Danny Chu

Practical Implementation of the Coronary Revascularization Heart Team

Multidisciplinary decision making has been shown to be highly effective in various aspects of medicine, most notably with the concept of tumor boards and transplant committees.1 ,2 The most updated guidelines for percutaneous coronary intervention (PCI), published jointly by the American College of Cardiology Foundation, American Heart Association, and the Society for Cardiovascular Angiography and Interventions, assign a class IC recommendation for the use of a collaborative Heart Team approach in the treatment of patients with complex coronary artery disease (CAD).3 The guidelines assert that this recommendation is based on retrospective analyses showing that patients with complex CAD referred for revascularization based on a Heart Team consensus have improved mortality compared with patients merely assigned to a particular strategy in the context of their trial enrollment. Despite the suggestion of improved mortality in this retrospective comparison, the Heart Team approach has not been adopted widely in the current clinical practice of cardiovascular medicine. This multidisciplinary innovation remains in its infancy, and numerous questions remain about its practicality, feasibility, and efficacy. For several reasons, there remains significant variability in the care delivered to patients with complex CAD.4 Numerous reports show that although differences in patient characteristics may explain some of the variability in revascularization decisions, much of this variance is physician driven, such as practicing in a fee-for-service model or high-risk anatomy for low-volume operators.4,5 As emphasis grows on informed decision making and patient-centered care, a critical evaluation of these difficult questions will be essential to discovering whether there is a clinically meaningful effect of the Heart Team approach on patients with complex CAD. Although the longstanding use of tumor boards in the field of oncology represents a functioning model of interdisciplinary care on which the Heart Team may be based, it is critical …

Are There Gaps in Current Thoracic Surgery Residency Training Programs

BACKGROUND Cardiothoracic surgery is rapidly evolving to adapt to a changing health care environment and a wider application of innovative techniques. The Society of Thoracic Surgeons Workforce on Thoracic Surgery Resident Issues Transition to Practice Task Force sought to identify new or existing gaps of training in contemporary thoracic surgery residency training programs. METHODS A voluntary survey consisting of 24 questions was distributed to recent graduates of thoracic surgery residency programs in the United States during the 2014 American Board of Thoracic Surgery oral examination application process. Fifty-five of 132 applicants anonymously participated. RESULTS The majority of respondents admitted that they needed more instruction or lacked confidence with the following specific cardiothoracic procedures: minimally invasive cardiac operations (25/52, 48%), robotic cardiac operations (29/52, 55.8%), endovascular operations (28/52, 53.8%), robotic pulmonary operations (29/52, 55.8%), minimally invasive esophageal operations (24/52, 46.2%), robotic esophageal operations (32/52, 61.5%), and operations on congenital cardiac conditions (31/52, 59.6%). The respondents further declared either a need for more instruction or lack of confidence in employment contracting (17/21, 81.0%), negotiating terms of employment (17/21, 81.0%), and professional service agreements (16/21, 76.2%). CONCLUSIONS Further exposure to minimally invasive robotic procedures, operations on congenital conditions, and issues of practice management appear to be needed in contemporary cardiothoracic training in the United States. These identified gaps may assist cardiothoracic surgery residency programs to optimally prepare future graduates for our evolving specialty.

Extubating in the operating room after adult cardiac surgery safely improves outcomes and lowers costs

OBJECTIVE Prolonged intubation has been implicated in the poor outcomes after adult cardiac surgery. Accelerated postoperative extubation has been a quality focus, but operating room (OR) extubation after cardiopulmonary bypass is rare. We examined the outcomes and direct costs of protocolized OR extubation versus early postoperative intensive care unit (ICU) extubation after nonemergency open cardiac surgery. METHODS From January 2012 to June 2013, 652 consecutive patients who had undergone various cardiac operations, including redo and multivalve operations, were extubated within 12 hours, 165 in the OR. The OR extubation patients were propensity matched from multivariable logistic regression to derive 106 matched pairs for OR extubation versus extubation < 12 hours (group 1) and 98 independently matched pairs for OR extubation versus extubation < 6 hours (group 2). RESULTS OR versus ICU extubation conveyed significant reductions in ICU hours (26.3, interquartile range [IQR], 22.0-31.0; vs 29.0, IQR, 25.0-51.0; P = .001, for group 1; 27.0, IQR, 22.0-32.0; vs 29.0, IQR, 25.0-54.0; P = .0002, for group 2) and postoperative length of stay (5 days, IQR, 4-6; vs 6 days, IQR, 5-7; P = .0008, for group 1; 5 days, IQR, 4-6; vs 6 days, IQR, 4-7; P = .0002, for group 2) but did not affect the reintubation rate (1.9% [2 of 106] vs 0.0% [0 of 106], P = .5, group 1; 3.1% [3 of 98] vs 2.0% [2 of 98], P = 1.0, group 2). OR versus ICU extubation conferred a >20% cost reduction from surgery completion to discharge (

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

3055, IQR,

Mitral valve surgery in the US Veterans Administration health system: 10-year outcomes and trends

2576-

Aortic root replacement with cryopreserved homograft for infective endocarditis in the modern North American opioid epidemic

3964; vs

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

3977, IQR,

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

3028-

Aortic clamping strategy and postoperative stroke

4947; P = .0007, group 1;

Hospital readmission rates are similar between patients with mechanical versus bioprosthetic aortic valves

3025, IQR,