Thorac Cardiovasc Surg 2019 29;31(2):234-241. Epub 2018 Sep 29.

Heart Institute, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, California. Electronic address:

A subset of neonates with single ventricle (SV) physiology has antegrade pulmonary blood flow that is deemed unlikely to be reliable until Glenn. We have used systemic to pulmonary shunt (SPS) with pulmonary artery banding (PAB) to optimize pulmonary blood flow while maintaining reserve antegrade flow. We hypothesize that this is an effective strategy that can be accomplished without the routine need for cardiopulmonary bypass. We retrospectively reviewed the records of 60 neonates who underwent combined SPS + PAB between 2004 and 2015. Data are presented as median with quartiles. Children were 8 (4-19) days old at surgery and included 38 (63%) boys. Atresia or severe stenosis of the subpulmonary atrioventricular (AV) valve associated with pulmonary blood flow across a bulboventricular foramen was present in 37 (62%). In 20 (33%), heterotaxy-associated unbalanced AV canal with pulmonary stenosis with or without anomalous pulmonary venous drainage was present. First-stage palliation was accomplished without cardiopulmonary bypass in 44 patients (73%). There were 7 (12%) hospital deaths, 4 among the 20 (20%) with heterotaxy. Fifty-three children were followed for a median 5.1 (1.8-8.2) years. Three early reinterventions were required after initial palliation (1 PAB adjustment, 2 SPS balloon angioplasties). Five additional heterotaxy patients experienced late mortality during follow-up. There were no early or emergent Glenn. Thirty-nine patients have reached Fontan circulation with a median pre-Fontan PA pressure of 14 (12-18) mm Hg. One patient converted to biventricular physiology and the remaining await completion Fontan. Heterotaxy was the only independent predictor of mortality (hazard ratio 10 (2.3-44, P < 0.001). In SV patients with unreliable antegrade PA flow, SPS + PAB is an effective first-stage palliation. SV patients with heterotaxy are at increased risk for mortality.
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http://dx.doi.org/10.1053/j.semtcvs.2018.09.019DOI Listing
December 2019

Eating well at your first job.

J Thorac Cardiovasc Surg 2018 10 14;156(4):1585-1586. Epub 2018 Aug 14.

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

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http://dx.doi.org/10.1016/j.jtcvs.2018.06.041DOI Listing
October 2018

Successful rescue therapy with venovenous extracorporeal membrane oxygenation for re-expansion pulmonary oedema in a patient with one lung.

Eur J Cardiothorac Surg 2019 Mar;55(3):582-584

Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

Re-expansion pulmonary oedema following the drainage of pleural fluid is rare. We report a patient with 1 lung who developed life-threatening re-expansion pulmonary oedema following thoracentesis and was rescued with venovenous (VV) extracorporeal membrane oxygenation (ECMO), surviving to discharge 28 days later. An aggressive early rescue therapy with VV ECMO should be pursued for all types of acute lung injury regardless of patient age, comorbidities or transplant candidacy, given the likelihood of native lung recovery following ECMO support.
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http://dx.doi.org/10.1093/ejcts/ezy262DOI Listing
March 2019

Surgical Management and Outcomes of Ebstein Anomaly in Neonates and Infants: A Society of Thoracic Surgeons Congenital Heart Surgery Database Analysis.

Ann Thorac Surg 2018 09 16;106(3):785-791. Epub 2018 May 16.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Ebstein anomaly (EA) encompasses a broad spectrum of morphology and clinical presentation. Those who are symptomatic early in infancy are generally at highest risk, but there are limited data regarding multicentric practice patterns and outcomes. We analyzed multiinstitutional data concerning operations and outcomes in neonates and infants with EA.

Methods: Index operations reported in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 to 2016) were potentially eligible for inclusion. Analysis was limited to patients with diagnosis of EA and less than 1 year of age at time of surgery (neonates ≤30 days, infants 31 to 365 days).

Results: The study population included 255 neonates and 239 infants (at 95 centers). Among neonates, median age at operation was 7 days (interquartile range, 4 to 13 days) and the majority required preoperative ventilation (61.6%, n = 157). The most common primary operation performed among neonates was Ebstein repair (39.6%, n = 101), followed by systemic-to-pulmonary shunt (20.4%, n = 52) and tricuspid valve closure (9.4%, n = 24). Overall neonatal operative mortality was 27.4% (n = 70), with composite morbidity-mortality of 51.4% (n = 48). For infants, median age at operation was 179 days (interquartile range, 108-234 days); the most common primary operation for infants was superior cavopulmonary anastomosis (38.1%, n = 91) followed by Ebstein repair (15.5%, n = 37). Overall operative mortality for infants was 9.2% (n = 22) with composite morbidity-mortality of 20.1% (48).

Conclusions: Symptomatic EA in early infancy is very high risk and a variety of operative procedures were performed. A dedicated prospective study is required to more fully understand optimal selection of treatment pathways to guide a systematic approach to operative management.
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http://dx.doi.org/10.1016/j.athoracsur.2018.04.049DOI Listing
September 2018

Arch Augmentation via Median Sternotomy for Coarctation of Aorta With Proximal Arch Hypoplasia.

Ann Thorac Surg 2018 10 16;106(4):1214-1219. Epub 2018 May 16.

Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California. Electronic address:

Background: Coarctation of the aorta can be associated with hypoplasia of the proximal transverse aortic arch. One approach to manage this condition is via left thoracotomy and extended end-to-end anastomosis with the expectation that the proximal arch will grow over time. Our preferred approach is to augment the aorta via midline sternotomy. We hypothesized that this approach is safe, durable, and allows reliable growth of the aorta.

Methods: We identified the records of patients with biventricular anatomy who had coarctation of the aorta, hypoplasia of the proximal transverse arch, and no other cardiac lesion that would mandate cardiopulmonary bypass use and midline sternotomy. The records of 62 such patients operated on between 2005 and 2016 were retrospectively reviewed. Patient demographics, clinical variables and outcome data were collected and analyzed using SAS 9.4. Data are presented as median (interquartile range [IQR]).

Results: Sixty-two patients (23 girls [37%]) underwent repair at 10 (IQR, 5 to 21) days of life. Forty-nine (79%) patients were on prostaglandin infusion to maintain ductal patency. Fifteen (24%) patients presented in shock with end organ dysfunction, 17 (27%) were on inotropes, and 26 (42%) were mechanically ventilated. The proximal transverse arch was 41% (IQR, 34% to 47%) of the size of ascending aorta as measured by echocardiography (z-score, -5 [IQR, -5.8 to -4.3]). Following median sternotomy, repair was carried out on cardiopulmonary bypass (41 [IQR, 37 to 47] minutes). The arch was reconstructed with (n = 26 [42%]) or without (n = 36 [58%]) coarctectomy usually using homograft patch aortoplasty (n = 58 [94%]). In all but 2 patients, repair was undertaken with circulatory arrest (27 [IQR, 22 to 31] minutes). Patients were extubated 4 (IQR, 3 to 5) days later and discharged home in 12 (IQR, 8 to 18) days. There was no mortality, and 8 morbidity events (3 recurrent nerve injury, 2 chylothorax, 1 phrenic nerve injury, 1 seizure, and 1 superficial wound infection) in 7 (11%) patients. All patients are alive at 41 (IQR, 11 to 64) months of follow-up. Reintervention was required in 6 (10%) patients (5 catheter based and 3 surgical) for recurrent distal coarctation. Reintervention-free survival at 1, 3, and 5 years was 87%. Only 1 child was currently on antihypertensive therapy, and all were in New York Heart Association functional class I symptoms. At last echocardiogram, the proximal transverse arch was 97% (IQR, 84% to 103%) of the diameter of the ascending aorta (z-score, 0.8 (IQR, 0.3 to 1.3]), ejection fraction was 70% (IQR, 60% to 76%), and only 2 patients had significant left ventricular hypertrophy.

Conclusions: Arch augmentation via median sternotomy is a safe and effective procedure that can be accomplished with low morbidity and mortality. The reconstructed arch retains excellent growth potential resulting in a very favorable physiologic outcome.
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http://dx.doi.org/10.1016/j.athoracsur.2018.04.025DOI Listing
October 2018

Liberal Use of Delayed Sternal Closure in Children Is Not Associated With Increased Morbidity.

Ann Thorac Surg 2018 08 23;106(2):581-586. Epub 2018 Apr 23.

Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital Los Angeles, Los Angeles, California.

Background: Delayed sternal closure (DSC) is often employed to optimize hemodynamics following pediatric cardiac surgery. Prior reports have suggested that DSC may be associated with increased morbidity. We sought to analyze the impact of a liberal policy of DSC on surgical outcomes at our center.

Methods: We retrospectively evaluated the clinical course of 1,000 consecutive patients between July 2005 and June 2015 whose sternum was electively left open following pediatric cardiac surgery. Data are presented as mean and standard error (parametric) or median and quartiles (nonparametric). Receiver-operating characteristic curve analysis was undertaken to identify significant points of inflection. A p less than 0.05 was considered significant.

Results: An a priori decision to leave the sternum open is made when complex surgery, especially in neonates and usually involving circulatory arrest, is expected to result in postoperative hemodynamic instability. Age at index surgery for the 1,000 patients was 7 (interquartile range [IQR], 3 to 19) days and weight 3.3 (IQR, 2.8 to 3.7) kg. There were 816 (82%) neonates and 569 (57%) boys. Index operations included 332 (33%) Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category 5, 483 (48%) STAT category 4, and 185 (19%) STAT category 3 procedures. A total of 103 (10%) patients required postoperative extracorporeal support. Following hemodynamic recovery, DSC was undertaken 3 (IQR, 2 to 4) days postoperatively and in 98.3% patients was performed in the intensive care unit. Overall, mortality was 6.3% and major Society of Thoracic Surgeons morbidity was 21.6%. There were 42 (4.2%) positive mediastinal surveillance cultures at the time of DSC, with the most common organism being coagulase-negative staphylococcus. Fifty-nine (5.9%) clinical sternal and mediastinal wound infections and a total of 117 infectious complications were encountered in 94 patients. Using Society of Thoracic Surgeons database outcome as benchmark, mortality and length of stay in our patients were comparable when analyzed by STAT categories or for the 2 most common index procedures (eg, Norwood and arterial switch operations). Receiver-operating characteristic curve analysis showed that 5 days of open sternum had a weak, but statistically significant, correlation with incidence of infectious complications (area under the curve, 0.56; p = 0.002). The need for DSC 5 or more days after the index procedure was observed in 177 (18%) patients and was not associated with increased wound infection. It was, however, independently associated on multiple regression analysis with major morbidity (odds ratio, 1.7; 95% confidence interval, 1.2 to 2.5; p = 0.002) and, in the subset of 897 patients who did not require extracorporeal support, with increased mortality (odds ratio, 2.2; 95% confidence interval, 1.3 to 3.6; p = 0.003).

Conclusions: A liberal policy of DSC does not adversely affect surgical outcomes, including infectious complications and length of stay. We submit that need for DSC should not, by itself, be considered a source of morbidity.
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http://dx.doi.org/10.1016/j.athoracsur.2018.03.053DOI Listing
August 2018

Need for Pulmonary Arterioplasty During Glenn Independently Predicts Inferior Surgical Outcome.

Ann Thorac Surg 2018 07 11;106(1):156-164. Epub 2018 Apr 11.

Division of Cardiothoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Heart Institute, Children's Hospital of Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California. Electronic address:

Background: Bidirectional cavopulmonary anastomosis (BDCA) can be accomplished with low morbidity and mortality. The impact of concomitant pulmonary arterioplasty (PAplasty) is not known. We hypothesized that the need for and extent of PAplasty adversely affect BDCA outcomes.

Methods: Patients who underwent BDCA at our institution between 2006 and 2014 were included. Patient demographics, operative characteristics, mortality, and morbidity were analyzed. Serious physiologic adverse event following Glenn (GAE) was defined as need for extracorporeal support, BDCA takedown or percutaneous intervention during same admission, hospital length of stay 1 SD or more from mean, or need for supplemental oxygen at discharge. PAplasty was categorized according to extent. Data were analyzed using SAS 9.4 (SAS Institute, Cary, NC).

Results: A total of 424 patients (231 boys, 54%) underwent BDCA for single ventricle physiology at a median of 7 (5.5 to 8.9) months of age and 6.5 (5.7 to 7.7) kg weight. A total of 112 (26%) patients required PAplasty: 23 were patch closures of the divided distal PA (type 1), 45 were central PA augmentations (type 2), 23 extended to the hilum on 1-branch PA (type 3), and 21 were bilateral hilum to hilum augmentation (type 4). Patients who required PAplasty tended to be significantly younger and more likely to have single right ventricles. There was no difference in PA pressure or resistance between patients who did and did not require PAplasty. Major Society of Thoracic Surgeons morbidity (13% vs 6%; p = 0.001), GAE (45% vs 34%; p = 0.04), and in-hospital mortality (5.4% vs 1.9%; p = 0.03) were higher in patients who required PAplasty compared with those who did not. Among the operative variables evaluated, need for PAplasty (hazard ratio [HR], 1.6; p = 0.03) independently predicted hospital mortality. Need for circulatory arrest (HR, 4; p = 0.005) and PAplasty (HR, 2.4; p = 0.0006) were independent predictors of Society of Thoracic Surgeons morbidity and need for PAplasty independently predicted GAE (HR, 1.8; p = 0.03).

Conclusions: The need for PAplasty at BDCA is an independent predictor of mortality and morbidity. It is important to consider this variable when developing outcome metrics for BDCA.
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http://dx.doi.org/10.1016/j.athoracsur.2018.03.011DOI Listing
July 2018

Resection of Metastatic Hepatocellular Carcinoma in the Ventricular Septum Causing Left Ventricular Outflow Tract Obstruction.

Ann Thorac Surg 2018 03;105(3):e107-e108

Division of Cardiothoracic Surgery, CardioVascular Thoracic Institute, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Isolated cardiac involvement of recurrent metastatic hepatocellular carcinoma (HCC) is extremely rare. We report a patient with left ventricular outflow tract (LVOT) obstruction due to isolated recurrent HCC involving the interventricular septum (IVS). A ventriculotomy with resection of the tumor and patch repair of the IVS was performed with successful relief of LVOT obstruction. The patient was discharged home 6 days later symptom-free.
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http://dx.doi.org/10.1016/j.athoracsur.2017.09.052DOI Listing
March 2018

Optimal Approach for Repair of Left Atrial-Esophageal Fistula Complicating Radiofrequency Ablation.

Ann Thorac Surg 2018 05 2;105(5):e229-e231. Epub 2018 Feb 2.

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

Left atrial-esophageal fistula after endovascular radiofrequency ablation for cardiac arrhythmias is a life-threatening complication. Immediate surgical repair offers the best chance for survival. The optimal surgical technique is unknown. We describe our recommended surgical approach.
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http://dx.doi.org/10.1016/j.athoracsur.2017.12.026DOI Listing
May 2018

Landmark lecture on surgery: paediatric cardiothoracic surgery - training the next generation of congenital heart surgeons.

Cardiol Young 2017 Dec;27(10):1986-1990

1Department of Surgery,Keck School of Medicine,University of Southern California,Los Angeles,California,United States of America.

Introduction Recent changes in surgical education have had an impact on our congenital training programmes. The mandate of the 8-hour workweek, a rapidly expanding knowledge base, and a host of other mandates has had an impact on the readiness of the fellows who are entering congenital programmes. To understand these issues completely, we interviewed the top congenital experts in the United States of America. The purpose of this paper is to share their insight and offer suggestions to address these challenges.

Methods: We used a qualitative thematic analysis approach and performed phone interviews with the top five congenital experts in the United States of America.

Results: Experts unanimously felt that duty-hour restrictions have negatively affected congenital training programmes in the following ways: current fellows do not seem as conditioned as fellows in the past, patient handoffs are not consistent with excellent performance, the mentor-mentee relationship has been affected by duty-hour restrictions, and fellows may be less prepared for real-world practice. Three positive themes emerged in response to duty-hour restrictions: fellows appear to be doing less menial task work, fellows are now better rested for learning, and we are attracting more individuals into the speciality. Experts agreed that congenital fellowships should be increased to 2 years. There was support for both the traditional and integrated residency pathways. Discussion We are in a new era of education and must work together to overcome the challenges that have arisen in recent years.
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http://dx.doi.org/10.1017/S1047951117002153DOI Listing
December 2017

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

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

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

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

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

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

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

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

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

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

Objective: To evaluate outcomes after mitral valve repair.

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

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

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

The Utility of Nurse-Managed Extracorporeal Life Support in an Adult Cardiac Intensive Care Unit.

Ann Thorac Surg 2017 Aug 10;104(2):510-514. Epub 2017 Feb 10.

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

Background: The use of extracorporeal life support (ECLS) worldwide has increased exponentially since 2009. The patient requiring ECLS demands an investment of hospital resources, including personnel. Educating bedside nurses to manage ECLS circuits broadens the availability of trained providers.

Methods: Experienced cardiothoracic intensive care unit (CTICU) nurses underwent training to manage ECLS circuits, including volume assessment, treatment of arterial blood gas values, the physiology of ECLS, and recognition of common emergencies. In addition to lectures and a written examination, simulation using water circuits and an ICU model allowed assessment of skills and understanding of concepts. Performance assessments were completed regularly at the bedside, and skills revalidation occurred every 6 months. A sequential cohort of 40 patients was tracked over 1 year.

Results: Despite doubling the census of ECLS patients in 1 year, management by specially trained CTICU nurses has positively affected patient care and outcomes. At a single institution, 40 patients had a median of 6 days (interquartile range, 2 to 226 days) of support in 2014, leading to 767 patient-days of support. Survival to hospital discharge increased to 45% in 2014. Most survivors were weaned from support. Neurologic injury was the most common cause of death, followed by failure to qualify for advanced therapies.

Conclusions: With on-going education and assessment, including crisis training, physiology, and cannulation strategies, CTICU nurses can safely operate ECLS circuits and can increase the availability of appropriately trained providers to accommodate the exponential increase in ECLS occurrences without negatively affecting outcomes and generally at a lower cost.
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http://dx.doi.org/10.1016/j.athoracsur.2016.11.005DOI Listing
August 2017
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