Telemedicine in the era of coronavirus 19: Implications for postoperative care in cardiac surgery

Background

The Coronavirus 19 (COVID‐19) pandemic forced an unprecedented shift of postoperative care for cardiac surgery patients to telemedicine. How patients and surgeons perceive telemedicine is unknown. We examined patient and provider satisfaction with postoperative telehealth visits following cardiac surgery.

Methods

Between April 2020 and September 2020, patients who underwent open cardiac surgery and had a postoperative appointment via telemedicine were administered a patient satisfaction survey over the phone. Time of survey administration ranged from 1 to 4 weeks following their appointment. Surgeons also completed a satisfaction survey following each telemedicine appointment they conducted.

Results

Fifty patients were surveyed. Of these, 36 (72%) had a postoperative appointment over the telephone, and 14 (28%) had a postoperative appointment via video‐chat. Overall, patients expressed satisfaction with the care that they received via our two telemedicine modalities (mean Likert scale agreement 4.8, SD 0.5). Despite this, 46% of patients said they would prefer their next postoperative appointment to be via telemedicine even if there was not a stay‐at‐home order in place. All surgeons surveyed reported (agree/strongly agree) that they would prefer to see their postoperative patients using telemedicine.

Conclusions

These findings highlight acceptability of continuing telemedicine use in the postoperative care of cardiac surgery patients.

Unplanned adnexectomy for ovarian cystadenoma with undiagnosed autoamputation of the contralateral ovary, lessons learned from medical mistakes

Autoamputation of the ovary is a rare occurrence of uncertain aetiology with only a few cases reported in literature. It usually develops following ovarian torsion or torsion of a dermoid cyst with subsequent necrosis of the pedicle and autoamputation. We present the case of a 42 year-old woman was admitted for a laparoscopic removal of a right ovarian cyst. The ultrasound showed a right ovarian cystic mass suggestive of a cystadenoma, and another heterogeneous small echogenic cyst of the left ovary. During laparoscopy, excessive bleeding from the ovarian cortex complicated the cyst stripping and, considering the age of the patient and the emerging technical difficulty of the procedure, a total adnexectomy for the right ovary was performed. While exploring the small cyst on the left ovary, a dermoid cyst was found in the Douglas pouch. This finding could be interpreted as an autoamputation of the adnexa due to an asymptomatic torsion of a previous ovarian cyst arising from the left ovary. Medical errors could occur due to lack of knowledge, expertise, as well as lack of training and surgical skills, but also due to an unfortunate association of very rare confounding factors. Even in the hands of experts, following the basic rules of surgery remains a milestone in teaching and preventing surgical complications.

Variants of the aortic arch in adult general population and their association with thoracic aortic aneurysm disease

BACKGROUND

Query a single institution computed tomography (CT) database to assess the prevalence of aortic arch anomalies in general adult population and their potential association with thoracic aortopathies.

METHODS

CT chest scan reports of patients aged 50-85 years old performed for any indication at a single health system between 2013 and 2016 were included in the analysis. Characteristics of patients with and without aortic arch anomalies were compared by t test and Fisher exact tests. Logistic regression analysis was performed to assess for independent risk factors of thoracic aortic aneurysm (TAA).

RESULTS

Of 21,336 CT scans, 603 (2.8%) described arch anomalies. Bovine arch (n = 354, 58.7%) was the most common diagnosis. Patients with arch anomalies were more likely to be female (p < .001), non-Caucasian(p < .001), and hypertensive (p < .001). Prevalence of TAA in arch anomalies group was 10.8% (n = 65) compared to 4.1% (n = 844) in the nonarch anomaly cohort (p < .001). The highest prevalence of thoracic aneurysm was associated with right-sided arch combined with aberrant left subclavian configuration (33%), followed by bovine arch (13%), and aberrant right subclavian artery (8.2%). On binary logistic regression, arch anomaly (OR = 2.85 [2.16-3.75]), aortic valve pathology (OR 2.93 [2.31-3.73]), male sex (OR 2.38 [2.01-2.80]), and hypertension (OR 1.47 [1.25-1.73]) were significantly associated with increased risk of thoracic aneurysm disease.

CONCLUSIONS

Reported prevalence of aortic arch anomalies by CT imaging in the older adult population is approximately 3%, with high association of TAA (OR = 2.85) incidence in this subgroup. This may warrant a more tailored surveillance strategy for aneurysm disease in this subpopulation.

Patterns of Surveillance Imaging for Incidentally Detected Ascending Aortic Aneurysms

BACKGROUND

Ascending aortic aneurysms (AsAA) remain a silent killer for which timely intervention and surveillance intervals are critical. Despite this, little is known about the follow-up care patients receive after incidental detection of an AsAA. We examined the pattern of surveillance and follow-up care for these high-risk patients.

METHODS

We identified patients at our institution with incidentally detected AsAAs (≥37 mm) between 2013 and 2016. We collected information on patients' aneurysms and clinical follow-up. Logistic regression models related aneurysm size and demographics to whether patients received follow-up imaging or referral.

RESULTS

From 2013 to 2016, 261 patients were identified to have incidentally detected AsAAs among the 21,336 computed tomography scans performed at our institution. The median aneurysm size was 4.2 cm (interquartile range, 4 to 4.4). Only 18 (6.9%) of the identified patients were referred to a cardiac surgeon for evaluation, and only 37.9% of the identified patients had a follow-up chest computed tomography scan within 1 year of detection; 34% had an echocardiogram. The median follow-up duration for the study was 5 years. Logistic regression models showed that aneurysm size and family history were significant predictors of whether a patient was referred to a cardiac surgeon (odds ratio 10.34; 95% confidence interval, 2.3 to 47.9), but not whether the patients received follow-up imaging.

CONCLUSIONS

Among 261 patients with incidentally detected AsAAs, only a third received any follow-up imaging within 1 year after detection, with very low clinical penetrance for expert referral. Surveillance of this high-risk patient population appears insufficient and may require standardization.

The relationship between cardiac surgeon experience and average patient risk profile: CA and NY statewide analysis

BACKGROUND

It is unknown how high and low-risk cases are distributed among cardiac surgeons of different experience levels. The purpose of this study was to determine if high and low-risk coronary artery bypass grafting (CABG) cases are distributed among surgeons in such a way that would optimize outcomes in light of recent studies that show mid-career surgeons may obtain better patient outcomes on more complex cases.

METHODS

We performed a cross-sectional study using aggregated New York (NY) and California (CA) statewide surgeon-level outcome data, including 336 cardiac surgeons who performed 43,604 CABGs. The surgeon observed and expected mortality rates (OMR and EMR) were collected and the number of years-in-practice was determined by searching for surgeon training history on online registries. Loess and linear regression models were used to characterize the relationship between surgeon EMR and surgeon years-in-practice.

RESULTS

The median number of surgeon years-in-practice was 20 (interquartile range [IQR] 11-28) with a median annual case volume of 46 (IQR 19, 70.25). The median surgeon observed to expected mortality (O:E) ratio was 0.87 (IQR 0.19-1.4). Median EMR for CA surgeons was 2.42% and 1.44% for NY surgeons. Linear regression models showed EMR was similar across years in practice. Regression models also showed surgeon O:E ratios were similar across years-in-practice.

CONCLUSION

High and low-risk CABG cases are relatively equally distributed among surgeons of differing experience levels. This equal distribution of high and low-risk cases does not reflect a triaging of more complex cases to more experienced surgeons, which prior research shows may optimize patient outcomes.

Clinicopathologic Features of Tissue Granulomas in Transplant Recipients: A Single Center Study in a Nontuberculosis Endemic Region

CONTEXT.—

There is a paucity of literature about tissue granulomas in transplant patients.

OBJECTIVE.—

To characterize the clinicopathologic features of granulomas in this population and develop a clinically judicious approach to their evaluation.

DESIGN.—

We performed chart reviews of solid organ and allogeneic hematopoietic stem cell transplant recipients at Yale New Haven Hospital to identify patients with granulomas on biopsy obtained pathologic specimens. Pretransplant and posttransplant specimens were included. Data points included demographics, clinical presentation, epidemiologic risk factors, biopsy indication, location and timing, immunosuppression, histopathology, microbiology, and associated clinical diagnosis. Granuloma-related readmissions and mortality were recorded at 1, 3, and 12 months.

RESULTS.—

Biopsy proven granulomas were identified in 56 of 2139 (2.6%) patients. Of 56, 16 (29%) were infectious. Common infectious etiologies were bartonellosis (n = 3) and cytomegalovirus hepatitis (n = 3). Tuberculosis was not identified. Clinical symptoms prompted tissue biopsy in 27 of 56 (48.2%) cases while biopsies were obtained for evaluation of incidental findings or routine disease surveillance in 29 of 56 (51.8%). Presence of symptoms was significantly associated with infectious etiologies; 11 of 27 (40.7%) symptomatic patients compared with 5 of 29 (17.2%) asymptomatic patients had infectious causes. One death from granulomatous cryptogenic organizing pneumonia occurred. In pretransplant asymptomatic patients, no episodes of symptomatic disease occurred posttransplantation.

CONCLUSIONS.—

Granulomas were uncommon in a large transplant population; most were noninfectious but presence of symptoms was associated with infectious etiologies. Granulomas discovered pretransplant without clear infectious etiology likely do not require prolonged surveillance after transplantation. Symptomatology and epidemiologic risks factors should guide extent of microbiologic evaluation.

Diagnosis of Thoracic Aortic Aneurysms by Computed Tomography Without Allometric Scaling

This diagnostic study of computed tomography scans at a single tertiary care center compares radiologist descriptions of abnormal size ascending aortas with definitions of aorta diameters defined by nomograms.

Association Between Cardiac Surgeons' Number of Years in Practice and Surgical Outcomes in New York Cardiac Centers

IMPORTANCE

More than half of US cardiothoracic surgeons are older than 55 years, and the association between surgeon number of years in practice and surgical outcomes remains unclear.

OBJECTIVE

To assess the association between cardiac surgeons' time in practice and operative outcomes for coronary artery bypass grafting (CABG) and valve surgery.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional analysis performed of surgeon-level outcomes data from the 2014-2016 New York State Cardiac Data Reporting System across the 38 New York cardiac surgery centers. Years in practice were characterized as early career (<10 years) and late career (≥10 years). Participants were 120 cardiothoracic surgeons who performed CABG and 112 cardiothoracic surgeons who performed valve procedures between 2014 and 2016. Data were analyzed in April 2020. Surgeons who trained outside of the United States or had unclear training history were excluded.

MAIN OUTCOMES AND MEASURES

Risk-adjusted operative mortality rate (RAMR). Mortality was defined as all-cause death within 30 days of surgery or within the index hospitalization, whichever was longer. Risk adjustment was performed by a multivariable risk model developed by the New York State Department of Public Health. Restricted cubic spline curve identified the association between risk-adjusted mortality rate and surgeon number of years in practice. Linear regression models adjusted for surgeons' annual case volumes.

RESULTS

A total of 112 CABG surgeons and 120 valve surgeons performed 39 436 CABG and 18 596 valve procedures between 2014 and 2016. The median number of surgeon years in practice was 20.0 (interquartile range [IQR], 12.0-28.5) years. The median surgeon annual case volume was 160.0 (IQR, 92.5-245.0) for CABG procedures and 104.0 (IQR, 43.0-210.0) for valve procedures. The median RAMR was 1.3% (IQR, 0.2%-2.2%) for CABG procedures and 3.1% (IQR, 1.7%-5.1%) for valve procedures. Surgeons with less than 10 years of practice had higher RAMR for valve procedures compared with surgeons with more than 10 years of practice (4.0 [IQR, 1.5-7.7] vs 2.9 [IQR, 1.7-4.7]; P = .20), but the finding was not statistically signficant. The RAMR for surgeons with less than 10 years of practice was similar compared with surgeons with more than 10 years of practice for CABG procedures (1.3 [IQR, 0.3-2.1] vs 1.3 [IQR, 0.0-2.2]; P = .73). A lower number of years in practice was significantly associated with higher RAMR for valve procedures (RAMR estimates for linear term: -1.144; 95% CI, -1.955 to -0.332; P = .006; quadratic term: 0.059; 95% CI, 0.015 to 1.102; P = .008; and cubic term: -0.001; 95% CI, -0.002 to 0.000; P = .01). This association was not observed for CABG.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, compared with late-career cardiac surgeons, early-career cardiac surgeons were associated with worse risk-adjusted outcomes for valve operations but not for CABG. This finding suggests certain competence deficiency for valve surgery early after finishing training in cardiac surgery.

Intraoperative retrograde TEVAR to control endoleak after emergent total arch replacement and frozen elephant trunk repair for ruptured Kommerell's diverticulum

We report an emergent complex hybrid repair of a type A intramural hematoma with a tear of the aortic arch at the site of Kommerell's diverticulum and an aberrant right subclavian artery. We identified a type IA endoleak intraoperatively, which was managed immediately with proximal extension. Performing this operation in the hybrid operating room facilitated optimal surgical management.

Surgical management of thoracic aortic emergency with pre- and postoperative COVID-19 disease

The nuance of operative decision making for those in need of emergent operation during coronavirus disease 2019 (COVID‐19) pandemic is increasingly complex in the absence of robust data or guidelines. We present two cases of thoracic aortic emergencies with COVID‐19 disease who survived high‐risk operations to highlight the potential for successful outcomes even in situations compounding patient disease, morbid operation, and the added risk associated with virulent disease in the pandemic time.