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Hirji SA, Shin B, Aranki S. Commentary: Pulmonary hypertension and survival in hypertrophic cardiomyopathy: A predictor or a surrogate? J Thorac Cardiovasc Surg 2024; 167:1755-1756. [PMID: 36336480 DOI: 10.1016/j.jtcvs.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Sameer A Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's, Hospital, Harvard Medical School, Boston, Mass
| | - Borami Shin
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's, Hospital, Harvard Medical School, Boston, Mass
| | - Sary Aranki
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's, Hospital, Harvard Medical School, Boston, Mass.
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Kaneko T, Newell PC, Nisivaco S, Yoo SGK, Hirji SA, Hou H, Romano M, Lim DS, Chetcuti S, Shah P, Ailawadi G, Thompson M. Incidence, characteristics, and outcomes of reintervention after mitral transcatheter edge-to-edge repair. J Thorac Cardiovasc Surg 2024; 167:143-154.e6. [PMID: 35570022 DOI: 10.1016/j.jtcvs.2022.02.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/20/2022] [Accepted: 02/05/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The use of transcatheter edge-to-edge repair (TEER) is growing substantially, and reintervention after TEER by way of repeat TEER or mitral valve surgery (MVS) is increasing as a result. In this nationally representative study we examined the incidence, characteristics, and outcomes of reintervention after index TEER. METHODS Between July 2013 and November 2017, we reviewed 11,396 patients who underwent index TEER using Medicare beneficiary data. These patients were prospectively tracked and identified as having repeat TEER or MVS. Primary outcomes included 30-day mortality, 30-day readmission, 30-day composite morbidity, and cumulative survival. RESULTS Among 11,396 patients who underwent TEER, 548 patients (4.8%) required reintervention after a median time interval of 4.5 months. Overall 30-day mortality was 8.6%, 30-day readmission was 20.9%, and 30-day composite morbidity was 48.2%. According to reintervention type, 294 (53.7%) patients underwent repeat TEER, and 254 (46.3%) underwent MVS. Patients who underwent MVS were more likely to be younger and female, but had a similar comorbidity burden compared with the repeat TEER cohort. After adjustment, there were no differences in 30-day mortality (adjusted odds ratio [AOR], 1.26 [95% CI, 0.65-2.45]) or 30-day readmission (AOR, 1.14 [95% CI, 0.72-1.81]). MVS was associated with higher 30-day morbidity (AOR, 4.76 [95% CI, 3.17-7.14]) compared with repeat TEER. Requirement for reintervention was an independent risk factor for long-term mortality in a Cox proportional hazard model (hazard ratio, 3.26 [95% CI, 2.53-4.20]). CONCLUSIONS Reintervention after index TEER is a high-risk procedure that carries a significant mortality burden. This highlights the importance of ensuring procedural success for index TEER to avoid the morbidity of reintervention altogether.
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Affiliation(s)
- Tsuyoshi Kaneko
- Divisions of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Paige C Newell
- Divisions of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sarah Nisivaco
- Divisions of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sang Gune K Yoo
- Department of Internal Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Sameer A Hirji
- Divisions of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Hechuan Hou
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Matthew Romano
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - D Scott Lim
- Division of Cardiovascular Medicine, University of Virginia Health System, Charlottesville, Va
| | - Stan Chetcuti
- Department of Cardiovascular Medicine, Michigan Medicine, Ann Arbor, Mich
| | - Pinak Shah
- Division of Cardiology, Brigham and Women's Hospital, Boston, Mass
| | - Gorav Ailawadi
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Michael Thompson
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
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Shafiq A, Maniya MT, Duhan S, Jamil A, Hirji SA. Skeletonized versus Pedicled harvesting of internal mammary artery: A systematic review and Meta-analysis. Curr Probl Cardiol 2024; 49:102160. [PMID: 37871714 DOI: 10.1016/j.cpcardiol.2023.102160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 10/25/2023]
Abstract
There are two recognized internal mammary artery (IMA) harvesting techniques during coronary artery bypass grafting (CABG): pedicled and skeletonized. This systematic review and meta-analysis sought to compare the clinical outcomes of the two harvesting techniques. A comprehensive electronic literature search of PubMed, Scopus, and Embase was conducted from inception till June 2023. Thirty-one studies with a total of 13005 patients met our inclusion criteria. The results from the included studies were presented as weighted mean difference (WMD) with its relevant standard deviation (SD) for continuous variables, while Odds Ratio (OR) was used for dichotomous variables. A 95% confidence interval (CI) was used, and the results were pooled using a random effects model. The skeletonized IMA demonstrated a significantly reduced risk of sternal wound infection (SWI) compared to the pedicled IMA (OR = 0.45 [95% CI, 0.32-0.66]; p = 0.0001). The conduit length used was significantly longer in the skeletonized IMA (WMD -2.48, 95% CI, [-3.75, -1.20], P = 0.0001) and a significantly higher postoperative flow rate was observed while using skeletonization compared to the pedicled harvesting (WMD -13.11, 95% CI, [-22.52, -3.70], P = 0.006). However, no significant difference was seen in mortality between the two techniques (OR = 1.19 [95% CI, 1.00-1.41]; p = 0.05). Pedicled harvesting demonstrated significantly reduced incidents of MI (OR = 1.38 [95% CI, 1.13-1.69]; p = 0.002), while significant results in graft patency were observed favoring pedicled harvesting over skeletonization (OR = 0.63 [95% CI, 0.40-0.98]; p = 0.04).
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Affiliation(s)
- Aimen Shafiq
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Sanchit Duhan
- Department of Medicine, Sinai Hospital of Baltimore, Maryland, USA
| | - Adeena Jamil
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Sameer A Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Hirji SA, Wegermann Z, Vemulapalli S, Newell P, Grau-Sepulveda M, O'Brien S, Thourani VH, Badhwar V, Kaneko T. Benchmarking Outcomes of Surgical Aortic Valve Replacement in Patients With Bicuspid Aortic Valves. Ann Thorac Surg 2023; 116:1222-1231. [PMID: 37454786 DOI: 10.1016/j.athoracsur.2023.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/04/2023] [Accepted: 06/05/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The relative roles for transcatheter and surgical aortic valve replacement (SAVR) for bicuspid aortic valve (AV) stenosis are debated. This study analyzes the 5-year longitudinal outcomes of isolated SAVR in bicuspid vs tricuspid AV patients, particularly in low-risk patients. METHODS All patients undergoing isolated index SAVR at 1146 United States hospitals in The Society of Thoracic Surgeons (STS) Adult Cardiac database between July 1, 2011, and December 31, 2018, with linkage to Medicare claims, were analyzed. RESULTS A total of 65,687 patients were analyzed, including of 9131 bicuspid patients (13.9%). Compared with tricuspid patients, bicuspid patients were significantly younger (median 70 vs 74 years, P < .001) with lower Society of Thoracic Surgeons predicted risk of mortality scores (mean 1.6% vs 2.3%, P < .001) and lower risk profile. Risk-adjusted 30-day mortality and major morbidity were similar, but risk-adjusted 5-year mortality was significantly lower in the bicuspid patients (adjusted hazard ratio, 0.72; 95% CI, 0.66-0.77), specifically in low-risk patients (adjusted hazard ratio, 0.69; 95% CI, 0.64-0.76). Additionally, the bicuspid cohort had a lower 5-year readmission risk of heart failure, stroke, bleeding, or other cardiovascular causes (all P < .05). CONCLUSIONS In this nationally representative study, 30-day mortality was similar, but risk-adjusted 5-year mortality was significantly lower in bicuspid patients undergoing isolated SAVR compared with tricuspid patients, specifically low-risk and normal left ventricular ejection fraction patients. This analysis provides a much-needed 5-year longitudinal national-level benchmark to better inform the discussion of transcatheter vs SAVR in bicuspid patients.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | | | | | - Paige Newell
- Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | | | - Sean O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Tsuyoshi Kaneko
- Department of Surgery, Washington University School of Medicine in St. Louis, St Louis, Missouri.
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Zaid S, Hirji SA, Bapat VN, Denti P, Modine T, Nguyen TC, Mack MJ, Reardon MJ, Kaneko T, Tang GHL. Surgical Explantation of Failed Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2023; 116:933-942. [PMID: 37354965 DOI: 10.1016/j.athoracsur.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/10/2023] [Accepted: 05/30/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Recent reports have demonstrated worse than expected outcomes of surgical explantation after transcatheter aortic valve replacement (TAVR). However in-depth analysis of the short- and mid-term risk of concomitant cardiac surgery at the time of TAVR explant is lacking. METHODS Data from the multicenter EXPLANT-TAVR registry of patients undergoing TAVR-explant between November 2009 and September 2020 were retrospectively analyzed. Patients undergoing concomitant procedures were included, but explants performed during the same admission as the initial TAVR or concomitant procedures performed on the aortic root, ascending aorta, or arch were excluded. Outcomes were evaluated between the isolated surgical aortic valve replacement (SAVR) and concomitant SAVR groups. Median follow-up was 6.6 months. RESULTS Among 199 patients, concomitant SAVR was performed in 94 patients (47.2%), primarily with mitral valve surgery (n = 45) followed by coronary artery bypass grafting (n = 23). Despite similar mean ages between groups (72.8 vs 73.4 years), concomitant SAVR had a higher median Society of Thoracic Surgeons Predicted Risk of Mortality score at the index TAVR (5.9% vs 3.7%, P = .001). There were no differences in median time-to-explant between groups (12.9 vs 8.7 months, P = .78). However concomitant SAVR had longer mean cardiopulmonary bypass (166 vs 114 minutes, P = .001) and cross-clamp times (123 vs 81 minutes, P = .001). Both 30-day (16.7% vs 9.9%) and 1-year mortality (36.1% vs 22.1%) were higher with concomitant SAVR but did not reach statistical significance (both P > .05). On Kaplan-Meier analysis, actuarial estimates of cumulative survival were significantly lower with concomitant SAVR at 3 years (56.8% vs 81.1%, P = .020). CONCLUSIONS For surgical explantation after TAVR failure, concomitant SAVR is associated with increased mortality. Further studies with longer follow-up are warranted to examine the benefit from earlier intervention before concomitant disease develops.
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Affiliation(s)
- Syed Zaid
- Division of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Vinayak N Bapat
- Division of Cardiothoracic Surgery, Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Paolo Denti
- Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy
| | - Thomas Modine
- Department of Cardiovascular Surgery, CHU Bordeaux, Bordeaux, France
| | - Tom C Nguyen
- Division of Cardiothoracic Surgery, University of California San Francisco Medical Center, San Francisco, California
| | - Michael J Mack
- Division of Cardiothoracic Surgery, Baylor Scott and White Health Heart Hospital, Plano, Texas
| | - Michael J Reardon
- Department of Cardiovascular Surgery, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Tsuyoshi Kaneko
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Health System, New York, New York.
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Alnajar A, Benck KN, Dar T, Hirji SA, Ibrahim W, Detweiler B, Vuddanda V, Balise R, Rao JS, Lu M, Lamelas J. Predictors of outcomes in patients with obesity following mitral valve surgery. JTCVS Open 2023; 15:127-150. [PMID: 37808032 PMCID: PMC10556846 DOI: 10.1016/j.xjon.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 10/10/2023]
Abstract
Objective Few studies have assessed the outcomes of mitral valve surgery in patients with obesity. We sought to study factors that determine the in-hospital outcomes of this population to help clinicians provide optimal care. Methods A retrospective analysis of adult patients with obesity who underwent open mitral valve replacement or repair between January 1, 2012, and December 31, 2020, was conducted using the National Inpatient Sample. Weighted logistic regression and random forest analyses were performed to assess factors associated with mortality and the interaction of each variable. Results Of the 48,775 patients with obesity, 34% had morbid obesity (body mass index ≥40), 55% were women, 66% underwent elective surgery, and 55% received isolated open mitral valve replacement or repair. In-hospital mortality was 5.0% (n = 2430). After adjusting for important covariates, a greater risk of mortality was associated with older patients (adjusted odds ratio [aOR], 1.24; 95% CI, 1.08-1.43), higher Elixhauser comorbidity score (aOR, 2.10; 95% CI, 1.87-2.36), prior valve surgery (aOR, 1.63; 95% CI, 1.01-2.63), and more than 2 concomitant procedures (aOR, 2.83; 95% CI, 2.07-3.85). Lower mortality was associated with elective admissions (aOR, 0.70; 95% CI, 0.56-0.87) and valve repair (aOR, 0.58; 95% CI, 0.46-0.73). Machine learning identified several interactions associated with early mortality, such as Elixhauser score, female sex, body mass index ≥40, and kidney failure. Conclusions The complexity of presentation, comorbidities in older and female patients, and morbid obesity are independently associated with an increased risk of mortality in patients undergoing open mitral valve replacement or repair. Morbid obesity and sex disparity should be recognized in this population, and physicians should consider older patients and females with multiple comorbidities for earlier and more opportune treatment windows.
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Affiliation(s)
- Ahmed Alnajar
- Division of Cardiothoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Fla
| | - Kelley N. Benck
- Division of Cardiothoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Tawseef Dar
- Division of Cardiothoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Sameer A. Hirji
- Division of Cardiothoracic Surgery, Brigham and Women's Hospital, Allston, Mass
| | - Walid Ibrahim
- Division of Cardiothoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
| | - Brian Detweiler
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Fla
| | - Venkat Vuddanda
- Division of Cardiothoracic Surgery, Brigham and Women's Hospital, Allston, Mass
| | - Raymond Balise
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Fla
| | - J. Sunil Rao
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Fla
| | - Min Lu
- Division of Biostatistics, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Fla
| | - Joseph Lamelas
- Division of Cardiothoracic Surgery, DeWitt Daughtry Department of Surgery, University of Miami Miller School of Medicine, Miami, Fla
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Zogg CK, Hirji SA, Percy ED, Newell PC, Shah PB, Kaneko T. Comparison of Postdischarge Outcomes Between Valve-in-Valve Transcatheter Mitral Valve Replacement and Reoperative Surgical Mitral Valve Replacement. Am J Cardiol 2023; 201:200-210. [PMID: 37385175 DOI: 10.1016/j.amjcard.2023.01.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 01/16/2023] [Accepted: 01/21/2023] [Indexed: 07/01/2023]
Abstract
Limited data are available comparing the postdischarge perioperative outcomes of isolated valve-in-valve transcatheter mitral valve replacement (VIV-TMVR) versus surgical reoperative mitral valve replacement (re-SMVR) on a nationwide scale. The objective of this study was to perform a robust head-to-head assessment of contemporary postdischarge outcomes between isolated VIV-TMVR and re-SMVR using a large national multicenter longitudinal database. Adult patients aged ≥18 years with failed/degenerated bioprosthetic mitral valves who underwent either isolated VIV-TMVR or re-SMVR were identified in the 2015 to 2019 Nationwide Readmissions Database. The risk-adjusted differences in 30-, 90-, and 180-day outcomes were compared using propensity score weighting with overlap weights to mimic the results of a randomized controlled trial. The differences between a transeptal and transapical VIV-TMVR approach were also compared. A total of 687 patients with VIV-TMVR and 2,047 patients with re-SMVR were included. After the overlap weighting to attain balance between treatment groups, VIV-TMVR was associated with significantly lower major morbidity within 30 (odds ratio [95% confidence interval (CI)] 0.0.31 [0.22 to 0.46]), 90 (0.34 [0.23 to 0.50]), and 180 (0.35 [0.24 to 0.51]) days. The differences in major morbidity were primarily driven by less major bleeding (0.20 [0.14 to 0.30]), new onset complete heart block (0.48 [0.28 to 0.84]) and need for permanent pacemaker placement (0.26 [0.12 to 0.55]). The differences in renal failure and stroke were not significant. VIV-TMVR was also associated with shorter index hospital stays (median difference [95% CI] -7.0 [4.9 to 9.1] days) and an increased ability for patients to be discharged home (odds ratio [95% CI] 3.35 [2.37 to 4.72]). There were no significant differences in total hospital costs; in-hospital or 30-, 90-, and 180-day mortality; or readmission. The findings remained similar when stratifying the VIV-TMVR access using a transeptal versus a transapical approach. The changes in outcomes over time suggest marked improvements for patients with VIV-TMVR relative to stagnant results for patients with re-SMVR from 2015 to 2019. In this large nationally representative cohort of patients with failed/degenerated bioprosthetic mitral valves, VIV-TMVR appears to confer a short-term advantage over re-SMVR in terms of morbidity, discharge home, and length of stay. It yielded equivalent outcomes for mortality and readmission. Longer-term studies are needed to assess further follow-up beyond 180 days.
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Affiliation(s)
- Cheryl K Zogg
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts; Yale School of Medicine, New Haven, Connecticut
| | - Sameer A Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Edward D Percy
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts; Division of Cardiology, Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts
| | - Paige C Newell
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts
| | - Pinak B Shah
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts; Division of Cardiology, Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham & Women's Hospital, Boston, Massachusetts; Division of Cardiology, Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts; Cardiovascular Division, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri.
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Hirji SA, Kewalramani D, Cangut B, Brown A. Suture Bicuspidization Repair for Mild or Moderate Tricuspid Regurgitation at the Time of Mitral Valve Surgery: Success or Bust? Eur J Cardiothorac Surg 2023:ezad237. [PMID: 37335875 DOI: 10.1093/ejcts/ezad237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 06/15/2023] [Indexed: 06/21/2023] Open
Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Womeńs Hospital, Harvard Medical School, Boston, MA, USA
| | - Divya Kewalramani
- Division of Cardiac Surgery, Department of Surgery, Brigham and Womeńs Hospital, Harvard Medical School, Boston, MA, USA
| | - Busra Cangut
- Division of Cardiac Surgery, Department of Surgery, Brigham and Womeńs Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Brown
- Libin Cardiovascular Institute, Section of Cardiac Surgery, Department of Cardiac Sciences, Cumming School of Medicine, Calgary, Alberta, Canada
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Tolis G, Piechura LM, Mohan N, Pomerantsev EV, Hirji SA, Bloom JP. Operative Teaching of Coronary Bypass and Need for Repeat Catheterization: Does it Matter Who is Sewing? J Surg Educ 2023; 80:826-832. [PMID: 37080797 DOI: 10.1016/j.jsurg.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/22/2023] [Accepted: 04/01/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE There are no studies to date comparing the patency of coronary bypass grafts constructed by attending surgeons versus trainees and the potential consequences of any such disparities. We explored this issue by comparing the patency of individual anastomoses performed by residents versus the attending surgeon. DESIGN We reviewed 765 continuous cases performed by a single surgeon which involved at least 1 coronary bypass anastomosis, totaling 2,173 distal anastomoses. At a median follow-up time of 36 months (interquartile range 20.5-47.3), 83 (10.9%) patients had undergone 110 cardiac catheterization procedures after their original operation for various indications. This angiographic information provided the data for our comparison cohorts. SETTING Cardiac surgery practice within an academic setting PARTICIPANTS: Adult patient undergoing coronary bypass grafting RESULTS: Of the 83 patients that underwent repeat catheterization, 23 (27.7%) were resident cases, 25 (30.1%) were attending cases and 35 (42.2%) were mixed. There were 4/83 (4.8%) patients with angiographic evidence of internal mammary artery graft compromise of which 3/4 (75%) had been constructed by the attending surgeon. Angiographic evidence of saphenous vein graft compromise was appreciated in 16/83 (19.3%) patients of which 9/16 (56.3%) of the grafts were constructed by the attending surgeon. CONCLUSIONS Liberal involvement of surgical trainees as primary operators in coronary revascularization cases led to equivalent rates of postoperative ischemic complications between the attending and resident groups. The outcome equivalence was also maintained when evaluated at the individual anastomosis patency level between the 2 groups. We conclude that academic programs should continue providing trainees significant experience as primary operating surgeons without fear of clinical outcome compromise.
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Affiliation(s)
- George Tolis
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Laura M Piechura
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Navyatha Mohan
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Eugene V Pomerantsev
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Sameer A Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jordan P Bloom
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Zogg CK, Metcalfe D, Sokas CM, Dalton MK, Hirji SA, Davis KA, Haider AH, Cooper Z, Lichtman JH. Reassessing the July Effect: 30 Years of Evidence Show No Difference in Outcomes. Ann Surg 2023; 277:e204-e211. [PMID: 33914485 PMCID: PMC8384940 DOI: 10.1097/sla.0000000000004805] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to critically evaluate whether admission at the beginning versus end of the academic year is associated with increased risk of major adverse outcomes. SUMMARY BACKGROUND DATA The hypothesis that the arrival of new residents and fellows is associated with increases in adverse patient outcomes has been the subject of numerous research studies since 1989. Methods: We conducted a systematic review and random-effects meta-analysis of July Effect studies published before December 20, 2019, looking for differences in mortality, major morbidity, and readmission. Given a paucity of studies reporting readmission, we further analyzed 7 years of data from the Nationwide Readmissions Database to assess for differences in 30-day readmission for US patients admitted to urban teaching versus nonteach-ing hospitals with 3 common medical (acute myocardial infarction, acute ischemic stroke, and pneumonia) and 4 surgical (elective coronary artery bypass graft surgery, elective colectomy, craniotomy, and hip fracture) conditions using risk-adjusted logistic difference-in-difference regression. RESULTS A total of 113 studies met inclusion criteria; 92 (81.4%) reported no evidence of a July Effect. Among the remaining studies, results were mixed and commonly pointed toward system-level discrepancies in efficiency. Metaanalyses of mortality [odds ratio (95% confidence interval): 1.01 (0.98-1.05)] and major morbidity [1.01 (0.99-1.04)] demonstrated no evidence of a July Effect, no differences between specialties or countries, and no change in the effect over time. A total of 5.98 million patient encounters were assessed for readmission. No evidence of a July Effect on readmission was found for any of the 7 conditions. CONCLUSION The preponderance of negative results over the past 30 years suggests that it might be time to reconsider the need for similarly-themed studies and instead focus on system-level factors to improve hospital efficiency and optimize patient outcomes.
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Affiliation(s)
- Cheryl K. Zogg
- Yale School of Medicine, New Haven, CT
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
- Yale School of Public Health, New Haven, CT
| | - David Metcalfe
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Claire M. Sokas
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
| | - Michael K. Dalton
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
| | - Sameer A. Hirji
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
| | | | - Adil H. Haider
- The Aga Khan University Medical College, Karachi, Pakistan
| | - Zara Cooper
- Center for Surgery and Public Health: Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA
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Hirji SA, Percy E, Trager L, Dewan KC, Seese L, Saeyeldin A, Hubbard J, Zafar MA, Rinewalt D, Alnajar A, Newell P, Kaneko T, Aranki S, Shekar P. In brief. Curr Probl Surg 2023; 60:101260. [PMID: 36642489 DOI: 10.1016/j.cpsurg.2022.101260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Affiliation(s)
- Sameer A Hirji
- Fellow in General and Cardiothoracic Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.
| | - Edward Percy
- Resident in Cardiac Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Lena Trager
- Medical Student, University of Minnesota Medical School, Minneapolis, MN
| | - Krish C Dewan
- Resident in Surgery, Rutgers Robert Wood Johnson University, New Brunswick, NJ
| | - Laura Seese
- Senior Resident in Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburg, PA
| | - Ayman Saeyeldin
- Advanced Heart Failure and Transplant Fellow, Baylor University Medical Center, Dallas, TX
| | - Jennifer Hubbard
- Fellow in Surgical Critical Care, Rhode Island Hospital, Brown University, Providence, RI
| | - Mohammad A Zafar
- Associate Research Scientist, Associate Research Director, Yale-Masone Aortic Research Fellow, Yale-New Haven Hospital, New Haven, CT
| | | | - Ahmed Alnajar
- Division of Cardiac Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Paige Newell
- Resident in General Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Tsuyoshi Kaneko
- Section of Cardiac Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sary Aranki
- Associate Professor of Surgery, Division of Thoracic and Cardiac Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA
| | - Prem Shekar
- Chair of Cardiac and Thoracic Surgery, Lahey Hospital and Medical Center, Burlington, MA
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12
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Mentias A, Desai MY, Keshvani N, Gillinov AM, Johnston D, Kumbhani DJ, Hirji SA, Sarrazin MV, Saad M, Peterson ED, Mack MJ, Cram P, Girotra S, Kapadia S, Svensson L, Pandey A. Ninety-Day Risk-Standardized Home Time as a Performance Metric for Cardiac Surgery Hospitals in the United States. Circulation 2022; 146:1297-1309. [PMID: 36154237 PMCID: PMC10776028 DOI: 10.1161/circulationaha.122.059496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 07/12/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Assessing hospital performance for cardiac surgery necessitates consistent and valid care quality metrics. The association of hospital-level risk-standardized home time for cardiac surgeries with other performance metrics such as mortality rate, readmission rate, and annual surgical volume has not been evaluated previously. METHODS The study included Medicare beneficiaries who underwent isolated or concomitant coronary artery bypass graft, aortic valve, or mitral valve surgery from January 1, 2013, to October 1, 2019. Hospital-level performance metrics of annual surgical volume, 90-day risk-standardized mortality rate, 90-day risk-standardized readmission rate, and 90-day risk-standardized home time were estimated starting from the day of surgery using generalized linear mixed models with a random intercept for the hospital. Correlations between the performance metrics were assessed using the Pearson correlation coefficient. Patient-level clinical outcomes were also compared across hospital quartiles by 90-day risk-standardized home time. Last, the temporal stability of performance metrics for each hospital during the study years was also assessed. RESULTS Overall, 919 698 patients (age 74.2±5.8 years, 32% women) were included from 1179 hospitals. Median 90-day risk-standardized home time was 71.2 days (25th-75th percentile, 66.5-75.6), 90-day risk-standardized readmission rate was 26.0% (19.5%-35.7%), and 90-day risk-standardized mortality rate was 6.0% (4.0%-8.8%). Across 90-day home time quartiles, a graded decline was observed in the rates of in-hospital, 90-day, and 1-year mortality, and 90-day and 1-year readmission. Ninety-day home time had a significant positive correlation with annual surgical volume (r=0.31; P<0.001) and inverse correlation with 90-day risk-standardized readmission rate (r=-0.40; P <0.001) and 90-day risk-standardized mortality rate (r=-0.60; P <0.001). Use of 90-day home time as a performance metric resulted in a meaningful reclassification in performance ranking of 22.8% hospitals compared with annual surgical volume, 11.6% compared with 90-day risk-standardized mortality rate, and 19.9% compared with 90-day risk-standardized readmission rate. Across the 7 years of the study period, 90-day home time demonstrated the most temporal stability of the hospital performance metrics. CONCLUSIONS Ninety-day risk-standardized home time is a feasible, comprehensive, patient-centered metric to assess hospital-level performance in cardiac surgery with greater temporal stability than mortality and readmission measures.
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Affiliation(s)
- Amgad Mentias
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Milind Y. Desai
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - A. Marc Gillinov
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Douglas Johnston
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Dharam J. Kumbhani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Sameer A. Hirji
- Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mary-Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA
| | - Marwan Saad
- Division of Cardiology, Warren Alpert Medical School of Brown University, Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Eric D. Peterson
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Michael J. Mack
- Division of Cardiology, Baylor Scott and White Health, Plano, TX
| | - Peter Cram
- Department of Internal Medicine University of Texas Medical Branch Galveston TX
| | - Saket Girotra
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City, IA
| | - Samir Kapadia
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lars Svensson
- Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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13
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Kaneko T, Hirji SA, Yazdchi F, Sun YP, Nyman C, Shook D, Cohen DJ, Stebbins A, Zeitouni M, Vemulapalli S, Thourani VH, Shah PB, O'Gara P. Association Between Peripheral Versus Central Access for Alternative Access Transcatheter Aortic Valve Replacement and Mortality and Stroke: A Report From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. Circ Cardiovasc Interv 2022; 15:e011756. [PMID: 36126131 DOI: 10.1161/circinterventions.121.011756] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In some patients, the alternative access route for transcatheter aortic valve replacement (TAVR) is utilized because the conventional transfemoral approach is not felt to be either feasible or optimal. However, accurate prognostication of patient risks is not well established. This study examines the associations between peripheral (transsubclavian/transaxillary, and transcarotid) versus central access (transapical and transaortic) in alternative access TAVR and 30-day and 1-year end points of mortality and stroke for all valve platforms. METHODS Using data from The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry with linkage to Medicare claims, patients who underwent alternative access TAVR from June 1, 2015 to June 30, 2018 were identified. Adjusted and unadjusted Cox proportional hazards modeling were performed to determine the association between alternate access TAVR site and 30-day and 1-year end points of mortality and stroke. RESULTS Of 7187 alternative access TAVR patients, 3725 (52%) had peripheral access and 3462 (48%) had central access. All-cause mortality was significantly lower in peripheral access versus central access group at in-hospital and 1 year (2.9% versus 6.3% and 20.3% versus 26.6%, respectively), but stroke rates were higher (5.0% versus 2.8% and 7.3% versus 5.5%, respectively; all P<0.001). These results persisted after 1-year adjustment (death adjusted hazard ratio, 0.72 [95% CI, 0.62-0.85] and stroke adjusted hazard ratio, 2.92 [95% CI, 2.21-3.85]). When broken down by individual subtypes, compared with transaxillary/subclavian access patients, transapical, and transaortic access patients had higher all-cause mortality but less stroke (P<0.05). CONCLUSIONS In this real-world, contemporary, nationally representative benchmarking study of alternate access TAVR sites, peripheral access was associated with favorable mortality and morbidity outcomes compared with central access, at the expense of higher stroke. These findings may allow for accurate prognostication of risk for patient counseling and decision-making for the heart team with regard to alternative access TAVR.
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Affiliation(s)
- Tsuyoshi Kaneko
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sameer A Hirji
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Farhang Yazdchi
- Division of Thoracic and Cardiac Surgery (T.K., S.H., F.Y.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yee-Ping Sun
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Charles Nyman
- Division of Cardiac Anesthesia (C.N., D.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Douglas Shook
- Division of Cardiac Anesthesia (C.N., D.S.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David J Cohen
- Cardiovascular Research Foundation, New York, NY (D.J.C.).,Duke Clinical Research Institute, Durham, NC (D.J.C.)
| | | | | | | | | | - Pinak B Shah
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Patrick O'Gara
- Division of Cardiovascular Medicine (Y.P.S., P.S., P.O.), Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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14
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Percy ED, Harloff MT, Newell PC, Chowdhury M, Singh S, Hirji SA, Yazdchi F, Vinholo TF, Kerolos M, Kaneko T, Sabe AA. Aortic root management in acute type A aortic dissection: A nationwide analysis. J Card Surg 2022; 37:3050-3056. [DOI: 10.1111/jocs.16717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/26/2022] [Accepted: 05/26/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Edward D. Percy
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
- Division of Cardiovascular Surgery University of British Columbia Vancouver British Columbia Canada
| | - Morgan T. Harloff
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
| | - Paige C. Newell
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
| | - Muntasir Chowdhury
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
- Marshall University Joan C. Edwards School of Medicine Huntington West Virginia USA
| | - Supreet Singh
- Rutgers New Jersey Medical School Newark New Jersey USA
| | - Sameer A. Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
| | - Thais F. Vinholo
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
| | - Mariam Kerolos
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
| | - Ashraf A. Sabe
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
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15
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Zogg CK, Becher RD, Dalton MK, Hirji SA, Davis KA, Salim A, Cooper Z, Jarman MP. Defining Referral Regions for Inpatient Trauma Care: The Utility of a Novel Geographic Definition. J Surg Res 2022; 275:115-128. [PMID: 35272088 PMCID: PMC9038698 DOI: 10.1016/j.jss.2021.12.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Geographic variation is an inherent feature of the US health system. Despite efforts to account for geographic variation in trauma system strengthening, it remains unclear how trauma "regions" should be defined. The objective of this study is to evaluate the utility of a novel definition of Trauma Referral Regions (TRR) for assessing geographic variation in inpatient trauma across the age span of hospitalized trauma patients. METHODS Using 2016-2017 State Inpatient Databases, we assessed the extent of geographic variability in three common metrics of hospital use (localization index, market share index, net patient flow) among TRRs and, as a comparison, trauma regions alternatively defined based on Hospital Referral Regions, Hospital Service Areas, and counties. RESULTS A total of 860,593 admissions from 102 TRRs, 127 Hospital Referral Regions, 884 Hospital Service Areas, and 583 counties were included. Consistent with expectations for distinct trauma regions, TRR presented with high average localization indices (mean [standard deviation]: 83.4 [11.7%]), low market share indices (mean [standard deviation]: 11.9 [7.0%]), and net patient flows close to 1.00. Similar results were found among stratified pediatric, adult, and older adult patients. Associations between TRRs and variations in important demographic features (e.g., travel time by road to the nearest Level I or II Trauma Center) suggest that while indicative of standalone trauma regions, TRRs are also able to simultaneously capture critical variations in regional trauma care. CONCLUSIONS TRRs offer a standalone set of geographic regions with minimal variation in common metrics of hospital use, minimal geographic clustering, and preserved associations with important demographic factors. They provide a needed, valid means of assessing geographic variation among trauma systems.
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Affiliation(s)
- Cheryl K Zogg
- Yale School of Medicine, New Haven, Connecticut; Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts.
| | | | - Michael K Dalton
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Sameer A Hirji
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | | | - Ali Salim
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Zara Cooper
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
| | - Molly P Jarman
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, and Harvard TH Chan School of Public Health, Boston, Massachusetts
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16
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Hirji SA, Singh S, Okoh AK, Malarczyk A, Percy ED, Harloff MT, Kolkailah AA, Zogg CK, Loccoh E, Yazdchi F, Russo MJ, O'Gara P, Shah P, Kaneko T. Debunking the July Effect in Transcatheter Interventions in Structural Heart Disease: Truth or Myth? Struct Heart 2022; 6:100001. [PMID: 37273471 PMCID: PMC10236779 DOI: 10.1016/j.shj.2022.100001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 10/07/2021] [Accepted: 11/24/2021] [Indexed: 06/06/2023]
Abstract
Background The "July effect", the perception of worse outcomes in the first month of training, has been previously demonstrated in critical care medicine and general surgery. However, the July effect in the context of structural heart interventions (i.e., transcatheter aortic valve replacement [TAVR] and MitraClip) remains unknown. Methods All adult patients undergoing TAVR or MitraClip in the 2012-2016 National Inpatient Sample were included. Outcomes were compared by procedure month and academic year quartiles (i.e., between the first academic year quartile [Q1] vs. the fourth quartile [Q4]). Outcomes between teaching and nonteaching hospitals were compared using risk-adjusted logistic difference-in-difference regression. Results During the study period, 94,170 TAVR (Q1: 25,250; Q4: 23,170) and 8750 MitraClip (Q1: 2220; Q4: 2150) procedures were performed. In-hospital mortality did not vary as per academic year quartiles for either procedure, even after risk adjustment. These findings persisted in sensitivity analysis by procedure month and newer device era (2015-2016; all p > 0.05). In the subgroup analysis, the unadjusted and adjusted Q1 vs. Q4 in-hospital mortality between teaching and nonteaching hospitals were similar for either procedure. In-hospital mortality also did not vary by procedure month when stratified by hospital teaching status for both procedures. However, postprocedural complication rates appeared to be improving among the TAVR teaching hospitals for stroke, major bleeding, and vascular complications (all p < 0.05). Conclusions In this large, nationwide study, the July effect was not evident for structural heart interventions. With increasing interest and growth in transcatheter procedures, early resident and fellow teaching can be achieved with appropriate supervision.
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Affiliation(s)
- Sameer A. Hirji
- Division of Cardiac Surgery, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Supreet Singh
- Cardiovascular Research Institute, RWJ Barnabas Health, Newark, New Jersey, USA
| | - Alexis K. Okoh
- Cardiovascular Research Institute, RWJ Barnabas Health, Newark, New Jersey, USA
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward D. Percy
- Division of Cardiac Surgery, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Morgan T. Harloff
- Division of Cardiac Surgery, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Emefah Loccoh
- Division of Cardiac Surgery, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark J. Russo
- Cardiovascular Research Institute, RWJ Barnabas Health, Newark, New Jersey, USA
| | - Patrick O'Gara
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pinak Shah
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Hirji SA, Aranki S. Commentary: 3-Dimensional models in adult cardiac surgery: A gimmick or a futuristic concept? JTCVS Tech 2022; 11:43-44. [PMID: 35169733 PMCID: PMC8828958 DOI: 10.1016/j.xjtc.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/01/2021] [Accepted: 01/07/2022] [Indexed: 10/31/2022] Open
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Kolkailah AA, Abougergi MS, Desai PV, Patel A, Fugar S, Okoh AK, Al-Ogaili A, Hirji SA, Kaneko T, Volgman AS, Doukky R, Grodin JL, McGuire DK. Does the “July effect” of new trainees at teaching hospitals impact outcomes for patients hospitalized with heart failure? Real-world analyses of more than half a million US admissions. American Heart Journal Plus: Cardiology Research and Practice 2022; 13. [PMID: 35720432 PMCID: PMC9205541 DOI: 10.1016/j.ahjo.2021.100072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Introduction: The “July effect” refers to the potential of adverse clinical outcomes related to the annual turnover of trainees. We investigated whether this impacts inpatient heart failure (HF) outcomes. Methods: Data from all adults (≥18 years) admitted with a primary diagnosis of HF at US teaching hospitals from the 2012–2014 National Inpatient Sample were analyzed. Non-teaching hospital admissions were excluded. The primary outcome was in-hospital mortality. Secondary metrics included hospital length of stay (LOS) and total cost adjusted for inflation. Logistic and linear regression models were used to adjust for confounders. Admissions were classified into 4 quarters (Q1–Q4), based on the academic calendar. Q1 and Q4 were designated to assess the effect of novice (July effect) versus experienced trainees, respectively. Results: There were 699,675 HF admissions during Q1 and Q4 in the study period. Mean age was 71 ± 15 years and 48% were females. There were 20,270 in-hospital deaths, with no difference between Q1 and Q4; crude odds ratio (OR) 1.00, 95% confidence interval (CI) 0.94–1.07, p = 0.95. After risk adjustment, there was no in-hospital mortality difference between Q1 and Q4 admissions; adjusted OR 0.96, 95% CI 0.89–1.03, p = 0.23. There was no difference in hospital LOS or total cost; 5.8 versus 5.8 days, p = 0.66 and $13,755 versus $13,586, p = 0.46, in Q1 and Q4, respectively. Conclusions: In this nationally representative sample, there was no evidence of a “July effect” on inpatient HF outcomes in the US. This suggests that HF patients should not delay seeking care during trainee transitions at teaching hospitals.
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Hirji SA, Ghandour H, Tolis G. Commentary: Sternal wound complications and internal mammary harvesting technique: An unresolved debate. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01697-4. [PMID: 34922748 DOI: 10.1016/j.jtcvs.2021.11.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Sameer A Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Hiba Ghandour
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - George Tolis
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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20
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Hirji SA, Seese L, Sabe AA. Commentary: Addition of papillary muscle septalization to tricuspid valve repair: Boom or bust? JTCVS Tech 2021; 10:289-290. [PMID: 34984388 PMCID: PMC8691942 DOI: 10.1016/j.xjtc.2021.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 10/03/2021] [Accepted: 10/13/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Sameer A. Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Laura Seese
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ashraf A. Sabe
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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21
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Hirji SA, Alnajar A, Kaneko T. Commentary: Managing catastrophic antiphospholipid syndrome-do we have a way out? JTCVS Tech 2021; 10:278-279. [PMID: 34984386 PMCID: PMC8691934 DOI: 10.1016/j.xjtc.2021.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sameer A. Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Ahmed Alnajar
- Department of Surgery, University of Miami, Miami, Fla
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
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22
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Hirji SA, Sabatino ME, Minhas AMK, Okoh AK, Fudim M, Vaduganathan M, Khan MS. Contemporary Nationwide Heart Transplantation and Left Ventricular Assist Device Outcomes in Patients with Histories of Bariatric Surgery. J Card Fail 2021; 28:330-333. [PMID: 34509598 DOI: 10.1016/j.cardfail.2021.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 11/16/2022]
Abstract
Bariatric surgery may play a role in the management of morbidly obese patients with end-stage heart failure through increasing eligibility and improving the outcomes of destination therapies. We conducted a nationally representative, retrospective cohort study of patients with previous bariatric surgery undergoing either heart transplantation or left ventricular assist device implantation. Of 200 patients, < 6% experienced in-hospital mortality after destination therapy, comparable to that reported in the general population of heart recipients. Risk-adjusted outcomes differed minimally from those of obese patients undergoing destination therapy without previous bariatric surgery. This study provides important safety benchmarking data and demonstrates the feasibility of bariatric surgery as a potential bridge to left ventricular assist device implantation or heart transplantation in obese patients with end-stage heart failure.
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Affiliation(s)
- Sameer A Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Marlena E Sabatino
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Alexis K Okoh
- Cardiovascular Research Institute, RWJ Barnabas Health, Newark, NJ
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Muthiah Vaduganathan
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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23
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Ahmed Z, Bravo CA, Mori M, Rios Herrera SA, Gluud C, Kataria R, Zarich SW, Hirji SA, Desai NR, Bhatt DL. Coronary artery bypass grafting surgery versus percutaneous coronary intervention for coronary artery disease. Hippokratia 2021. [DOI: 10.1002/14651858.cd013374.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zain Ahmed
- Department of Cardiovascular Medicine; Yale School of Medicine; New Haven USA
| | - Claudio A Bravo
- Division of Cardiology, Department of Internal Medicine; University of Washington; Seattle Washington USA
| | - Makoto Mori
- Department of Cardiac Surgery; Yale School of Medicine; New Haven USA
| | | | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research; Capital Region, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | - Rachna Kataria
- Department of Cardiovascular Disease; Montefiore Medical Center, Albert Einstein College of Medicine; Bronx NY USA
| | - Stuart W Zarich
- Department of Cardiology; Yale School of Medicine; New Haven USA
| | - Sameer A Hirji
- Department of Surgery; Brigham and Women's Hospital, Harvard Medical School; Boston MA USA
| | - Nihar R Desai
- Department of Cardiovascular Medicine; Yale School of Medicine; New Haven USA
| | - Deepak L Bhatt
- Heart & Vascular Centre; Brigham and Women's Hospital; Boston MA USA
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24
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Hirji SA, Kaneko T. Reply: Surgical Explantation of Transcatheter Aortic Bioprostheses and Concurrent Other Cardiac Procedures. J Am Coll Cardiol 2021; 77:666. [PMID: 33538265 DOI: 10.1016/j.jacc.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/02/2020] [Indexed: 11/19/2022]
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25
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Harloff MT, Papoy AR, Hirji SA, Percy ED, Yazdchi F, Aghayev A, Kaneko T. Aortic Root Replacement to Accommodate Future Valve-in-Valve Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2021; 111:e437-e438. [DOI: 10.1016/j.athoracsur.2020.08.107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/10/2020] [Accepted: 08/29/2020] [Indexed: 11/15/2022]
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26
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Hirji SA, Vinholo TF, Rinewalt DE. Commentary: Measurement of Right Heart Hemodynamics After Pulmonary Hromboendarterectomy-A Step in the Right Direction. Semin Thorac Cardiovasc Surg 2021; 34:90-91. [PMID: 34004289 DOI: 10.1053/j.semtcvs.2021.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 04/28/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thais Faggion Vinholo
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel E Rinewalt
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts.
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27
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Hirji SA, Percy ED, Zogg CK, Malarczyk A, Harloff MT, Yazdchi F, Kaneko T. Comparison of in-hospital outcomes and readmissions for valve-in-valve transcatheter aortic valve replacement vs. reoperative surgical aortic valve replacement: a contemporary assessment of real-world outcomes. Eur Heart J 2021; 41:2747-2755. [PMID: 32445575 DOI: 10.1093/eurheartj/ehaa252] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/16/2020] [Accepted: 03/23/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS We sought to perform a head-to-head comparison of contemporary 30-day outcomes and readmissions between valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) patients and a matched cohort of high-risk reoperative surgical aortic valve replacement (re-SAVR) patients using a large, multicentre, national database. METHODS AND RESULTS We utilized the nationally weighted 2012-16 National Readmission Database claims to identify all US adult patients with degenerated bioprosthetic aortic valves who underwent either VIV-TAVR (n = 3443) or isolated re-SAVR (n = 3372). Thirty-day outcomes were compared using multivariate analysis and propensity score matching (1:1). Unadjusted, VIV-TAVR patients had significantly lower 30-day mortality (2.7% vs. 5.0%), 30-day morbidity (66.4% vs. 79%), and rates of major bleeding (35.8% vs. 50%). On multivariable analysis, re-SAVR was a significant risk factor for both 30-day mortality [adjusted odds ratio (aOR) of VIV-SAVR (vs. re-SAVR) 0.48, 95% confidence interval (CI) 0.28-0.81] and 30-day morbidity [aOR for VIV-TAVR (vs. re-SAVR) 0.54, 95% CI 0.43-0.68]. After matching (n = 2181 matched pairs), VIV-TAVR was associated with lower odds of 30-day mortality (OR 0.41, 95% CI 0.23-0.74), 30-day morbidity (OR 0.53, 95% CI 0.43-0.72), and major bleeding (OR 0.66, 95% CI 0.51-0.85). Valve-in-valve TAVR was also associated with shorter length of stay (median savings of 2 days, 95% CI 1.3-2.7) and higher odds of routine home discharges (OR 2.11, 95% CI 1.61-2.78) compared to re-SAVR. CONCLUSION In this large, nationwide study of matched high-risk patients with degenerated bioprosthetic aortic valves, VIV-TAVR appears to confer an advantage over re-SAVR in terms of 30-day mortality, morbidity, and bleeding complications. Further studies are warranted to benchmark in low- and intermediate-risk patients and to adequately assess longer-term efficacy.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA 02115, USA
| | - Edward D Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA 02115, USA
| | - Cheryl K Zogg
- Yale School of Medicine, New Haven, 67 Cedar Street, New Haven, CT 06510, USA
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA 02115, USA
| | - Morgan T Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA 02115, USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA 02115, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, Boston, MA 02115, USA
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28
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Hirji SA, Zogg CK, Nguyen TC. Commentary: To operate or wait? Contextualizing early outcomes of cardiac surgery in COVID-19-positive patients. J Thorac Cardiovasc Surg 2021; 162:e373-e374. [PMID: 34020800 PMCID: PMC8078055 DOI: 10.1016/j.jtcvs.2021.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - Tom C Nguyen
- Division of Cardiothoracic Surgery, Department of Surgery, University of San Francisco, San Francisco, Calif.
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29
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Hundemer GL, Srivastava A, Jacob KA, Krishnasamudram N, Ahmed S, Boerger E, Sharma S, Pokharel KK, Hirji SA, Pelletier M, Safa K, Kulvichit W, Kellum JA, Riella LV, Leaf DE. Acute kidney injury in renal transplant recipients undergoing cardiac surgery. Nephrol Dial Transplant 2021; 36:185-196. [PMID: 32892219 DOI: 10.1093/ndt/gfaa063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a key risk factor for chronic kidney disease in the general population, but has not been investigated in detail among renal transplant recipients (RTRs). We investigated the incidence, severity and risk factors for AKI following cardiac surgery among RTRs compared with non-RTRs with otherwise similar clinical characteristics. METHODS We conducted a retrospective cohort study of RTRs (n = 83) and non-RTRs (n = 83) who underwent cardiac surgery at two major academic medical centers. Non-RTRs were matched 1:1 to RTRs by age, preoperative (preop) estimated glomerular filtration rate and type of cardiac surgery. We defined AKI according to Kidney Disease: Improving Global Outcomes criteria. RESULTS RTRs had a higher rate of AKI following cardiac surgery compared with non-RTRs [46% versus 28%; adjusted odds ratio 2.77 (95% confidence interval 1.36-5.64)]. Among RTRs, deceased donor (DD) versus living donor (LD) status, as well as higher versus lower preop calcineurin inhibitor (CNI) trough levels, were associated with higher rates of AKI (57% versus 33% among DD-RTRs versus LD-RTRs; P = 0.047; 73% versus 36% among RTRs with higher versus lower CNI trough levels, P = 0.02). The combination of both risk factors (DD status and higher CNI trough level) had an additive effect (88% AKI incidence among patients with both risk factors versus 25% incidence among RTRs with neither risk factor, P = 0.004). CONCLUSIONS RTRs have a higher risk of AKI following cardiac surgery compared with non-RTRs with otherwise similar characteristics. Among RTRs, DD-RTRs and those with higher preop CNI trough levels are at the highest risk.
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Affiliation(s)
- Gregory L Hundemer
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Nephrology, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Anand Srivastava
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Neeraja Krishnasamudram
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Salman Ahmed
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily Boerger
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Shreyak Sharma
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kapil K Pokharel
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc Pelletier
- Division of Cardiac Surgery, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Kassem Safa
- Transplant Center and Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Win Kulvichit
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leonardo V Riella
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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30
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Hirji SA, Mohan N, Kaneko T. Commentary: Management of bioprosthetic valve failure-strategic planning for the future. J Thorac Cardiovasc Surg 2021; 163:1802-1803. [PMID: 33744011 DOI: 10.1016/j.jtcvs.2021.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Navyatha Mohan
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Mass.
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31
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Sá MPBO, Simonato M, Van den Eynde J, Cavalcanti LRP, Alsagheir A, Tzani A, Fovino LN, Kampaktsis PN, Gallo M, Laforgia PL, Ruhparwar A, Weymann A, Hirji SA, Kaneko T, H L Tang G. Balloon versus self-expandable transcatheter aortic valve implantation for bicuspid aortic valve stenosis: A meta-analysis of observational studies. Catheter Cardiovasc Interv 2021; 98:E746-E757. [PMID: 33555107 DOI: 10.1002/ccd.29538] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 12/15/2020] [Accepted: 01/17/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is a rising trend for transcatheter aortic valve implantation (TAVI) in bicuspid aortic stenosis patients. Data on the use of self-expandable (SEV) vs. balloon-expandable (BEV) valves in these patients are scarce. Therefore, we systematically compared clinical outcomes in bicuspid aortic stenosis patients treated with SEV and BEV. METHODS Data were extracted from PubMed/MEDLINE, EMBASE, CENTRAL/CCTR, ClinicalTrials.gov, SciELO, LILACS, Google Scholar and reference lists of relevant articles. Eight studies published from 2013 to 2020 including a total of 1,080 patients (BEV: n = 620; SEV: n = 460) were selected. Primary endpoints were procedural, 30-day and 1-year mortality. Secondary endpoints were new pacemaker implantation, annular rupture, coronary obstruction, moderate-to-severe paravalvular leak, need of second valve, stroke and acute kidney injury. RESULTS We found no statistically significant difference in mortality between patients treated with BEV vs. SEV during index procedure, at 30 days and at 1 year. BEVs showed a statistically significant higher risk of annulus rupture (2.5%) in comparison with SEV (0%) (OR 5.81 [95% CI, 3.78-8.92], p < .001). New generation BEVs were also associated with significantly less paravalvular leak when compared to new generation SEVs (OR 0.08 [95% CI, 0.02-0.35], p = .001). CONCLUSIONS This meta-analysis of observational studies of TAVI for bicuspid valves, showed no difference in short- and mid-term TAVI mortality with BEVs and SEVs. BEVs presented a higher risk of annular rupture in comparison with SEV.
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Affiliation(s)
- Michel Pompeu B O Sá
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco-PROCAPE, University of Pernambuco, Recife, Pernambuco, Brazil
| | - Matheus Simonato
- Division of Cardiac Surgery, Escola Paulista de Medicina-UNIFESP, São Paulo, São Paulo, Brazil
| | - Jef Van den Eynde
- Department of Cardiovascular Diseases, Unit of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Luiz Rafael P Cavalcanti
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco-PROCAPE, University of Pernambuco, Recife, Pernambuco, Brazil
| | - Ali Alsagheir
- Division of Cardiac Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Division of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Aspasia Tzani
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Luca Nai Fovino
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | | | - Michele Gallo
- Department of Cardiac Surgery, Cardiocentro Ticino, Lugano, Switzerland
| | - Pietro L Laforgia
- I.R.C.C.S. Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Mount Sinai Medical Center, New York, New York, USA
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32
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Shariff M, Kumar A, Hirji SA, Majmundar M, Adalja D, Doshi R. Ten Years Mortality Trends of Tricuspid Regurgitation in the United States, 2008 to 2018. Am J Cardiol 2021; 140:156-157. [PMID: 33259799 DOI: 10.1016/j.amjcard.2020.11.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 11/24/2020] [Indexed: 01/19/2023]
Affiliation(s)
- Mariam Shariff
- Department of Critical Care Medicine, St. John's Medical College Hospital, Bengaluru, India
| | - Ashish Kumar
- Department of Critical Care Medicine, St. John's Medical College Hospital, Bengaluru, India
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Monil Majmundar
- Department of Internal Medicine, New York Medical College, Metropolitan Medical Hospital Center, New York, New York
| | - Devina Adalja
- Department of Medicine, GMERS Gotri Medical College, Vadodara, Gujarat, India
| | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada Reno School of Medicine, Reno, Nevada.
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33
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Hirji SA, Salenger R, Boyle EM, Williams J, Reddy VS, Grant MC, Chatterjee S, Gregory AJ, Arora R, Engelman DT. Expert Consensus of Data Elements for Collection for Enhanced Recovery After Cardiac Surgery. World J Surg 2021; 45:917-925. [PMID: 33521878 DOI: 10.1007/s00268-021-05964-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite the emergence of Enhanced Recovery Protocols (ERPs) in cardiac surgery, there is no consensus on the essential elements for data reporting for quality improvement efforts, as well as accountability and standardization of outcome reporting across institutions. The aim of this study was to establish a consensus on essential data elements for cardiac ERAS®. METHODS A 2-round modified Delphi technique was utilized based on existing recommendations from the recently published ERAS® cardiac surgery consensus guidelines. Round 1 included a steering committee of 10 experts who oversaw formulation of a focused list of data elements into 3 main areas: Preoperative, intraoperative and postoperative. Round 2 consisted of a multidisciplinary, multinational, heterogenous group of 50 voting experts from across the United States and Europe. All participants evaluated their level of agreement with each data element using a 5-point Likert scale with consensus threshold of 70%. RESULTS In round 1, 17 data elements were considered essential (consensus > = 70%, either positive or negative) and 6 were considered marginal (consensus < = 70%, either positive or negative). In round 2, positive consensus was achieved for 15/17 (88.2%) data elements in the essential category, and all six data elements (100%) in the marginal category, indicating a high level of overall agreement. CONCLUSION This initial study, which identified 21 key data elements for collection in an ERAS® cardiac program, will aid clinicians in establishing a framework for evaluating the quality of their contemporary ERP processes and will allow acquisition of data to help benchmark performance metrics between hospitals.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rawn Salenger
- Division of Cardiac Surgery, University of Maryland Saint Joseph Medical Center, Towson, MD, USA
| | - Edward M Boyle
- Department of Cardiac Surgery, St. Charles Medical Center, Bend, OR, USA
| | - Judson Williams
- Department of Cardiothoracic Surgery, WakeMed Heart Center, WakeMed Clinical Research Institute, Raleigh, NC, USA
| | | | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institution, Baltimore, MD, USA
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine Program, Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Foothills Medical Center, Calgary, AB, Canada
| | - Rakesh Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, St. Boniface Hospital, Winnipeg, MB, Canada.
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, Springfield, MA, USA.,, Springfield, MA, USA
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34
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Simonato M, Whisenant B, Ribeiro HB, Webb JG, Kornowski R, Guerrero M, Wijeysundera H, Søndergaard L, De Backer O, Villablanca P, Rihal C, Eleid M, Kempfert J, Unbehaun A, Erlebach M, Casselman F, Adam M, Montorfano M, Ancona M, Saia F, Ubben T, Meincke F, Napodano M, Codner P, Schofer J, Pelletier M, Cheung A, Shuvy M, Palma JH, Gaia DF, Duncan A, Hildick-Smith D, Veulemans V, Sinning JM, Arbel Y, Testa L, de Weger A, Eltchaninoff H, Hemery T, Landes U, Tchetche D, Dumonteil N, Rodés-Cabau J, Kim WK, Spargias K, Kourkoveli P, Ben-Yehuda O, Teles RC, Barbanti M, Fiorina C, Thukkani A, Mackensen GB, Jones N, Presbitero P, Petronio AS, Allali A, Champagnac D, Bleiziffer S, Rudolph T, Iadanza A, Salizzoni S, Agrifoglio M, Nombela-Franco L, Bonaros N, Kass M, Bruschi G, Amabile N, Chhatriwalla A, Messina A, Hirji SA, Andreas M, Welsh R, Schoels W, Hellig F, Windecker S, Stortecky S, Maisano F, Stone GW, Dvir D. Transcatheter Mitral Valve Replacement After Surgical Repair or Replacement. Circulation 2021; 143:104-116. [DOI: 10.1161/circulationaha.120.049088] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Mitral valve-in-valve (ViV) and valve-in-ring (ViR) are alternatives to surgical reoperation in patients with recurrent mitral valve failure after previous surgical valve repair or replacement. Our aim was to perform a large-scale analysis examining midterm outcomes after mitral ViV and ViR.
Methods:
Patients undergoing mitral ViV and ViR were enrolled in the Valve-in-Valve International Data Registry. Cases were performed between March 2006 and March 2020. Clinical endpoints are reported according to the Mitral Valve Academic Research Consortium (MVARC) definitions. Significant residual mitral stenosis (MS) was defined as mean gradient ≥10 mm Hg and significant residual mitral regurgitation (MR) as ≥ moderate.
Results:
A total of 1079 patients (857 ViV, 222 ViR; mean age 73.5±12.5 years; 40.8% male) from 90 centers were included. Median STS-PROM score 8.6%; median clinical follow-up 492 days (interquartile range, 76–996); median echocardiographic follow-up for patients that survived 1 year was 772.5 days (interquartile range, 510–1211.75). Four-year Kaplan-Meier survival rate was 62.5% in ViV versus 49.5% for ViR (
P
<0.001). Mean gradient across the mitral valve postprocedure was 5.7±2.8 mm Hg (≥5 mm Hg; 61.4% of patients). Significant residual MS occurred in 8.2% of the ViV and 12.0% of the ViR patients (
P
=0.09). Significant residual MR was more common in ViR patients (16.6% versus 3.1%;
P
<0.001) and was associated with lower survival at 4 years (35.1% versus 61.6%;
P
=0.02). The rates of Mitral Valve Academic Research Consortium–defined device success were low for both procedures (39.4% total; 32.0% ViR versus 41.3% ViV;
P
=0.01), mostly related to having postprocedural mean gradient ≥5 mm Hg. Correlates for residual MS were smaller true internal diameter, younger age, and larger body mass index. The only correlate for residual MR was ViR. Significant residual MS (subhazard ratio, 4.67; 95% CI, 1.74–12.56;
P
=0.002) and significant residual MR (subhazard ratio, 7.88; 95% CI, 2.88–21.53;
P
<0.001) were both independently associated with repeat mitral valve replacement.
Conclusions:
Significant residual MS and/or MR were not infrequent after mitral ViV and ViR procedures and were both associated with a need for repeat valve replacement. Strategies to improve postprocedural hemodynamics in mitral ViV and ViR should be further explored.
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Affiliation(s)
- Matheus Simonato
- The Cardiovascular Research Foundation, New York (M.Simonato, G.W.S., O.B-Y.)
- Escola Paulista de Medicina – Universidade Federal de São Paulo, São Paulo, Brazil (M.Simonato, J.H.P., D.F.G.)
| | | | - Henrique Barbosa Ribeiro
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil (H.B.R., J.H.P.)
| | - John G. Webb
- St. Paul’s Hospital, Vancouver, Canada (J.G.W., A.Cheung, U.L.)
| | - Ran Kornowski
- Rabin Medical Center, Petah Tikva, Israel (R.K., P.C.)
| | | | | | | | | | | | | | | | - Jörg Kempfert
- Deutsches Herzzentrum Berlin, Berlin, Germany (J.K., A.U.)
| | - Axel Unbehaun
- Deutsches Herzzentrum Berlin, Berlin, Germany (J.K., A.U.)
| | | | | | | | | | - Marco Ancona
- I.R.C.C.S. Ospedale San Raffaele, Milan, Italy (M.M., M.Ancona)
| | | | - Timm Ubben
- Asklepios Klinik St. Georg, Hamburg, Germany (T.U., F.Meincke)
| | - Felix Meincke
- Asklepios Klinik St. Georg, Hamburg, Germany (T.U., F.Meincke)
| | | | - Pablo Codner
- Rabin Medical Center, Petah Tikva, Israel (R.K., P.C.)
| | | | - Marc Pelletier
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, OH (M.P.)
| | - Anson Cheung
- St. Paul’s Hospital, Vancouver, Canada (J.G.W., A.Cheung, U.L.)
| | - Mony Shuvy
- Hadassah Medical Center, Jerusalem, Israel (M.Shuvy)
| | - José Honório Palma
- Escola Paulista de Medicina – Universidade Federal de São Paulo, São Paulo, Brazil (M.Simonato, J.H.P., D.F.G.)
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil (H.B.R., J.H.P.)
| | - Diego Felipe Gaia
- Escola Paulista de Medicina – Universidade Federal de São Paulo, São Paulo, Brazil (M.Simonato, J.H.P., D.F.G.)
| | - Alison Duncan
- The Royal Brompton Hospital, London, United Kingdom (A.D.)
| | | | | | | | - Yaron Arbel
- Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel (Y.A.)
| | - Luca Testa
- I.R.C.C.S. Policlinico San Donato, Milan, Italy (L.T.)
| | - Arend de Weger
- Leids Universitair Medisch Centrum, Leiden, the Netherlands (A.d.W.)
| | | | | | - Uri Landes
- St. Paul’s Hospital, Vancouver, Canada (J.G.W., A.Cheung, U.L.)
| | | | | | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Canada (J.R-C.)
| | | | | | | | - Ori Ben-Yehuda
- The Cardiovascular Research Foundation, New York (M.Simonato, G.W.S., O.B-Y.)
- University of California San Diego (O.B-Y.)
| | | | - Marco Barbanti
- Università degli Studi di Catania, Catania, Italy (M.B.)
| | | | | | | | - Noah Jones
- Mount Carmel Health System, Columbus, OH (N.J.)
| | | | | | | | | | - Sabine Bleiziffer
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Germany (S.B.)
| | | | | | - Stefano Salizzoni
- Città della Salute e della Scienza - “Molinette” Hospital, Torino, Italy (S.Salizzoni)
| | | | | | | | - Malek Kass
- University of Manitoba, Winnipeg, Canada (M.K.)
| | | | | | - Adnan Chhatriwalla
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (A.Chhatriwalla)
| | - Antonio Messina
- Fondazione Poliambulanza Istituto Ospedaliero, Brescia, Italy (A.M.)
| | | | - Martin Andreas
- Medizinische Universität Wien, Vienna, Austria (M.Andreas)
| | | | | | - Farrel Hellig
- Sunninghill Hospital, Johannesburg, South Africa (F.H.)
| | | | | | | | - Gregg W. Stone
- The Cardiovascular Research Foundation, New York (M.Simonato, G.W.S., O.B-Y.)
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.W.S.)
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Teja B, Alibhai N, Rubenfeld GD, Taggart LR, Jivraj N, Hirji SA, O’Gara BP, Shaefi S. Prevalence of Clostridioides difficile Infection in Critically Ill Patients with Extreme Leukocytosis and Diarrhea. Infect Dis Rep 2021; 13:18-22. [PMID: 33401377 PMCID: PMC7839043 DOI: 10.3390/idr13010003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 11/27/2020] [Accepted: 12/11/2020] [Indexed: 01/28/2023] Open
Abstract
While early empiric antibiotic therapy is beneficial for patients presenting with sepsis, the presentation of sepsis from Clostridioides difficile (formerly Clostridium difficile) infection (CDI) has not been well studied in large cohorts. We sought to determine whether the combination of extreme leukocytosis and diarrhea was strongly predictive of CDI in a cohort of 8659 patients admitted to the intensive care unit. We found that CDI was present in 15.0% (95% CI, 12.1–18.3%) of patients with extreme leukocytosis and diarrhea and that mortality for those with CDI, diarrhea, and extreme leukocytosis was 33.8% (95% CI, 23.2–44.3%). These data support consideration of empiric treatment for CDI in unstable critically ill patients with extreme leukocytosis and diarrhea, along with treatment of other possible sources of sepsis as appropriate. Empiric treatment for CDI can usually be discontinued promptly, along with narrowing of other broad-spectrum antimicrobial coverage, if a sensitive C. difficile test is negative.
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Affiliation(s)
- Bijan Teja
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON M5B 1T8, Canada; (G.D.R.); (N.J.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
- Correspondence:
| | - Nafeesa Alibhai
- Honors Integrated Sciences, University of British Columbia, Vancouver, BC V6T 1Z2, Canada;
| | - Gordon D. Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON M5B 1T8, Canada; (G.D.R.); (N.J.)
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5T 3M6, Canada
| | - Linda R. Taggart
- Division of Infectious Diseases, Department of Medicine, St. Michael’s Hospital, Toronto, ON M5B 1W8, Canada;
| | - Naheed Jivraj
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON M5B 1T8, Canada; (G.D.R.); (N.J.)
| | - Sameer A. Hirji
- Department of General Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Brian P. O’Gara
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (B.P.O.); (S.S.)
| | - Shahzad Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; (B.P.O.); (S.S.)
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36
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Harloff MT, Chowdhury M, Hirji SA, Percy ED, Yazdchi F, Shim H, Malarczyk AA, Sobieszczyk PS, Sabe AA, Shah PB, Kaneko T. A step-by-step guide to transseptal valve-in-valve transcatheter mitral valve replacement. Ann Cardiothorac Surg 2021; 10:113-121. [PMID: 33575181 DOI: 10.21037/acs-2020-mv-104] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
With the recent success of transcatheter aortic valve replacement (TAVR), transcatheter options for the management of mitral valve pathology have also gained considerable attention. Valve-in-valve (ViV) transcatheter mitral valve replacement (TMVR) is one such technique that has emerged as a safe and effective therapeutic option for patients with degenerated mitral valve bioprostheses at high-risk for repeat surgical mitral valve replacement. Several access strategies, including trans-apical, transseptal, trans-jugular, and trans-atrial access have been described for ViV-TMVR. Initial experiences were performed primarily via a trans-apical approach through a left mini-thoracotomy because it offers direct access and coaxial device alignment. With the advancements in TMVR technology, such as the development of smaller delivery catheters with high flexure capabilities, the transseptal approach via the femoral vein has emerged as the preferred option. This technique offers the advantages of a totally percutaneous approach, avoids the need to enter the thoracic cavity or pericardial space, and provides superior outcomes compared to a trans-apical approach. In this review, we outline key aspects of patient selection, imaging, procedural techniques, and examine contemporary clinical outcomes of transseptal ViV-TMVR.
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Affiliation(s)
- Morgan T Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muntasir Chowdhury
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward D Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hunbo Shim
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra A Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Piotr S Sobieszczyk
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ashraf A Sabe
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pinak B Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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37
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Hirji SA, Cote CL, Javadikasgari H, Malarczyk A, McGurk S, Kaneko T. Atrial functional versus ventricular functional mitral regurgitation: Prognostic implications. J Thorac Cardiovasc Surg 2020; 164:1808-1815.e4. [PMID: 33526277 DOI: 10.1016/j.jtcvs.2020.12.098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial functional mitral regurgitation (FMR) occurs because of left atrial dilatation or atrial fibrillation in heart failure with preserved left ventricular (LV) function, contrary to ventricular FMR, which occurs because of LV dysfunction. Despite pathophysiological differences, current guidelines do not discriminate between these 2 entities. METHODS From January 2002 to March 2019, all adult patients with ≥3+ mitral regurgitation who underwent mitral valve repair or replacement were identified. Postoperative outcomes and midterm time-to-event rates (survival and reoperation) were compared. RESULTS Overall, 94 atrial FMR (mean age, 67.6 years) and 84 ventricular FMR (mean age, 64 years) patients met inclusion criteria. Differences in baseline cardiac morphology and function of the atrial FMR and ventricular FMR patients were as follows: concomitant atrial fibrillation (37.2% vs 14.3%), heart failure (42.6% vs 63.1%), LV ejection fraction (60% vs 37%), at least moderate LV dilation (4.8% vs 40.6%), and moderate/severe right heart dysfunction (15.2% vs 5.1%), respectively. Operative mortality was 0% in the atrial FMR versus 1.2% in the ventricular FMR cohort. Actuarial estimates of survival and freedom from reoperation at 5 and 10 years was significantly higher in the atrial FMR cohort versus the ventricular FMR cohort. Ventricular FMR also remained a significant predictor of midterm mortality in our risk-adjusted analysis (adjusted hazard ratio for ventricular FMR, 1.8; 95% confidence interval, 1.001-3.26). CONCLUSIONS There are important differences in baseline characteristics in terms of cardiac morphology and function among atrial FMR and ventricular FMR patients, which appear to affect in-hospital and midterm outcomes. Because of these discrepancies, early discrimination between these 2 etiologies of FMR might facilitate more tailored approaches to management.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Claudia L Cote
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass; Division of Cardiac Surgery, Halifax Infirmary, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hoda Javadikasgari
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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38
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Harloff MT, Percy ED, Hirji SA, Yazdchi F, Shim H, Chowdhury M, Malarczyk AA, Sobieszczyk PS, Sabe AA, Shah PB, Kaneko T. A step-by-step guide to trans-axillary transcatheter aortic valve replacement. Ann Cardiothorac Surg 2020; 9:510-521. [PMID: 33312914 DOI: 10.21037/acs-2020-av-79] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The application of transcatheter aortic valve replacement (TAVR) has expanded rapidly over the last decade as a less invasive option for the treatment of severe aortic stenosis. In order to perform successful TAVR, vascular access must be obtained with a large-bore catheter to deliver the transcatheter valve to the aortic annulus. Several techniques have been developed for this purpose including transfemoral (TF), trans-aortic, trans-apical, trans-caval, trans-carotid, and trans-axillary (TAx) with varying degrees of success. Among them, TF access is the most common and preferred method owing to its superior and well-established outcomes. However, in the setting of diseased iliofemoral arterial vessels, severe tortuosity, or iliofemoral arteries of insufficient caliber, TF access may not be possible. In these scenarios, one of the aforementioned alternative access routes needs to be considered. TAx-TAVR is an attractive alternative because it can be accomplished via access to a peripheral vessel as opposed to needing to enter the pericardial space or thoracic cavity. In addition, the open surgical cut-down procedure used to expose the axillary artery is familiar to cardiac surgeons who are accustomed to cannulating it for cardiopulmonary bypass. With advancements in TAVR technology including the evolution of delivery systems and corresponding smaller sheath sizes, total percutaneous access via the axillary artery is gaining substantial attention. In this review, we outline key aspects of patient selection, imaging and procedural techniques, and examine contemporary clinical outcomes with this approach.
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Affiliation(s)
- Morgan T Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward D Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hunbo Shim
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muntasir Chowdhury
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra A Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Piotr S Sobieszczyk
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Ashraf A Sabe
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pinak B Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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39
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Hirji SA, Boskovski MT, Moon M, Kaneko T. Reply: Training the next generation of thoracic surgical trainees-the "Cardiothoracic Surgical Community" role in promoting mentorship and scholarship in the coronavirus disease 2019 (COVID-19) era. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)32695-7. [PMID: 33268116 PMCID: PMC7580672 DOI: 10.1016/j.jtcvs.2020.09.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Marko T Boskovski
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Marc Moon
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Mo
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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40
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Hirji SA, Percy ED, McGurk S, Malarczyk A, Harloff MT, Yazdchi F, Sabe AA, Bapat VN, Tang GH, Bhatt DL, Thourani VH, Leon MB, O’Gara P, Shah PB, Kaneko T. Incidence, Characteristics, Predictors, and Outcomes of Surgical Explantation After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2020; 76:1848-1859. [DOI: 10.1016/j.jacc.2020.08.048] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/19/2020] [Accepted: 08/19/2020] [Indexed: 12/22/2022]
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41
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Hirji SA, Halpern AL, Helmkamp LJ, Roberts SH, Houk AK, Osho A, Okoh AK, Meguid RA, Seese L, Weyant MJ, Rinewalt DE. Geographic and temporal patterns of growth in the utilization of donation after circulatory death donors for lung transplantation in the United States. J Heart Lung Transplant 2020; 39:1313-1315. [PMID: 32921583 DOI: 10.1016/j.healun.2020.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alison L Halpern
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Laura J Helmkamp
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado, Aurora, Colorado
| | - Sophia H Roberts
- Department of Surgery, Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, Missouri
| | - Anna K Houk
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Asishana Osho
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Alexis K Okoh
- Department of Medicine, Robert Wood Johnston Barnabas Health, Newark, New Jersey
| | - Robert A Meguid
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Laura Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburg, Pennsylvania
| | - Michael J Weyant
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Daniel E Rinewalt
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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42
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Varshney AS, Hirji SA, Givertz MM. Outcomes in the 2018 UNOS donor heart allocation system: A perspective on disparate analyses. J Heart Lung Transplant 2020; 39:1191-1194. [PMID: 32950380 DOI: 10.1016/j.healun.2020.08.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/24/2020] [Accepted: 08/24/2020] [Indexed: 11/24/2022] Open
Abstract
The United Network for Organ Sharing (UNOS) implemented a revised donor heart allocation system on October 18, 2018 with principle aims to reduce waitlist mortality, enhance geographic organ sharing, and improve organ distribution equity. Five recently published analyses compared outcomes of heart transplant (HT) recipients transplanted under the revised versus previous system. All demonstrated increased pre-transplant temporary mechanical circulatory support use and graft ischemic times under the revised system. However, despite using data from the same UNOS Registry, three analyses demonstrated increased risk of post-transplant mortality under the revised system, while two others found no significant difference in mortality risk. These studies differed in their analytic cohorts, study periods, follow-up duration, and statistical methodologies. Additionally, some may have introduced survivor bias or violated non-informative censoring. Given these variable findings, longer-term outcome assessment is warranted before the HT community can truly understand the impact of the 2018 UNOS system revision on post-transplant outcomes.
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Affiliation(s)
- Anubodh S Varshney
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Hirji SA, Zogg CK, Vaduganathan M, Kiehm S, Percy ED, Yazdchi F, Pelletier M, Shah PB, Bhatt DL, O'Gara P, Kaneko T. Quantifying the Impact of Care Fragmentation on Outcomes After Transcatheter Aortic Valve Implantation. Am J Cardiol 2020; 128:113-119. [PMID: 32650903 DOI: 10.1016/j.amjcard.2020.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/28/2020] [Accepted: 05/05/2020] [Indexed: 10/24/2022]
Abstract
The Center for Medicare & Medicaid Services has identified readmission as an important quality metric in assessing hospital performance and value of care. The aim of this study was to quantify the impact of "care fragmentation" on transcatheter aortic valve implantation (TAVI) outcomes. Readmission to nonindex hospitals was defined as any hospital other than the hospital where the TAVI was performed. In this multicenter, population-based, nationally representative study, a nationally weighted cohort of US adult patients who underwent TAVI in the National Readmission Database between 01/01/2010 and 9/31/2015 were analyzed. Patient characteristics, trends, and outcomes after 90-day nonindex readmission were evaluated. Thirty-day metric was used as a reference group for comparison. A weighted total of 51,092 patients met inclusion criteria. Overall, the 90-day readmission rate after TAVI was 27.6% (30-day reference group: 17.4%), and 42% of these readmissions were to nonindex hospitals. Noncardiac causes accounted for most nonindex readmissions, but major cardiac procedures were more likely performed at index hospitals during readmission within 90 days. Despite the high co-morbidity burden of patients readmitted to nonindex hospitals, unadjusted and risk-adjusted all-cause mortality, readmission length of stay and total hospital costs following nonindex readmission were lower compared with index readmission at 90 days. In conclusion, in this real world, nationally representative cohort of TAVI patients in the United States, care fragmentation remains prevalent and represent an enduring, residual target for future health policies. Although the impactful readmissions may be directed toward index hospitals, concerted efforts are needed to address mechanisms that increase care fragmentation.
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Hirji SA, Guetter CR, Trager L, Yazdchi F, Landino S, Lee J, Anastasopulos A, Percy E, McGurk S, Pelletier MP, Aranki S, Shekar PS, Kaneko T. Sex-based differences in mitral valve Re-operation after mitral valve repair: Truth or myth? Am J Surg 2020; 220:1344-1350. [PMID: 32788080 DOI: 10.1016/j.amjsurg.2020.06.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 04/24/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Outcomes after mitral valve (MV) repair are known to be worse in women. Less is known about sex-based differences in MV repair durability. METHODS All adult patients undergoing MV repair from 2002 to 2016 were reviewed. Of 2463 cases, 947 (39%) were women. Re-operation risk was defined as any intervention for repair failure or MV disease progression. Median follow-up was 8.2 years. RESULTS Women were older with higher STS-risk scores and were more likely to have rheumatic disease (RHD). Operative mortality was clinically higher in women (2.7% vs 1.7%; P = 0.09). Although women had significantly higher 10-year re-operation risk (7% vs 4%), adjusted longitudinal analysis showed that this was associated with RHD in women (HR 4.04; P = 0.001). Female sex alone was not a significant predictor (P = 0.21). CONCLUSIONS Re-operation following MV repair was infrequent. Women had increased re-operation risk that was largely attributable to their worse preoperative profiles rather than female sex alone.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Camila R Guetter
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lena Trager
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Farhang Yazdchi
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samantha Landino
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jiyae Lee
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alexandra Anastasopulos
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Percy
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Siobhan McGurk
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc P Pelletier
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sary Aranki
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Prem S Shekar
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Boskovski MT, Hirji SA, Brescia AA, Chang AC, Kaneko T. Enhancing thoracic surgical trainee competence in the coronavirus disease 2019 (COVID-19) era: Challenges and opportunities for mentorship. J Thorac Cardiovasc Surg 2020; 160:1126-1129. [PMID: 32948279 PMCID: PMC7319623 DOI: 10.1016/j.jtcvs.2020.06.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/13/2020] [Accepted: 06/15/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Marko T Boskovski
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - Andrew C Chang
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Hirji SA, Shah R, Aranki S, McGurk S, Singh S, Mallidi HR, Pelletier M, Shekar P, Kaneko T. The impact of hospital size on national trends and outcomes in isolated open proximal aortic surgery. J Thorac Cardiovasc Surg 2020; 163:1269-1278.e9. [PMID: 32713639 DOI: 10.1016/j.jtcvs.2020.03.180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 03/12/2020] [Accepted: 03/13/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the impact of hospital size on national trend estimates of isolated open proximal aortic surgery for benchmarking hospital performance. METHODS Patients age >18 years who underwent isolated open proximal aortic surgery for aneurysm and dissection from 2002 to 2014 were identified using the National Inpatient Sample. Concomitant valvular, vessel revascularization, re-do procedures, endovascular, and surgery for descending and thoracoabdominal aorta were excluded. Discharges were stratified by hospital size and analyzed using trend, multivariable regression, propensity-score matching analysis. RESULTS Over a 13-year period, 53,657 isolated open proximal aortic operations were performed nationally. Although the total number of operations/year increased (∼2.9%/year increase) and overall in-hospital mortality decreased (∼4%/year; both P < .001 for trend), these did not differ by hospital size (P > .05). Large hospitals treated more sicker and older patients but had shorter length of stay and lower hospital costs (both P < .001). Even after propensity-score matching, large hospital continued to demonstrate superior in-hospital outcomes, although only statistically for major in-hospital cardiac complications compared with non-large hospitals. In our subgroup analysis of dissection versus non-dissection cohort, in-hospital mortality trends decreased only in the non-dissection cohort (P < .01) versus dissection cohort (P = .39), driven primarily by the impact of large hospitals (P < .01). CONCLUSIONS This study demonstrates increasing volume and improving outcomes of isolated open proximal aortic surgeries nationally over the last decade regardless of hospital bed size. Moreover, the resource allocation of sicker patients to larger hospital resulted shorter length of stay and hospital costs, while maintaining similar operative mortality to small- and medium-sized hospitals.
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Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Rohan Shah
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Sary Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Steve Singh
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Hari R Mallidi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Marc Pelletier
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Prem Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Okoh AK, Sossou C, Dangayach NS, Meledathu S, Phillips O, Raczek C, Patti M, Kang N, Hirji SA, Cathcart C, Engell C, Cohen M, Nagarakanti S, Bishburg E, Grewal HS. Coronavirus disease 19 in minority populations of Newark, New Jersey. Int J Equity Health 2020; 19:93. [PMID: 32522191 PMCID: PMC7286208 DOI: 10.1186/s12939-020-01208-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 06/02/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The purpose of this study is to report the clinical features and outcomes of Black/African American (AA) and Latino Hispanic patients with Coronavirus disease 2019 (COVID-19) hospitalized in an inter-city hospital in the state of New Jersey. METHODS This is a retrospective cohort study of AA and Latino Hispanic patients with COVID-19 admitted to a 665-bed quaternary care, teaching hospital located in Newark, New Jersey. The study included patients who had completed hospitalization between March 10, 2020, and April 10, 2020. We reviewed demographics, socioeconomic variables and incidence of in-hospital mortality and morbidity. Logistic regression was used to identify predictor of in-hospital death. RESULTS Out of 416 patients, 251 (60%) had completed hospitalization as of April 10, 2020. The incidence of In-hospital mortality was 38.6% (n = 97). Most common symptoms at initial presentation were dyspnea 39% (n = 162) followed by cough 38%(n = 156) and fever 34% (n = 143). Patients were in the highest quartile for population's density, number of housing units and disproportionately fell into the lowest median income quartile for the state of New Jersey. The incidence of septic shock, acute kidney injury (AKI) requiring hemodialysis and admission to an intensive care unit (ICU) was 24% (n = 59), 21% (n = 52), 33% (n = 82) respectively. Independent predictors of in-hospital mortality were older age, lower serum Hemoglobin < 10 mg/dl, elevated serum Ferritin and Creatinine phosphokinase levels > 1200 U/L and > 1000 U/L. CONCLUSIONS Findings from an inter-city hospital's experience with COVID-19 among underserved minority populations showed that, more than one of every three patients were at risk for in-hospital death or morbidity. Older age and elevated inflammatory markers at presentation were associated with in-hospital death.
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Affiliation(s)
- Alexis K Okoh
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA.
| | - Christoph Sossou
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Neha S Dangayach
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Sherin Meledathu
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Oluwakemi Phillips
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Corinne Raczek
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Michael Patti
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Nathan Kang
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Sameer A Hirji
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Charles Cathcart
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Christian Engell
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Marc Cohen
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Sandhya Nagarakanti
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Eliahu Bishburg
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
| | - Harpreet S Grewal
- Heart and Lung Research Center, RWJ Barnabas Health, Newark Beth Israel Medical Center, 201 Lyons, Avenue, Suite G5., Newark, New Jersey, 07112, USA
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Hirji SA, Kaneko T. Commentary: Patch repair for aortomitral endocarditis: Playing the short game or the long game? JTCVS Tech 2020; 3:104-105. [PMID: 34317834 PMCID: PMC8302911 DOI: 10.1016/j.xjtc.2020.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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Hirji SA, Kaneko T. Commentary: Paying it forward with concomitant tricuspid valve intervention-does a stitch in time really save lives? J Thorac Cardiovasc Surg 2020; 162:51-52. [PMID: 32241611 DOI: 10.1016/j.jtcvs.2020.02.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Sameer A Hirji
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Shah RM, Hirji SA, Percy E, Landino S, Yazdchi F, Bellavia A, Pelletier MP, Shekar PS, Kaneko T. Cardiac Surgery in Patients With Opioid Use Disorder: An Analysis of 1.7 Million Surgeries. Ann Thorac Surg 2020; 109:1194-1201. [DOI: 10.1016/j.athoracsur.2019.07.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/07/2019] [Accepted: 07/09/2019] [Indexed: 11/28/2022]
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