Joshua H. Burack

Public reporting of surgical mortality: a survey of New York State cardiothoracic surgeons

BACKGROUND Public disclosure of individual surgeons mortality following coronary artery bypass (CAB) is part of the New York State Department of Health Cardiac Surgery Reporting System (CSRS). The effects on the practice of cardiac surgery, as perceived by surgeons, remain unknown. METHODS All 150 New York State cardiac surgeons were sent an anonymous mail survey in 1997. Data was analyzed to determine the dominant opinion regarding the CSRS. RESULTS One hundred and four surgeons (69.3%) responded. The majority (70%) did not experience a change in practice. Data reporting was performed by the surgeon or an employee (58%). Many picked the incorrect definition of chronic obstructive pulmonary disease (COPD) (45%) or statistical method (60%). The aspect of CSRS most in need of improvement was gaming with risk factors (40%). Most surgeons (62%) refused to operate on at least one high-risk CAB patient over the prior year, primarily because of public reporting. Refusal was more common in surgeons in practice less than 10 years, those with less than 100 cases per year, and those with a mixed cardiothoracic practice (p < 0.05, Pearsons chi2 test). A significantly higher percentage of high-risk CAB patients were treated non-operatively, when compared with ascending aortic dissection patients (not disclosed) (p < 0.001, Wilcoxon signed ranks test). CONCLUSIONS The public disclosure of surgical results may be based on imperfect data and appears to have resulted in denial of surgical treatment to high-risk patients.

Transthoracic intraaortic balloon pump: A simplified technique

A technique of transthoracic intraaortic balloon pump insertion and a clinical experience with 14 patients is reported. The technique of transthoracic intraaortic balloon pump insertion can be done in a rapid and atraumatic fashion. A short prosthetic graft is used, and intraaortic balloon pump removal does not require resternotomy. The technique is a safe alternative in postcardiotomy failure patients with inadequate peripheral arterial access.

STUDIES IN THORACIC AORTIC GRAFT INFECTIONS: THE DEVELOPMENT OF A PORCINE MODEL AND A COMPARISON OF COLLAGEN-IMPREGNATED DACRON GRAFTS AND CRYOPRESERVED ALLOGRAFTS

OBJECTIVE A porcine model of thoracic aortic graft infection was created, and various anatomic sites and the timing of inoculation of the graft to induce infection were investigated. Ultimately, the ability of cryopreserved allograft to resist infection was compared with that of collagen-impregnated Dacron graft. METHODS Yorkshire pigs (n = 16) underwent placement of an expanded polytetrafluoroethylene patch graft in the ascending aorta and the left atrial appendage (phase I). Eight animals were immediately given a 50-mL bolus (1 x 10(8) cfu/mL) of Staphylococcus aureus whereas the other 8 received the infusion 24 hours later. Animals were put to death 8 weeks later and the grafts were sterilely explanted and analyzed via microbiologic culture and standard histologic procedures for evidence of infection. The results displayed that the aortic graft and a delay of induced bacteremia of 24 hours were more reliable methods of producing infection. During phase II, 13 pigs were randomized to receive either a collagen-impregnated Dacron graft (n = 6) or a cryopreserved allograft (n = 7) in the ascending aortic position only and infusion of S aureus 24 hours after the operation. The experiment then proceeded to completion. RESULTS Phase I results displayed that use of an aortic graft and induced bacteremia 24 hours after the operation was a more reliable and reproducible method of producing infection. In phase II, graft infection was present in 38.5% (5/13) of animals, with only 16.7% (1/6) in the collagen-impregnated Dacron graft group and 57.2% (4/7) in the cryopreserved allograft group becoming infected. There was no significant difference between the collagen-impregnated Dacron graft and cryopreserved allograft groups in the incidences of thoracic aortic graft infections (P =.27, Fisher exact test). CONCLUSIONS This novel porcine model of thoracic aortic graft infection is a reproducible method for the investigation of thoracic aortic graft infections. The phase I study investigated the timing of the induced bacteremia and the most susceptible position of a graft. Phase II demonstrated that collagen-impregnated Dacron grafts are equivalent, if not superior, to cryopreserved allografts in resisting central vascular graft infections in the ascending aorta.

Laboratory Studies in Cross-Species Lung Transplantation

Abstract. The lack of sufficient suitable human donor lungs for the many patients requiring pulmonary transplantation as life-saving therapy for end-stage lung diseases has generated extensive interest in cross-species lung transplantation. Ethical concerns and those of animal rights advocates have prompted studies of nonprimate species as potential solid organ donors for humans. This paper provides an overview of some of the laboratory studies of cross-species pulmonary transplantation performed over the past 20 years and focuses, in particular, on more recent work (from our laboratory and others) in the area of porcine-to-primate pulmonary xenotransplantation.

A rare case of osteomyelitis of the sternum in an adult with sickle cell disease.

Osteomyelitis is an uncommon, but well described complication of bone infarctions in adults with sickle cell anemia [1-4]. The tibia and other long bones are most commonly involved [[1]]. Painful e...