Faculty Bibliography

BACKGROUND: There are limited data in the literature concerning the effect of a blood conservation strategy (BCS) on aortic valve replacement (AVR) patients. METHODS: From 2007 to 2011, 778 patients underwent AVR at a single institution. During this period, a multidisciplinary BCS was initiated with emphasis on limiting intraoperative hemodilution, tolerance of perioperative anemia, and blood management education for the cardiac surgery care providers. RESULTS: Mortality was 3.0% (23 of 778) overall and 1.7% (9 of 522) for isolated first-time AVR. There was no difference in rates of mortality (p = 0.5) or major complications (p = 0.4) between the pre-BCS and post-BCS groups; however, the BCS was associated with a lower risk of major complications (odds ratio, 1.7; p = 0.046) by multivariable analysis. The incidence of red blood cell (RBC) transfusion decreased from 82.9% (324 of 391) to 68.0% (263 of 387; p < 0.01). Of those patients who did not receive any day-of-operation RBC transfusions, 64.5% (191 of 296) did not receive any postoperative RBC transfusions. Lower risk of RBC transfusion was associated with isolated AVR (p < 0.01), a minimally invasive approach (p < 0.01), and BCS (p < 0.01), whereas a greater risk of RBC transfusion was associated with older age (p < 0.01), prior cardiac operation (p = 0.01), female sex (p < 0.01), and smaller body surface area (p < 0.01). Day-of-operation RBC transfusion of 2 units or more was associated with increased deaths (p = 0.01), prolonged intubation (p < 0.01), postoperative renal failure (p = 0.01), and increased incidence of any complication (p < 0.01). CONCLUSIONS: Perioperative BCS reduced RBC transfusion in AVR patients without an increase in mortality or morbidity. Guidelines for BCS in routine cardiac operations should be extended to AVR patients.

BACKGROUND AND AIM OF THE STUDY: Optimal repair of the mitral valve involves the implantation of an annuloplasty device to geometrically reshape and/or stabilize the annulus and improve long-term durability. It has been reported previously that trigone-to-trigone semi-rigid posterior band (PB) annuloplasty is associated with excellent short-term outcomes, physiologic motion of the anterior mitral annulus and leaflet, and lower postoperative transvalvular gradients compared to complete ring (CR) annuloplasty. The aim of this retrospective study was to compare the long-term effectiveness of PB and CR annuloplasty in patients with degenerative mitral valve regurgitation (MR). METHODS: Between 1993 and 2010, a total of 1,612 patients with degenerative MR underwent mitral valve repair (MVr) with either PB (n = 1,101) or CR (n = 511). Initially, CR was the annuloplasty device of choice, but after 2001 PB was preferred. A retrospective review of clinical and echocardiographic follow up was performed on these patients. The eight-year cumulative freedom from adverse events were determined by life-table analysis. RESULTS: Hospital mortality was 1.9% overall (n = 30/1612), but 1.3% (12/939) for isolated MVr, and 2.7% (18/673) for MVr with concomitant procedures (p = 0.04). Hospital mortality was similar for both PB (1.9%; 21/1101) and CR (1.8%; 9/511) (p = 0.8). The mean MR grade was reduced from 3.9 +/- 0.3 preoperatively to 0.6 +/- 0.9 at follow up using PB (p < 0.01), and from 3.9 +/- 0.4 to 0.9 +/- 0.9 using CR (p < 0.01). PB was associated with a similar long-term freedom from death (77 +/- 0.03% versus 83 +/- 0.02%; p = 0.4), reoperation (95 +/- 0.01% versus 92 +/- 0.01%; p = 0.06), and reoperation or recurrent severe MR (91 +/- 0.02% versus 92 +/- 0.01%; p = 0.7), and slightly greater freedom from valve-related complications compared to CR (91 +/- 0.02% versus 87 +/- 0.02%; p = 0.02). CONCLUSION: The long-term outcome of mitral valve annuloplasty with PB was comparable to that with CR for degenerative disease. Anterior annuloplasty was found to be unnecessary in this patient population.

OBJECTIVE: A concern with the initiation of totally endoscopic robotic mitral valve repair (TERMR) programs has been the risk for the learning curve. To minimize this risk, we initiated a TERMR program with a defined team and structured learning approach before clinical implementation. METHODS: A dedicated team (two surgeons, one cardiac anesthesiologist, one perfusionist, and two nurses) was trained with clinical scenarios, simulations, wet laboratories, and "expert" observation for 3 months. This team then performed a series of TERMRs of varying complexity. RESULTS: Thirty-two isolated TERMRs were performed during the first programmatic year. All operations included mitral valve repair, left atrial appendage exclusion, and annuloplasty device implantation. Additional procedures included leaflet resection, neochordae insertion, atrial ablation, and papillary muscle shortening. Longer clamp times were associated with number of neochordae (P < 0.01), papillary muscle procedures (P < 0.01), and leaflet resection (P = 0.06). Sequential case number had no impact on cross-clamp time (P = 0.3). Analysis of nonclamp time demonstrated a 71.3% learning percentage (P < 0.01; ie, 28.7% reduction in nonclamp time with each doubling of case number). There were no hospital deaths or incidences of stroke, myocardial infarction, unplanned reoperation, respiratory failure, or renal failure. Median length of stay was 4 days. All patients were discharged home. CONCLUSIONS: Totally endoscopic robotic mitral valve repair can be safely performed after a pretraining regimen with emphasis on experts' current practice and team training. After a pretraining regimen, cross-clamp times were not subject to learning curve phenomena but were dependent on procedural complexity. Nonclamp times were associated with a short learning curve.

In the 1990s, the success of 'minimally invasive' laparoscopic operations in other surgical subspecialties sparked an interest in minimally-invasive approaches for cardiac surgery, specifically for mitral valve repair. In 1996 at New York University (NYU) we began our experience with minimally invasive mitral valve repair performed through a small right anterior mini-thoracotomy incision using the Port-Access system in a phase I clinical trial. This was the beginning of our extensive right mini-thoracotomy experience for mitral valve repair at NYU. Currently at our institution the preferred approach for the right mini-thoracotomy mitral valve surgery is through the 3rd or 4th interspace mini-thoracotomy incision. Perfusion is accomplished with direct aortic or femoral cannulation, long femoral venous cannula drainage, and a retrograde cardioplegia catheter placed trans-atrialy in the coronary sinus under TEE guidance. An antegrade cardioplegia and venting needle is placed in the ascending aorta and direct external aortic clamping is achieved with one of several specialized crossclamps. With over four decades of experience, more than 4,000 patients have undergone mitral valve repair at NYU including 1,922 performed through a right mini-thoracotomy. We have reported an overall operative mortality of 1.3%, 8-year freedom from reoperation of 95%, freedom from reoperation or severe recurrent mitral regurgitation of 93%, and freedom from all valve-related complications of 90% for our initial series of 1,071 right mini-thoracotomy mitral valve repair. Based on our extensive experience we believe that mitral valve repair through a right mini-thoracotomy provides a durable and safe alternative to a traditional sternotomy with the benefits of improved cosmesis, reduced post-operative pain, less blood loss with fewer blood transfusions, fewer infections, shorter length of stay, and faster return to activity. It is our standard of care approach for mitral valve surgery.

OBJECTIVE: Recent Society of Thoracic Surgeons and Society of Cardiovascular Anesthesiologists (STS/SCA) guidelines highlight the safety of blood conservation strategies in routine cardiac surgery. We evaluated the feasibility and impact of such a program in complex aortic surgery. METHODS: Between March 2010 and October 2011, 63 consecutive aortic replacement procedures were performed: aortic root (n = 17; 27%), ascending aorta (n = 15; 23.8%), aortic arch (n = 19; 30.2%), descending aorta (n = 8; 12.7%), and thoracoabdominal aorta (n = 4; 6.3%). Aortic dissections were present in 32 patients. A multidisciplinary approach to blood conservation included minimal perioperative crystalloid, small priming circuits, hemoconcentration, meticulous hemostasis, and tolerance of postoperative anemia (hemoglobin of >/= 7mg/dL). RESULTS: Operative mortality was 11.1%. Multivariate predictors of mortality were low preoperative hematocrit (HCT, P = 0.05) and endocarditis (P = 0.021). Seventy-four percent of patients required no intraoperative packed red blood cell (pRBC) transfusion. For nondissection patients, 80.6% required /= 2 U (P = 0.001). CONCLUSIONS: These findings demonstrate that a perioperative blood conservation management strategy can be extended to complex aortic surgery and is associated with better clinical outcomes.

The Hypothesis 2 arm of the STICH trial compared outcomes in ischemic cardiomyopathy patients undergoing CABG plus SVR vs. CABG alone. Although the trial results suggest equivalency of these therapies, important trial flaws have been identified which cast critical doubt regarding the generalizability of the trial findings.

Increased platelet activity is associated with adverse cardiovascular events. The mean platelet volume (MPV) correlates with platelet activity; however, the relation between the MPV and long-term mortality in patients undergoing percutaneous coronary intervention (PCI) is not well established. Furthermore, the role of change in the MPV over time has not been previously evaluated. We evaluated the MPV at baseline, 30 days, 60 days, 90 days, 1 year, 2 years, and 3 years after the procedure in 1,512 patients who underwent PCI. The speed of change in the MPV was estimated using the slope of linear regression. Mortality was determined by query of the Social Security Death Index. During a median of 8.7 years, mortality was 49.3% after PCI. No significant difference was seen in mortality when stratified by MPV quartile (first quartile, 50.1%; second quartile, 47.7%; third quartile, 51.3%; fourth quartile, 48.3%; p = 0.74). For the 839 patients with available data to determine a change in the MPV over time after PCI, mortality was 49.1% and was significantly greater in patients with an increase (52.9%) than in those with a decrease (44.2%) or no change (49.1%) in the MPV over time (p <0.0001). In conclusion, no association was found between the baseline MPV and long-term mortality in patients undergoing PCI. However, increased mortality was found when the MPV increased over time after PCI. Monitoring the MPV after coronary revascularization might play a role in risk stratification.

OBJECTIVE: To understand how teaching behaviors contribute to simulation-based learning, we used a 7-category educational framework to assess the teaching behaviors used in basic skills training. METHODS: Twenty-four first-year cardiothoracic surgery residents and 20 faculty participated in the Boot Camp vessel anastomosis sessions. A portable chest model with synthetic graft and target vessels and a tissue-based porcine model simulated coronary artery anastomosis. After each 2-hour session on days 1 and 2, residents assessed teaching behaviors of faculty using a 20-item questionnaire based on the 5-point Likert scale. After session on day 1, faculty completed a self-assessment questionnaire. At 3 months, faculty completed self-assessment questionnaires regarding teaching behaviors in simulation and clinical settings. Each questionnaire item represents 1 or more teaching categories: "learning climate," "control of session," "communication of goals," "promoting understanding and retention," "evaluation," "feedback," and "self-directed learning." RESULTS: Generally, resident ratings indicated that faculty showed positive teaching behaviors. Faculty self-assessment ratings were all lower (P < .025) than those assigned to them by the residents except for 1 component representative of "feedback," which approached significance (P = .04); 2 items, representative of "promoting understanding and retention" and "evaluation", had mean scores of less than 3. At 3 months, compared with self-assessment at Boot Camp, faculty ratings suggested improved teaching behaviors in their simulation settings in the following: "learning climate," "control of session," "communication of goals," "promoting understanding and retention," and "evaluation." The simulation environment was perceived as more positive for technical skills training in certain aspects compared with clinical setting: instructor reviewed function and operation of equipment with learner before session (representative of "promoting understanding and retention") and instructor allowed the learner ample time to practice (representative of "control of session" and "promoting understanding and retention") (P < .025). CONCLUSIONS: Simulation-based skills training is perceived by residents to be associated with positive teaching behaviors. Faculty self-ratings indicate that they do not always use many of these teaching behaviors and that their performance can be improved. The simulation setting may provide greater opportunity for positive teaching behaviors compared with the clinical environment.

OBJECTIVES: Simulated mitral valve replacement may aid in the assessment of technical skills required for adequate performance in the operating room. We sought to design and assess a mitral valve replacement training station that is low-cost, nonperishable, portable, and reproducible as a first step in developing a mitral valve surgical skills curriculum. METHODS: Nineteen physicians (7 general surgery residents, 8 cardiothoracic surgery residents, and 4 attending cardiothoracic surgeons) underwent simulated mitral valve replacement testing. Simulated mitral valve replacement was performed on a training station consisting of a replaceable "mitral annulus" inside a restrictive "left atrium." Eight components of performance were graded on a 5-point scale. A composite score (100 point maximum) was calculated by weighting the grades by procedural time. The effect of training level was evaluated using analysis of variance and post hoc Tukey honestly significant difference. RESULTS: The speed of simulated mitral valve replacement varied among general surgery residents, cardiothoracic surgery residents, and attending cardiothoracic surgeons (52.9 +/- 9.0 vs 32.8 +/- 4.7 vs 28.0 +/- 3.5 minutes, respectively; F = 25.3; P < .001). Level of training significantly affected all 8 evaluation components (P < .001). Composite scores increased with level of training (general surgery residents 32.9 +/- 11.4, cardiothoracic surgery residents 65.1 +/- 11.5, and attending cardiothoracic surgeons 88.3 +/- 7.8 of a possible 100 points; F = 35.7; P < .001). Cardiothoracic surgery residents who reported having performed 10 to 50 mitral valve replacements as the primary surgeon had a composite score of 65.0 +/- 2.8 (P < .01 compared with attending cardiothoracic surgeons). CONCLUSIONS: Simulated mitral valve replacement can be performed using this simple, affordable, portable setup. Performance scores correlate with level of training and experience, but residents who performed 10 to 50 mitral valve replacements still failed to reach attending-level proficiency. This training simulator may facilitate skills practice and evaluation of competency in cardiac surgery trainees.