Clinton D. Kemp

The pathophysiology of heart failure

Heart failure is a clinical syndrome that results when the heart is unable to provide sufficient blood flow to meet metabolic requirements or accommodate systemic venous return. This common condition affects over 5 million people in the United States at a cost of

The top 10 list for a safe and effective sign-out

10-38 billion per year. Heart failure results from injury to the myocardium from a variety of causes including ischemic heart disease, hypertension, and diabetes. Less common etiologies include cardiomyopathies, valvular disease, myocarditis, infections, systemic toxins, and cardiotoxic drugs. As the heart fails, patients develop symptoms which include dyspnea from pulmonary congestion, and peripheral edema and ascites from impaired venous return. Constitutional symptoms such as nausea, lack of appetite, and fatigue are also common. There are several compensatory mechanisms that occur as the failing heart attempts to maintain adequate function. These include increasing cardiac output via the Frank-Starling mechanism, increasing ventricular volume and wall thickness through ventricular remodeling, and maintaining tissue perfusion with augmented mean arterial pressure through activation of neurohormonal systems. Although initially beneficial in the early stages of heart failure, all of these compensatory mechanisms eventually lead to a vicious cycle of worsening heart failure. Treatment strategies have been developed based upon the understanding of these compensatory mechanisms. Medical therapy includes diuresis, suppression of the overactive neurohormonal systems, and augmentation of contractility. Surgical options include ventricular resynchronization therapy, surgical ventricular remodeling, ventricular assist device implantation, and heart transplantation. Despite significant understanding of the underlying pathophysiological mechanisms in heart failure, this disease causes significant morbidity and carries a 50% 5-year mortality.

Simulation in cardiothoracic surgical training: Where do we stand?

With the advent of the 80-hour workweek, much attention has been focused on the benefits of shorter work hours regarding resident fatigue and reduced medical errors. Along with this change, however, there has been more reliance on multiple teams of residents who assume the care of inpatients at different times. In this new paradigm, a safe and effective sign-out process is needed to ensure a seamless transition of care from one resident to another. Several studies have been published on the sign-out process among interns in internal medicine, but the literature is sparse with regards to the best way to hand over care of a busy inpatient surgical service. To aid in this process, the Halsted surgical interns performed a review of the current literature on this topic. They also reflected on their personal experiences and developed a 10-point method for safe and effective sign-outs. This process is emphasized for incoming interns and used across the various surgical services at The Johns Hopkins Hospital.

Association of operative time of day with outcomes after thoracic organ transplant

OBJECTIVES Simulation may reduce the risks associated with the complex operations of cardiothoracic surgery and help create a more efficient, thorough, and uniform curriculum for cardiothoracic surgery fellowship. Here, we review the current status of simulation in cardiothoracic surgical training and provide an overview of all simulation models applicable to cardiothoracic surgery that have been published to date. METHODS We completed a comprehensive search of all publications pertaining to simulation of cardiothoracic surgical procedures by using PubMed. RESULTS Numerous cardiothoracic surgical simulators at various stages of development, assessment, and commercial manufacturing have been published to date. There is currently a predominance of models simulating coronary artery bypass grafting and bronchoscopy and a relative paucity of simulators of open pulmonary and esophageal procedures. Despite the wide range of simulators available, few models have been formally assessed for validity and educational value. CONCLUSIONS Surgical simulation is becoming an increasingly important educational tool in training cardiothoracic surgeons. Our next steps forward will be to develop an objective, standardized way to assess surgical simulation training compared with the current apprenticeship model.

Outcomes of Adjuvant Chemoradiation After Pancreaticoduodenectomy With Mesenterico-Portal Vein Resection for Adenocarcinoma of the Pancreas

CONTEXT Recent emphasis on systems-based approaches to patient safety has led to several studies demonstrating worse outcomes associated with surgery at night. OBJECTIVE To evaluate whether operative time of day was associated with thoracic organ transplant outcomes, hypothesizing that it would not be associated with increased morbidity or mortality. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective cohort study of adult heart and lung transplant recipients in the United Network for Organ Sharing database from January 2000 through June 2010. Primary stratification was by operative time of day (night, 7 PM-7 AM; day, 7 AM-7 PM). MAIN OUTCOME MEASURES Primary end points were short-term survival, assessed by the Kaplan-Meier method at 30, 90, and 365 days. Secondary end points encompassed common postoperative complications. Risk-adjusted multivariable Cox proportional hazards regression examined mortality. RESULTS A total of 27,118 patients were included in the study population. Of the 16,573 who underwent a heart transplant, 8346 (50.36%) did so during the day and 8227 (49.64%) during the night. Of the 10,545 who underwent a lung transplant, 5179 (49.11%) did so during the day and 5366 (50.89%) during the night. During a median follow-up of 32.2 months (interquartile range, 11.2-61.1 months), 8061 patients (28.99%) died. Survival was similar for organ transplants performed during the day and night. Survival rates at 30 days for heart transplants during the day were 95.0% vs 95.2% during the night (hazard ratio [HR], 1.05; 95% confidence interval, 0.83-1.32; P = .67) and for lung transplants during the day were 96.0% vs 95.5% during the night (HR, 1.22; 95% CI, 0.97-1.55; P = .09). At 90 days, survival rates for heart transplants were 92.6% during the day vs 92.7% during the night (HR, 1.05; 95% CI, 0.88-1.26; P = .59) and for lung transplants during the day were 92.7% vs 91.7% during the night (HR, 1.23; 95% CI, 1.04-1.47; P = .02). At 1 year, survival rates for heart transplants during the day were 88.0% vs 87.7% during the night (HR, 1.05; 95% CI, 0.91-1.21; P = .47) and for lung transplants during the day were 83.8% vs 82.6% during the night (HR, 1.08; 95% CI, 0.96-1.22; P = .19). Among lung transplant recipients, there was a slightly higher rate of airway dehiscence associated with nighttime transplants (57 of 5022 [1.1%] vs 87 of 5224 [1.7%], P = .02). CONCLUSION Among patients who underwent thoracic organ transplants, there was no significant association between operative time of day and survival up to 1 year after organ transplant.

Thoracic Outlet Syndrome Caused by Fibrous Dysplasia of the First Rib

PURPOSE Surgery followed by chemotherapy and radiation (CRT) offers patients with pancreatic adenocarcinoma a chance for extended survival. In some patients, however, resection is difficult because of vascular involvement by the carcinoma, necessitating resection and grafting of the mesenterico-portal vessels. The purpose of this study was to compare outcomes between pancreaticoduodenectomy (PD) with and without mesenterico-portal vein resection (VR) in patients receiving adjuvant CRT for pancreatic adenocarcinoma. METHODS AND MATERIALS Between 1993 and 2005, 160 patients underwent PD with 5-FU-based adjuvant CRT followed by maintenance chemotherapy at the Johns Hopkins Hospital; 20 (12.5%) of the 160 underwent VR. Clinical outcomes, including median survival, overall survival, and complication rates were assessed for both groups. RESULTS Patients who underwent VR had significantly longer operative times (p = 0.009), greater intraoperative blood loss (p = 0.01), and longer postoperative lengths of stay (p = 0.03). However, postoperative morbidity, median survival, and overall survival rates were similar between the two groups. Most patients (70%) from both groups were able to complete CRT, and a subgroup analysis demonstrated no appreciable differences in terms of complications. None of the VR patients who received adjuvant CRT developed veno-oclusive disease or graft failure/leakage. CONCLUSION In a cohort of patients treated with adjuvant 5-FU-based CRT at the Johns Hopkins Hospital, having a VR at the time of PD resulted in similar complication rates and survival. These data support the feasibility and safety of adjuvant CRT in patients undergoing VR at the time of PD.

Late Complications Following Continuous-Flow Left Ventricular Assist Device Implantation.

Fibrous dysplasia causing thoracic outlet syndrome is rare. A 41-year-old woman presented with neurogenic thoracic outlet syndrome with imaging that demonstrated a large tumor of her proximal left first rib. Transaxillary excision was unsuccessful due to involvement of the subclavian vasculature and brachial plexus. Subsequent posterolateral thoracotomy and resection of her first rib revealed fibrous dysplasia. Thoracotomy should be considered in these cases for optimal vascular control and identification of thoracic outlet anatomy.

THE GooseMan: A simulator for transhiatal esophagectomy

Left ventricular assist devices have become standard therapy for patients with end-stage heart failure. They represent potential long-term solutions for a growing public health problem. However, initial enthusiasm for this technology has been tempered by challenges posed by long-term support. This review examines these challenges and out current understanding of their etiologies.

Palliative iliac vein-to-right atrium bypass in a patient with a prior vena cava ligation for invasive renal cell carcinoma

Esophageal cancer is the fastest growing cancer in the United States and the seventh leading cause of cancerrelated death worldwide. The gold standard therapy is surgical resection commonly performed as a transhiatal esophagectomy (THE), which involves blindly dissecting the esophagus in the mediastinum through abdominal and cervical neck incisions. Compared with transthoracic esophagectomy, which requires creating a direct thoracic incision, THE has similar long-term survival but is less invasive and has fewer complications, a shorter recovery time, and decreased in-hospital mortality. Yet, morbidity and mortality from THE remain high compared with other thoracic procedures, largely a result of complications that arise during the blind mobilization process, such as injury to blood vessels, pleural entry, tracheobronchial injury, and hypotension and arrhythmia from compression of the heart. Although THE is difficult to perform, it is also difficult to teach because limited space and lack of visualization in the mediastinum minimize opportunities for careful supervision. In addition, learning opportunities are limited because many surgeons perform transthoracic esophagectomy or laparoscopic esophagectomy instead. Surgical simulation may provide a safe and accessible alternative for THE training; however, there are currently no simulators that can be adapted for this operation. Thus, we developed THE GooseMan, a simple bench model for THE simulation training made of synthetic materials along with porcine organs that costs<

Extracorporeal membrane oxygenation for profound cardiogenic shock due to cocaine toxicity

200 to build. It includes a plastic torso, artificial diaphragm, large foam lungs, an artificial pressure-detecting heart, aortic and azygous circulation, and a porcine organ block. The model facilitates practice of esophageal mobilization and gastric tubularization while simulating the complications of hypotension as well as aortic and azygous bleeding.