Faculty Bibliography

BACKGROUND: Bundled Payments for Care Improvement (BPCI) initiatives were developed by Medicare in an effort to reduce expenditures while preserving quality of care. Payment model 2 reimburses based on a target price for 90-day episode of care postprocedure. The challenge for valve patients is the historically high (>35%) 90-day readmission rate. We analyzed our institutional cardiac surgical service line adaptation to this initiative. METHODS: On May 1, 2015, we instituted a readmission reduction initiative (RRI) that included presurgical risk stratification, comprehensive predischarge planning, and standardized postdischarge management led by cardiac nurse practitioners (CNPs) who attempt to guide any postdischarge encounters (PDEs). A prospective database also was developed, accruing data on all cardiac surgery patients discharged after RRI initiation. We analyzed detailed PDEs for all valve patients with complete 30-day follow-up through November 2015. RESULTS: Patients included 219 surgical patients and 126 transcatheter patients. Sixty-four patients had 79 PDEs. Of these 79 PDEs, 46 (58.2%) were guided by CNPs. PDEs were due to fluid overload/effusion (21, 27%), arrhythmia (17, 22%), bleeding/thromboembolic events (13, 16%), and falls/somatic complaints (12, 15%). Thirty-day readmission rate was 10.1% (35/345). Patients with transcatheter aortic valve replacement had a higher rate of readmission than surgical patients (15.0% vs 6.9%), but were older with more comorbidities. The median readmission length of stay was 2.0 days (interquartile range 1.0-5.0 days). Compared with 2014, the 30-day readmission rate for BPCI decreased from 18% (44/248) to 11% (20/175), P = .05. CONCLUSIONS: Our reengineering of pre/postdischarge management of BPCI valve patients under tight CNP control has significantly reduced costly 30-day readmissions in this high-risk population.

OBJECTIVE: Although the benefits of minimally invasive valvular surgery are well established, the applicability of extending these techniques to reoperative aortic valve surgery is unknown. We evaluated our experience with a minimally invasive approach to this patient population. METHODS: From January 2010 to September 2015, 21 patients underwent reoperative isolated aortic valve replacement via a minimally invasive approach by a single surgeon. All patients had preoperative evaluation with computerized tomography and coronary catheterization. Surgical approaches were right anterior thoracotomy (6/21) or upper hemisternotomy (15/21). Central aortic cannulation was preferred with femoral artery cannulation used in four patients (19%). In patients with left internal mammary artery (LIMA) grafts, no attempt to dissect or occlude the graft was made. Cold blood cardioplegia was administered antegrade (12/21) or retrograde (9/21); systemic cooling with a mean low temperature of 27.5 degrees C was employed. RESULTS: Mean age was 75.1 years with a range from 33 to 92 years, and 67% (14/21) were male. All procedures were completed with a minimally invasive approach. Mean +/- SD cross-clamp time was 51.5 +/- 9.2 minutes. Fourteen patients had patent LIMA grafts. No aortic, LIMA, or cardiac injuries occurred. There were no hospital deaths nor occurrences of perioperative myocardial infarction, stroke, wound infection, renal failure, or endocarditis/sepsis. One patient required a reoperation for bleeding. Sixty-two percent of patients were discharged to home; mean +/- SD length of stay was 6 +/- 3 days. CONCLUSIONS: With appropriate preoperative evaluation and careful surgical planning, a minimally invasive approach to reoperative aortic valve surgery can be performed in a safe and effective manner.

OBJECTIVES: The purpose of this study was to evaluate the relationship between the Risk Assessment and Predictor Tool (RAPT) and patient discharge disposition in an institution participating in bundled payment program for total joint replacement, spine fusion and cardiac valve surgery patients. METHOD: Between April 2014 and April 2015, RAPT scores of 767 patients (535 primary unilateral total joint arthroplasty; 150 cardiac valve replacement; 82 spinal fusions) were prospectively captured. Total RAPT scores were grouped into three levels for risk of complications: <6='high risk', between 6 and 9 ='medium risk', and >9='low risk' for discharge to a post-acute facility. Associations between RAPT categories and patient discharge to home versus any facility were conducted. Multivariate analysis was performed to determine if there was any correlation between RAPT score and discharge to any facility. RESULTS: 70.5% of total joint patients, 80.7% of cardiac valve surgery patients and 70.7% of spine surgery patients were discharged home rather than to a post-acute facility. RAPT risk categories were related to discharge disposition as 72% of those in the high risk group were discharged to a facility and 91% in the low risk group were discharged to home in the total joint replacement cohort. In the cardiac cohort, only 33% of the high risk group was discharged to a facility, and 94% of the low risk group was discharged to home. In the spinal fusion cohort, 60% of those in the high risk group were discharged to a facility and 86% in the low risk group were discharged to home. Multivariate analysis showed that being in the high risk category versus low risk category was significantly associated with substantially increased odds of discharge to a facility. CONCLUSION: The RAPT tool has shown the ability to predict discharge disposition for total joint and spine surgery patients, but not cardiac valve surgery patients, where the majority of patients in all categories were discharged home, at an institution participating in a bundled payment program. The ability to identify discharge disposition pre-operatively is valuable for improving care coordination, directing care resources and establishing and maintaining patient and family expectations.

We describe a 21-year-old woman who presented with chest pain and dyspnea on exertion and who was found to have a large pericardial mass. Multimodality imaging was instrumental in narrowing the differential diagnosis and planning surgical treatment, which included coronary artery bypass and right-sided heart reconstruction. The final pathologic diagnosis was lymphohemangioma; to our knowledge, this was the largest cardiac/pericardial vascular tumor ever to be reported in the literature.

This monograph outlines the rich history of cardiothoracic surgery at New York University (NYU), beginning with its origins at The Bellevue Hospital in the mid-1800's. Numerous early clinical accomplishments were significant, leading up to the arrival of Dr Frank Spencer in 1966. Under Dr Spencer's leadership, the department progressed with development of a culture of innovation, leadership and education that carries through today. The program encompasses three major hospitals and will soon graduate its 50th class of trainees, many of whom have had outstanding careers and a major impact on the field of cardiothoracic surgery. This culture continues under the direction of our current chair, Dr Aubrey Galloway, whose vision has orchestrated and refined a new period of innovation and excellence.

BACKGROUND: Many cardiothoracic surgeons supplement their case volume through the performance of vascular surgical procedures. Information regarding this practice is not well defined. METHODS: In January of 2013, a survey was conducted of The Society of Thoracic Surgeons (STS) membership to assess the performance of vascular operations by cardiothoracic surgeons. RESULTS: The overall response rate was 8.7%. Of the surgeons practicing vascular surgery, 60% were aged 45 to 64 years and 92% were male. Eleven percent of surgeons are board certified in vascular surgery, and 61% have been practicing 16 or more years, with 33% practicing in the southern United States. Twenty-two percent of surgeons stated that at least 30% of their practice was devoted to vascular surgery. Eighty-one percent of respondents would like to see vascular surgery training become part of the formal curriculum for cardiothoracic surgery education, and 90% said that cardiothoracic surgery education should offer a cardiovascular track with emphasis on thoracic and vascular surgery, including endovascular surgery. CONCLUSIONS: This survey provides expanded data on the performance and breadth of practice of vascular surgery by the STS membership.

Mitral valve prolapse (MVP) is the leading indication for isolated mitral valve surgery in the United States. Disorganization of collagens and glycosaminoglycans in the valvular extracellular matrix (ECM) are histological hallmarks of MVP. We performed a transcriptome analysis to study the alterations in ECM-related gene expression in humans with sporadic MVP. Mitral valve specimens were obtained from individuals undergoing valve repair for MVP (n = 7 patients) and from non-beating heart-tissue donors (n = 3 controls). Purified RNA was subjected to whole-transcriptome microarray analysis. Microarray results were validated by quantitative reverse transcription polymerase chain reaction (RT-qPCR). Gene ontology enrichment analysis was performed. 2,046 unique genes showed significant differential expression (false discovery rate <0.5%). After demonstrating appropriate sample clustering, microarray results were globally validated using a subset of 22 differentially expressed genes by RT-qPCR (Pearson's correlation r=0.65, p=0.001). Gene ontology enrichment analyses performed with ErmineJ and DAVID Bioinformatics Database demonstrated overrepresentation of ECM components (p<0.05). Functional annotation clustering calculated enrichment of ECM-related ontology groups (enrichment score = 4.1). ECM-related gene expression is significantly altered in MVP. Our study is consistent with the histologically observed alterations in collagen and mucopolysaccharide profiles of myxomatous mitral valves. Furthermore, whole-transcriptome analyses suggest dysregulation of multiple pathways, including TGF-beta signaling.

Objective: The purpose of this study was to compare operative strategies and patient outcomes in acute type A aortic dissection (ATAAD) repairs before and after the implementation of a multidisciplinary aortic surgery program. Methods: Between May, 2005, and July, 2014, 101 patients underwent ATAAD repair at our institution. A dedicated multidisciplinary aortic surgery team (experienced aortic surgeon, perfusionists, cardiac anesthesiologists, nurses, radiologists) was formed in 2010. We retrospectively compared ATAAD repair outcomes in patients before (2005-2009, n=39) and after (2010-2014, n=62) the implementation of our program. Expected operative mortality was calculated using the International Registry of Acute Aortic Dissection (IRAD) preoperative prediction model. Results: This study demonstrated a significant reduction in operative mortality after implementation of the aortic surgery program (30.8% vs. 9.7%; P=0.014). There was also an increase in the complexity of surgical technique and perfusion strategies with fewer postoperative complications related to respiratory (P<0.0001) and renal failure (P=0.034). No statistical difference in baseline demographics and IRAD-predictive variables were noted between groups (Table SA17-1). However, there was a 3.5-fold reduction in the observed to- expected (O/E) operative mortality ratio (1.52-0.44) (Fig. SA17-1). The success of the aortic program resulted in a 50%increase in volume with a significant number of patients being admitted directly to our aortic center for ATAAD repair, thus avoiding delays related to transfer from a secondary hospital. Conclusions: Patient outcomes can be improved if the surgical treatment of ATAAD were restricted to institutions with a high-volume multidisciplinary aortic surgery program. (Figure Presented)

OBJECTIVE: The present study aimed to evaluate the effect of blood conservation strategies on patient outcomes after aortic surgery. DESIGN: Retrospective cohort analysis of prospective data. SETTING: University hospital. PARTICIPANTS: Patients undergoing thoracic aortic surgery. INTERVENTIONS: One hundred thirty-two consecutive high-risk patients (mean EuroSCORE 10.4%) underwent thoracic aortic aneurysm or dissection repair from January 2010 to September 2011. A blood conservation strategy (BCS) focused on limitation of hemodilution and tolerance of perioperative anemia was used in 57 patients (43.2%); the remaining 75 (56.8%) patients were managed by traditional methods. Mortality, major complications, and red blood cell transfusion requirements were assessed. Independent risk factors for clinical outcomes were determined by multivariate analyses. MEASUREMENTS AND MAIN RESULTS: Hospital mortality was 9.8% (13 of 132). Lower preoperative hemoglobin was an independent predictor of mortality (p<0.01, odds ratio [OR] 1.7). Major complications were associated with perioperative transfusion: 0% complication rate in patients receiving<2 units of packed red blood cells versus 32.3% (20 of 62) in patients receiving>/=2 units. The blood conservation strategy had no significant impact on mortality (p = 0.4) or major complications (p = 0.9) despite the blood conservation patients having a higher incidence of aortic dissection and urgent/emergent procedures and lower preoperative and discharge hemoglobin. In patients with aortic aneurysms, BCS patients received 1.5 fewer units of red blood cells (58% reduction) than non-BCS patients (p = 0.01). Independent risk factors for transfusion were lower preoperative hemoglobin (p<0.01, OR 1.5) and lack of BCS (p = 0.02, OR 3.6). CONCLUSIONS: Clinical practice guidelines for blood conservation should be considered for high-risk complex aortic surgery patients.

OBJECTIVE: Systolic anterior motion (SAM) can occur after mitral valve repair (MVr), most frequently in patients with degenerative valve disease. Our initial observations (1981-1990) revealed that most patients with SAM can be successfully treated medically. Here the authors review the last 16 years of their experience with SAM after MVr. METHODS: Between January 1996 and October 2011, 1918 patients with degenerative mitral valve disease underwent MVr at our institution. We performed a retrospective analysis of SAM in this patient population. RESULTS: The incidence of SAM was 4.6% (89 of 1918) overall, 4.0% (77 of 1906) in patients who did not have SAM preoperatively (de novo). Compared with our previously published report, the incidence of SAM decreased from 6.4% to 4.0% (P = .03). Hospital mortality was 2.0% (38 of 1918) overall, 1.3% (14 of 1078) for isolated MVr. One patient with de novo SAM (1 of 77; 1.3%) died after emergency MVr. All patients with de novo SAM were successfully managed conservatively with intravenous fluids, alpha agonists, and/or beta blockers. A higher incidence of SAM was associated with a left ventricular ejection fraction greater than 60% (P = .01), posterior leaflet resection (P = .048), and hypertrophic obstructive cardiomyopathy (P < .01). The incidence of SAM was lower in patients who underwent device mitral annuloplasty with a semirigid posterior band compared with a complete ring (P = .03). CONCLUSIONS: In the more recent era, SAM occurs one-third less frequently after repair of degenerative mitral valve disease. Use of an incomplete annuloplasty band rather than a complete ring is associated with a lower incidence of SAM. The mainstay treatment of SAM continues to be medical management.