Chris C. Cook

Great Vessel and Cardiac Trauma

Thoracic great vessel and cardiac trauma are characterized by anatomic location and mechanism of injury: blunt or penetrating. Management strategies are also directed by the extent and mechanism of injury. Advances in imaging and catheter-based technologies have allowed easier and more accurate diagnosis and less-invasive treatments. Although the advantages of endovascular techniques are attractive, open surgical repair remains the definitive treatment for many of these thoracic injuries. Given the increasing sophistication of these technologies and the demonstrated usefulness of a disease-oriented approach toward patient management, trauma centers have adopted a multidisciplinary team model for management of multitrauma victims. In this review, the authors detail the diagnosis and management of blunt aortic, nonaortic great vessel, blunt cardiac, and penetrating cardiac injuries.

Left Atrial Wall Hematoma/Dissection After Mitral Valve Replacement

A 63-year-old woman with a significant history of rheumatic mitral stenosis/regurgitation, tricuspid regurgitation, atrial fibrillation, and giant left atrium (LA; 90 mm in diameter) underwent mitral valve replacement with a mechanical valve, tricuspid annuloplasty, and LA appendage closure. The mitral valve was approached by a conventional left atriotomy from the right side of the LA. The postoperative course was uneventful initially, and the patient was extubated on postoperative day 1. On postoperative day 2, however, acute hemodynamic deterioration occurred that required reintubation and a high dose of inotropes. Transthoracic echocardiography showed a large mass in the LA that occupied almost the entire LA cavity (Figure …

Safety and Efficacy of Implementing a Multidisciplinary Heart Team Approach for Revascularization in Patients With Complex Coronary Artery Disease: An Observational Cohort Pilot Study

IMPORTANCE Since the advent of transcatheter aortic valve replacement, the multidisciplinary heart team (MHT) approach has rapidly become the standard of care for patients undergoing the procedure. However, little is known about the potential effect of MHT on patients with coronary artery disease (CAD). OBJECTIVE To determine the safety and efficacy of implementing the MHT approach for patients with complex CAD. DESIGN, SETTING, AND PARTICIPANTS Observational cohort pilot study of 180 patients with CAD involving more than 1 vessel in a single major academic tertiary/quaternary medical center. From May 1, 2012, through May 31, 2013, MHT meetings were convened to discuss evidence-based management of CAD. All cases were reviewed by a team of interventional cardiologists and cardiac surgeons within 72 hours of angiography. All clinical data were reviewed by the team to adjudicate optimal treatment strategies. Final recommendations were based on a consensus decision. Outcome measures were tracked for all patients to determine the safety and efficacy profile of this pilot program. EXPOSURES Multidisciplinary heart team meeting. MAIN OUTCOMES AND MEASURES Thirty-day periprocedural mortality and rate of major adverse cardiac events. RESULTS Most of the patients underwent percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG); a small percentage of patients underwent a hybrid procedure or medical management. Incidence of 30-day periprocedural mortality was low across all groups of patients (PCI group, 5 of 64 [8%]; CABG group, 1 of 87 [1%]). The rate of major adverse cardiac events during a median follow-up of 12.1 months ranged from 12 of 87 patients (14%) in the CABG group to 15 of 64 (23%) in the PCI group. CONCLUSIONS AND RELEVANCE Outcomes of patients with complex CAD undergoing the optimal treatment strategy recommended by the MHT were similar to those of published national standards. Implementation of the MHT approach for patients with complex CAD is safe and efficacious.

Effect of Aortic Clamping Strategy on Postoperative Stroke in Coronary Artery Bypass Grafting Operations

IMPORTANCE Aortic clamping technique has been implicated in stroke risk at the time of on-pump coronary artery bypass grafting (CABG) procedures. We hypothesized that partial aortic clamping (PAC) use in performing proximal coronary anastomosis does not increase risk of stroke. OBJECTIVE To determine whether postoperative stroke incidence is influenced by single aortic clamping (SAC) or side-biting PAC use in performing proximal anastomosis during CABG procedures. DESIGN, SETTING, AND PARTICIPANTS In a retrospective cohort study, we analyzed data from 1819 patients who underwent conventional, isolated, nonemergent, first-time, arrested-heart, on-pump CABG at a single US major academic, tertiary/quaternary medical center from January 1, 2005, to December 31, 2013. Postoperative stroke was defined according to Society of Thoracic Surgeons (STS) criteria as any confirmed neurological deficit of abrupt onset that did not resolve within 24 hours. Institutional STS data including STS predicted risk of postoperative stroke score were used to compare patients receiving proximal aortic anastomoses performed with either SAC (n = 1107) or combined PAC (n = 712) techniques. EXPOSURES Use of SAC or PAC in performing proximal coronary anastomosis. MAIN OUTCOMES AND MEASURES Thirty-day periprocedural postoperative stroke rates. RESULTS There were no significant differences in preoperative risk or STS predicted risk of mortality between groups. Patients in the SAC group had longer myocardial ischemic time compared with those in the PAC group (mean [SD], 73.2 [22.8] vs 66.5 [22.8] minutes, respectively; P < .001) but shorter overall perfusion time (mean [SD], 96.6 [30.1] vs 102.2 [30.1] minutes, respectively; P < .001). The 30-day observed mortality rates between the SAC and PAC groups were equally low (21 of 1107 patients [1.9%] vs 13 of 712 patients [1.8%], respectively; P > .99) and congruent with STS predicted risk of mortality. Preoperative STS predicted risk of postoperative stroke scores were nearly identical between the SAC and PAC groups (mean [SD], 1.5% [1.4%] vs 1.6% [1.4%]; P = .95), and the 30-day actual observed postoperative stroke rates between the SAC and PAC groups were similar (17 of 1107 patients [1.5%] vs 10 of 712 patients [1.4%], respectively; P > .99). CONCLUSIONS AND RELEVANCE In this contemporary study of on-pump CABG, we did not identify any significant differences in the incidence of postoperative stroke regardless of the clamping method used to perform proximal anastomosis.

The Effect of Comprehensive Society of Thoracic Surgeons Quality Improvement on Outcomes and Failure to Rescue

BACKGROUND The Society of Thoracic Surgeons (STS) quality benchmarks guide clinical outcome improvement in cardiac surgery. Failure to rescue (FTR) from postoperative morbidity is a proposed metric of program quality. We examined the effect of a quality improvement initiative guided by STS quality measures on outcomes and FTR. METHODS Prospectively collected STS data on 3,065 consecutive patients who underwent nonemergency cardiac operations at a single institution from January 1, 2010, to January 31, 2014, were retrospectively analyzed. On January 1, 2012, the quality improvement initiative was implemented. Clinical outcomes and FTR rates were compared between operations performed before (group A) and after (group B) implementation. RESULTS STS predicted preoperative mortality and composite of mortality plus morbidity were similar in group A and group B (2.9% ± 3.7% vs 3.1% ± 4.0%, p = 0.21; 17.8% ± 12.1% vs 18.3% ± 12.4%, p = 0.24, respectively). However, the observed mortality and composite mortality plus morbidity were lower in group B vs group A (31 of 1,576 [2.0%] vs 46 of 1,489 [3.1%], p = 0.05; 168 of 1,576 [10.7%] vs 301 of 1,489 [20.2%], p = 0.0001, respectively). Despite clinical outcome improvement, no differences in FTR rates were observed across all seven major morbidity indicators in group A vs B (35 of 290 [12.1%] vs 19 of 156 [12.1%], p = 1.00, respectively). The finding of similarity in the FTR rate remained consistent during procedural subgroup analysis for isolated coronary artery bypass grafting in group A vs B (22 of 174 [12.6%] vs 9 of 77 [11.7%], p = 1.00, respectively). CONCLUSIONS Implementation of quality improvement initiatives significantly improves outcomes without affecting FTR rates. Further study is needed to determine if FTR provides additive value to quality assessment over existing STS metrics.

Endoscopic transoral stapling of Zenker's diverticula

The pharyngoesophageal pouch was first described by Ludlow in 1764 and later by Zenker. It is a pulsion diverticulum of the posterior pharynx, arising in Killians triangle. Zenkers diverticula are related to a non-compliant upper esophageal sphincter and have been associated with gastroesophageal reflux. Surgical therapy has been recommended for dysphagia and regurgitation. Many surgical options exist. More recently, minimally invasive, transoral stapling has been used. Transoral stapling may be a less morbid operation and may allow patients a quicker return to oral diet and usual activities.

Pancreaticopleural Fistula Presenting as Right-Sided Hemothorax

Pancreaticopleural fistula represents a rare complication of pancreatitis. We report the case of a pancreaticopleural fistula presenting as recurrent right-sided hemothorax in a 43-year-old man. The patient was successfully treated with open surgical drainage and decortication, followed by octreotide, total parenteral nutrition, and stent placement in the pancreatic duct.

Technology-Enhanced Simulation Improves Trainee Readiness Transitioning to Cardiothoracic Training

OBJECTIVE Transitioning from medical school and general surgery training to cardiothoracic (CT) surgical training poses unique challenges for trainees and patient care. We hypothesized that participation in technology-enhanced simulation modules that provided early exposure to urgent/emergent CT patient problems would improve cognitive skills and readiness to manage common urgencies/emergencies. DESIGN Traditional and integrated cardiothoracic residents at our institution participated in a technology-enhanced simulation curriculum. The course comprised of didactics, hands-on simulation, virtual models, and mock oral examinations. Residents also were given a validated pretest and post-test to evaluate knowledge retention and integration. Resident performance was graded using a previously validated objective structured clinical examination. Resident perception of course usefulness and relevance was determined through the completion of a perception survey. SETTING This study occurred at the University of Pittsburgh School of Medicine with the Department of Cardiothoracic Surgery. The facility used was the Peter Winter Institute for Simulation, Education and Research. PARTICIPANTS From 2013 to 2015, 25 traditional and integrated cardiothoracic residents participated in these training modules who have completed all portions of the simulation were used for analysis. RESULTS For our participants, knowledge base significantly increased by 7.9% (pretest = 76.0% vs. post-test = 83.9%, p < 0.01). According to trained-rater evaluation, 93.6% of responses to the 11 objective structured clinical examination competencies were deemed adequate. Postcourse perception survey demonstrated 92% of participants scoring the sessions as important or very important toward development and confidence in managing the cardiothoracic scenarios. These findings were present despite historical assumption that these learners were prepared for complex patient care. CONCLUSIONS After completing a technology-enhanced course combining didactics, simulation, and real-time assessment, residents demonstrated objective improvements in cognitive skills and readiness in managing CT patients. Resident postcourse feedback indicated enhanced confidence, suggesting increased preparedness transitioning to CT surgery. This has strong implications for improved patient safety during these potentially labile transition periods.