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Now showing items 1 - 16 of 7410

  • Early Structural Valve Degeneration of Trifecta Bioprosthesis

    Fukuhara, Shinichi   Shiomi, Suzuna   Yang, Bo   Kim, Karen   Bolling, Steven F.   Haft, Jonathan   Tang, Paul   Pagani, Francis   Prager, Richard L.   Chetcuti, Stanley   Grossman, P. Michael   Patel, Himanshu J.   Deeb, G. Michael  

    Background. Structural valve degeneration (SVD) is a major flaw of bioprostheses. An apparent increase in the SVD rate has been observed among patients who received the Trifecta bioprosthesis (Abbott Vascular, Santa Clara, CA). Methods. This study retrospectively reviewed 1058 consecutive patients who underwent aortic valve placement with a stented bioprosthesis between January 2011 and December 2015. Patients were grouped into a Trifecta group (508 [48.0%] patients with Trifecta bioprostheses) and a non-Trifecta group (550 [52.0%] patients with other bioprostheses). Results. Patients in the Trifecta group were older (69.7 years vs 64.6 years; P =3D .001), were more likely female (40.4% vs 28.0%; P =3D .001), more often had aortic stenosis (85.1% vs 77.1%; P =3D .001), and received smaller valves (23.0 mm vs 25.0 mm; P < .001) than patients in the non-Trifecta group. SVD occurred in 28 patients (Trifecta, n =3D 22; non-Trifecta, n =3D 6) within 7 years. Aortic regurgitation or mixed stenosis/regurgitation was observed as the mode of failure in more than 50% of the Trifecta group, whereas none in non-Trifecta group. The cumulative incidence of SVD was higher in the Trifecta group both in the entire cohort (13.3% vs 4.6%; P =3D .010) and in the younger cohort (age <=3D 65 years; 27.9% vs 6.9%; P =3D .004), with a notable increase between 5 and 7 years. Multivariable competing risks regression in the Trifecta group revealed younger age (hazard ratio, 0.56 per 10-point decrease; 95% confidence interval, 0.44 to 0.72; P < .001) to be the sole contributor to SVD. Conclusions. The SVD rate of the Trifecta bioprosthesis has been greater than expected, compared with other bioprostheses, particularly in younger patients. In view of the large number of Trifecta bioprostheses implanted worldwide, further investigation involving other institutions is warranted. (C) 2020 by The Society of Thoracic Surgeons
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  • Eye of the Beholder: The Reinvention of Seeing

    Prager, Richard L.  

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  • Quality metrics in coronary artery bypass grafting

    Khan, Faiza M.   Hameed, Irbaz   Milojevic, Milan   Wingo, Matthew   Krieger, Katherine   Girardi, Leonard N.   Prager, Richard L.   Gaudino, Mario  

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  • Incorporating Innovation and New Technology Into Cardiothoracic Surgery

    Dearani, Joseph A.   Rosengart, Todd K.   Marshall, M. Blair   Mack, Michael J.   Jones, David R.   Prager, Richard L.   Cerfolio, Robert J.  

    The appropriate implementation of new technology, root cause analysis of "imperfect" outcomes, and the continuous reappraisal of postgraduate training are needed to improve the care of tomorrow's patients. Healthcare delivery remains one of the most expensive sectors in the United States, and the application of new and expensive technology that is necessary for the advancement of this complex specialty must be aligned with providing the best care for our patients. There are a several pathways to innovation: One is partnering with industry and the other is the investigational laboratory. Innovation and the funding thereof come from both the public and private sector. Most new trials that are likely to impact cardiothoracic surgery are industry-sponsored trials to meet the requirements necessary for regulatory approval. Cost considerations are paramount when considering integration of innovative technology and treatments into a clinical cardiothoracic surgical practice. The value of any new innovation is determined by the quality divided by the cost, and lean initiatives maximize this equation. The importance and implications of conflict of interest have been a concern for physicians, particularly when new technology or procedures are incorporated into clinical practice, and full disclosures by medical professionals and others involved are essential. Our societies and associations provide a platform for presentation and peer-reviewed discussion of new procedures, innovations, and trials and provide a venue for the sharing of knowledge on the highest quality patient care through education and research. (C) 2019 by The Society of Thoracic Surgeons
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  • Incorporating Innovation and New Technology Into Cardiothoracic Surgery

    Dearani, Joseph A.   Rosengart, Todd K.   Marshall, M. Blair   Mack, Michael J.   Jones, David R.   Prager, Richard L.   Cerfolio, Robert J.  

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  • Battling the Chimaera: How Much Disclosure of Rare Risks Is Necessary?

    Prager, Richard L.   Berlioz, Alejandro Murillo   Trachiotis, Gregory D.   Zwischenberger, Joseph B.   Sade, Robert M.  

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  • Introduction to Dr Joseph E. Bavaria’s Presidential Address

    Prager, Richard L.  

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  • Understanding the Association Between Frailty and Cardiac Surgical Outcomes

    Bergquist, Curtis S.   Jackson, Elizabeth A.   Thompson, Michael P.   Cabrera, Lourdes   Paone, Gaetano   DeLucia, Alphonse, III   He, Chang   Prager, Richard L.   Likosky, Donald S.  

    Background. Previous work identified a direct relationship between frailty and adverse outcomes in cardiac surgery, but assessment of the effect across subgroups of patients has largely been ignored. This study identified whether the association of frailty (measured by gait speed) with adverse outcomes differed across subgroups of patients. Methods. The study evaluated 53,932 patients who underwent cardiac operations between 2011 and 2016 across 33 Michigan institutions. Five-meter gait speed (in seconds) was divided into groups: faster (<5.0 seconds), intermediate (5.0 to 5.99 seconds), and slower (>=3D 6.0 seconds). The study used mixed logistic regression to estimate the relationship between increasing gait speed time and a patient's odds of major morbidity or mortality, by adjusting for patient-related demographics, disease characteristics, surgeon, and hospital. Effect modification by subgroup of patients and gait speed test time was tested with interaction terms. The study's secondary end point was an analysis of discharge disposition. Results. Nearly one fourth (22.7%) of patients had at least one gait speed test. Slower (34% of patients) versus faster (28%) patients were older (72.5 years vs 62.6 years), had more comorbidities, and had the primary outcome (16.6% vs 9.5%) (p < 0.0001). Significant interactions with gait speed existed for patients' comorbidities (chronic lung disease, atrial fibrillation, p < 0.05), although marginal interactions existed for patients' age (p =3D 0.059) and diabetes (p =3D 0.063). Slower patients were more often discharged to a facility rather than home. Conclusions. Slower gait speed was associated with increased odds of major morbidity or mortality. This effect was amplified among patients with preexisting comorbidities. Future studies should evaluate the impact of preprocedural interventions on frailty, including those aimed at addressing comorbidities. (C) 2018 by The Society of Thoracic Surgeons
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  • The Society of Thoracic Surgeons National Database 2016 Annual Report

    Jacobs, Jeffrey P.   Shahian, David M.   Prager, Richard L.   Edwards, Fred H.   McDonald, Donna   Han, Jane M.   D'Agostino, Richard S.   Jacobs, Marshall L.   Kozower, Benjamin D.   Badhwar, Vinay   Thourani, Vinod H.   Gaissert, Henning A.   Fernandez, Felix G.   Wright, Cameron D.   Paone, Gaetano   Cleveland, Joseph C., Jr.   Brennan, J. Matthew   Dokholyan, Rachel S.   Brothers, Leo   Vemulapalli, Sreekanth   Habib, Robert H.   O'Brien, Sean M.   Peterson, Eric D.   Grover, Frederick L.   Patterson, G. Alexander   Bavaria, Joseph E.  

    The art and science of outcomes analysis, quality improvement, and patient safety continue to evolve, and cardiothoracic surgery leads many of these advances. The Society of Thoracic Surgeons (STS) National Database is one of the principal reasons for this leadership role, as it provides a platform for the generation of knowledge in all of these domains. Understanding these topics is a professional responsibility of all cardiothoracic surgeons. Therefore, beginning in January 2016, The Annals of Thoracic Surgery began publishing a monthly series of scholarly articles on outcomes analysis, quality improvement, and patient safety. This article provides a summary of the status of the STS National Database as of October 2016 and summarizes the articles about the STS National Database that appeared in The Annals of Thoracic Surgery 2016 series, "Outcomes Analysis, Quality Improvement, and Patient Safety." (C) 2016 by The Society of Thoracic Surgeons
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  • The University of Michigan Cardiac and Thoracic Surgery

    Prager, Richard L.   Bove, Edward L.   Chang, Andrew   Orringer, Mark B.  

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  • Invited Commentary

    Prager, Richard L.  

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  • Drivers of Payment Variation in 90-Day Coronary Artery Bypass Grafting Episodes

    Guduguntla, Vinay   Syrjamaki, John D.   Ellimoottil, Chad   Miller, David C.   Prager, Richard L.   Norton, Edward C.   Theurer, Patricia   Likosky, Donald S.   Dupree, James M.  

    IMPORTANCE Coronary artery bypass grafting (CABG) is scheduled to become a mandatory Medicare bundled payment program in January 2018. A contemporary understanding of 90-day CABG episode payments and their drivers is necessary to inform health policy, hospital strategy, and clinical quality improvement activities. Furthermore, insight into current CABG payments and their variation is important for understanding the potential effects of bundled payment models in cardiac care. OBJECTIVE To examine CABG payment variation and its drivers. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used Medicare and private payer claims to identify patients who underwent nonemergent CABG surgery from January 1, 2012, through October 31, 2015. Ninety-day price-standardized, risk-adjusted, total episode payments were calculated for each patient, and hospitals were divided into quartiles based on the mean total episode payments of their patients. Payments were then subdivided into 4 components (index hospitalization, professional, postacute care, and readmission payments) and compared across hospital quartiles. Seventy-six hospitals in Michigan representing a diverse set of geographies and practice environments were included. MAIN OUTCOMES AND MEASURES Ninety-day CABG episode payments. RESULTS A total of 5910 patients undergoing nonemergent CABG surgery were identified at 33 of the 76 hospitals; of these, 4344 (73.5%) were men and mean (SD) age was 68.0 (9.3) years. At the patient level, risk-adjusted, 90-day total episode payments for CABG varied from $11 723 to $356 850. At the hospital level, the highest payment quartile of hospitals had a mean total episode payment of $54 399 compared with $45 487 for the lowest payment quartile (16.4% difference, P < .001). The highest payment quartile hospitals compared with the lowest payment quartile hospitals had 14.6% higher index hospitalization payments ($34 992 vs $30 531, P < .001), 33.9% higher professional payments ($8060 vs $6021, P < .001), 29.6% higher postacute care payments ($7663 vs $5912, P < .001), and 35.1% higher readmission payments ($3576 vs $2646, P =3D .06). The drivers of this variation are diagnosis related group distribution, increased inpatient evaluation and management services, higher utilization of inpatient rehabilitation, and patients with multiple readmissions. CONCLUSIONS AND RELEVANCE Wide variation exists in 90-day CABG episode payments for Medicare and private payer patients in Michigan. Hospitals and clinicians entering bundled payment programs for CABG should work to understand local sources of variation, with a focus on patients with multiple readmissions, inpatient evaluation and management services, and postdischarge outpatient rehabilitation care.
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  • Transfusion Rate as a Quality Metric: Is Blood Conservation a Learnable Skill?

    Paone, Gaetano   Brewer, Robert   Likosky, Donald S.   Theurer, Patricia F.   Bell, Gail F.   Cogan, Chad M.   Prager, Richard L.  

    Background. Between January 2008 and December 2012, a multicenter quality collaborative initiated a focus on blood conservation as a quality metric, with educational presentations and quarterly reporting of institutional-level perioperative transfusion rates and outcomes. This prospective cohort study was undertaken to determine the effect of that initiative on transfusion rates after isolated coronary artery bypass grafting (CABG). Methods. Between January 1, 2008, and December 31, 2012, 30,271 patients underwent isolated CABG in Michigan. Evaluated were annual crude and adjusted trends in overall transfusion rates for red blood cells (RBCs), fresh frozen plasma (FFP), and platelets, and in operative death. Results. Transfusion rates continuously decreased for all blood products. RBC use decreased from 56.4% in 2008 (baseline) to 38.3% in 2012, FFP use decreased from 14.8% to 9.1%, and platelet use decreased from 20.5% to 13.4% ptrend < 0.001 for all). A significant reduction occurred in deep sternal wound infection, reoperation for bleeding, renal failure, prolonged ventilation, initial ventilator time, and intensive care unit duration. The percentage of patients discharged home significantly increased (p(trend) < 0.001). Mortality rates did not differ significantly (p(trend) = 0.11). Conclusions. In a multicenter quality collaborative, increased attention to transfusion-related outcomes and blood conservation techniques, coincident with regular reporting and review of perioperative transfusion rates as a quality metric, was associated with a significant decrease in blood product utilization. These reductions were concurrent with significant improvement in most perioperative outcomes. This intervention was also safe, as it was not associated with any increases in mortality. (C) 2013 by The Society of Thoracic Surgeons
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  • Public Reporting of Cardiac Surgery Performance: Part 2-Implementation

    Shahian, David M.   Edwards, Fred H.   Jacobs, Jeffrey P.   Prager, Richard L.   Normand, Sharon-Lise T.   Shewan, Cynthia M.   O'Brien, Sean M.   Peterson, Eric D.   Grover, Frederick L.  

    Appropriate implementation is essential to create a credible public reporting system. Ideally, data should be obtained from an audited clinical data registry, and structure, process, or outcomes metrics may be reported. Composite measures are increasingly used, as are measures of appropriateness, patient satisfaction, functional status, and health-related quality of life. Classification of provider performance should use statistical criteria appropriate to the policy objectives and to the desired balance of sensitivity and specificity. Public reports should use simplified visual or tabular presentation aids that maximize correct interpretation of numerical data. Because of sample size issues, and to emphasize that cardiac surgery requires team-based care, public reporting should generally be focused at the program rather than individual surgeon level. This may also help to mitigate risk aversion, the avoidance of high-risk patients. (Ann Thorac Surg 2011;92:S12-S23) (C) 2011 by The Society of Thoracic Surgeons
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  • The Role of Regional Collaboratives in Quality Improvement:Time to Organize,and How?

    Milojevic, Milan   Bond, Chris   Theurer, Patricia F.   Jones, Robert N.   Dabir, Reza   Likosky, Donald S.   Leyden, Tom   Clark, Melissa   Prager, Richard L.  

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  • Long-Term Survival and Echocardiographic Findings After Surgical Ventricular Restoration

    Hobbs, Reilly D.   Assi, Ali   Bolling, Steven F.   Patel, Himanshu J.   Deeb, G. Michael   Romano, Matthew A.   Haft, Jonathan W.   Prager, Richard L.   Pagani, Francis D.   Tang, Paul C.  

    Background. This study investigates the long-term survival and durability of mitral procedures on patients undergoing surgical ventricular restoration. Methods. From 1992 to 2017, 109 patients underwent surgical ventricular restoration. Survival was determined from hospital records and the National Death Index. Preoperative demographics, clinical characteristics and features, operative technique, and follow-up echocardiography findings were analyzed using Cox regression and log-rank to determine variables influencing survival. Results. The mean age was 61.57 +/- 12.81 years. There were 101 (93%) true and 8 (7%) pseudo-aneurysms. Concomitant surgeries included mitral valve (MV) repair (n =3D 40, 37%), MV replacement (n =3D 5, 5%), tricuspid valve repair (n =3D 4, 4%), aortic valve replacement (n =3D 3, 3%), coronary bypass grafting (n =3D 76, 70%; 1.6 +/- 1.3 grafts), and ventricular septal defect closure (n =3D 5, 5%). Redosternotomies were performed in 12 patients (11%). Median duration of echocardiographic follow up was 2.9 years (interquartile range, 9.0) and was obtained in 59 patients (54%). Left ventricular ejection fraction improved from 28% +/- 13% to 33% +/- 16% (p =3D 0.011). Median duration of echocardiographic follow-up of MV repair was 3.6 years (interquartile range, 9.5). MV repair led to sustained improvements in mitral regurgitation (MR; p =3D 0.001) where only 2 (5%) experienced recurrence of moderate to severe MR. For patients who did not undergo an MV procedure there was no difference in preoperative and follow-up MR severity (p =3D 0.586). Median patient follow-up was 7.1 years (interquartile range, 8.5). Overall 5-, 10-, and 15-year survival rates were 71.9%, 48.1%, and 26.2%, respectively. Conclusions. Surgical ventricular restoration was associated with sustained improvement in left ventricular ejection fraction with almost half surviving to 10 years postoperatively. For patients undergoing concomitant MV repair, the improvement in mitral competence is durable. (C) 2019 by The Society of Thoracic Surgeons
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