Publications (94) View all
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Article: An Extracorporeal Membrane Oxygenation Cannulation Curriculum Featuring a Novel Integrated Skills Trainer Leads to Improved Performance Among Pediatric Cardiac Surgery Trainees.
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ABSTRACT: INTRODUCTION: American Heart Association guidelines recommend timely extracorporeal membrane oxygenation (ECMO) cannulation during cardiopulmonary resuscitation for pediatric cardiac arrest refractory to conventional resuscitation. Traditional cannulation training relies on the apprenticeship model. We hypothesized that a simulation-based ECMO cannulation curriculum featuring a novel integrated skills trainer would improve ECMO cannulation during cardiopulmonary resuscitation performance by cardiothoracic surgery trainees. METHODS: An embedded surgical neck cannulation trainer, designed in collaboration with expert surgeons, formed the focus for a simulation-based cannulation curriculum. The course included a didactic presentation and 2 neck cannulations during cardiopulmonary resuscitation with video-assisted expert feedback with a further cannulation at 3 months. Primary outcome was time to cannulation on the trainer. Secondary outcomes were performance on a validated Global Rating Scale (GRS) of surgical technique and a novel Composite ECMO Cannulation Score (CECS). RESULTS: Ten cardiothoracic surgery trainees participated. The trainer was rated as authentic, and sessions was rated as highly useful. Median time to cannulation decreased between cannulation 1 and 2 (15 minutes 24 seconds vs. 12 minutes 15 seconds, P = 0.002). Improvement was sustained at 3 months (13 minutes 36 seconds, P = 0.157 vs. attempt 2). Likewise, GRS increased significantly at attempt 2 versus 1 (77% vs. 62%, P = 0.003) as did CECS (88% vs. 52%, P = 0.002). No deterioration in GRS or CECS was measured at 3 months. CONCLUSIONS: Cardiothoracic surgery trainees found a contextualized ECMO cannulation during cardiopulmonary resuscitation cannulation curriculum to be highly useful and demonstrated sustained improvement in time to cannulation, CECS, and GRS. Further work will focus on determining the clinical impact of this training and defining the optimal interval and number of training sessions.Simulation in healthcare: journal of the Society for Simulation in Healthcare 04/2013; · 1.83 Impact Factor -
Article: Surgical technical performance scores are predictors of late mortality and unplanned reinterventions in infants after cardiac surgery.
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ABSTRACT: We have previously shown that surgical Technical Performance Scores (TPS) are important predictors of early postoperative morbidity across a wide spectrum of procedures and that intraoperative recognition and intervention of residual defects resulted in improved outcomes. We hypothesized that these scores would also be important predictors of midterm outcomes. Neonates and infants aged younger 6 months were prospectively followed from the index surgery for a minimum of 1 year. The TPS were calculated using previously published criteria, including intraoperative course, predischarge echocardiograms or catheterizations, and clinical data, and graded as optimal, adequate, or inadequate. Case complexity was determined by the Risk Adjustment for Congenital Heart Surgery-1 category. The primary outcome was mortality, and the secondary outcome was the need for unplanned reinterventions. Outcomes were analyzed using nonparametric methods and a logistic regression model. A total of 166 patients were included in our study, with 7 early deaths. The remaining 159 patients (Risk Adjustment for Congenital Heart Surgery-1 category 4-6, 76 [48%]; neonates, 78 [49%]) were followed for a minimum of 1 year after surgery. There were 14 late deaths or late transplantations and 55 late reinterventions. On univariate analysis, the TPS were associated with mortality (P < .001) and reintervention (P = .04). On logistic regression analysis, inadequate TPS was associated with late mortality (P < .001; odds ratio, 7.2; 95% confidence interval, 2.2-23.6), and Risk Adjustment for Congenital Heart Surgery-1 category (P = .004; odds ratio, 3.7; 1.5-8.8) at index surgery was associated with need for late unplanned reintervention. Technical performance affects midterm survival after infant heart surgery. Inadequate TPS can be used to prospectively identify patients at ongoing risk of demise and the need for reintervention. An aggressive approach to diagnosing and treating residual lesions at the initial operation is warranted.The Journal of thoracic and cardiovascular surgery 08/2012; 144(5):1095-1101.e7. · 3.41 Impact Factor -
Article: Congenital heart surgeon's technical proficiency affects neonatal hospital survival.
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ABSTRACT: Risk factors for mortality after neonatal cardiac surgery have been seldom studied. We sought to identify contemporary risk factors for mortality and the impact of surgical technical performance on surgical outcomes after neonatal cardiac surgery. We conducted a matched case-control study comparing 56 neonates who died after cardiac surgery (2002-2008) with 56 survivors matched by surgical procedure and year of surgery. Surgical efficacy for repair or palliation was graded using a reliable simple surgical technical score. Patient and surgical characteristics were compared for the survivors and nonsurvivors using paired analyses. There was no significant difference between patients who died and their matched controls in terms of age, Aristotle score, Risk Adjustment in Congenital Heart Surgery-1 category, and single versus biventricular repair. When compared with survivors, patients who died were more likely to be premature (41% vs 5%, P < .001), to weigh less than 2.5 kg (25% vs 9%, P = .05), and to have inadequate surgical repair or palliation (55% vs 9%, P < .001). Cardiopulmonary bypass time was longer for the patients who died (median, 159 vs 133 minutes, P = .002). Highest postoperative lactate (median, 9.0 vs 6.0, P < .001), use of extracorporeal membrane oxygenation (71% vs 13%, P < .001), and reoperation during the same admission (75% vs 2%, P < .001) were also associated with death. In multivariable analysis, inadequate surgical repair or palliation (odds ratio, 11, P = .02) and need for postoperative extracorporeal membrane oxygenation (odds ratio, 5.1, P = .009) were the only risk factors associated with hospital death. Our study highlights the need for optimal technical performance to minimize neonatal deaths. This has important implications when sustaining or developing a pediatric cardiac program.The Journal of thoracic and cardiovascular surgery 03/2012; 144(5):1119-24. · 3.41 Impact Factor -
Article: Biventricular strategies for neonatal critical aortic stenosis: High mortality associated with early reintervention.
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ABSTRACT: To characterize the risk of reintervention after biventricular strategies to treat neonatal critical aortic stenosis, and the effect of reintervention on survival. In a multi-institutional inception cohort of 139 neonates, the time-related risk of reintervention was analyzed using parametric multiphase competing-risk models and a modulated renewal repeated-events method. The risk factors were identified through multivariate regression and selected with bootstrap resampling for reliability. Univentricular survival predictions were generated using the Congenital Heart Surgeons' Society Univentricular Repair Survival Advantage score. One half of survivors required reintervention within 3 years. The risk of undergoing early reintervention decreased with successive procedures (P<.0001); however, second (n=27) and third (n=8) reinterventions were associated with a greater late risk of repeat reintervention compared with the index procedure (P=.02). The morphologic risk factors for earlier reintervention included left ventricular dysfunction, fewer aortic cusps, associated subaortic or arch obstruction, and a larger tricuspid annulus. The risk of death did not improve after successive reinterventions. Therefore, the overall survival for those requiring repeated reinterventions was compromised by the cumulative procedural risk of death. The most important risk factor for death after the first reintervention (P<.01) was a shorter interval from the index biventricular procedure, particularly if less than 30 days. Fifteen neonates required reintervention within 30 days of the index biventricular procedure (9 deaths, 60%). For the same 15 neonates, the survival predictions using published models estimated fewer than one half the number deaths with index univentricular repair strategies (4/15, 27%, P=.03). Success of index biventricular procedures has important survival implications: early reintervention implies a poor prognosis and might reflect incorrect management decisions. The morphologic characteristics can help identify such neonates, and univentricular repair might, instead, be preferable.The Journal of thoracic and cardiovascular surgery 02/2012; 144(2):409-17, 417.e1. · 3.41 Impact Factor -
Article: Protecting the Infant Brain During Cardiac Surgery: A Systematic Review
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ABSTRACT: Prevention of brain injury during congenital heart sur-gery has focused on intraoperative and perioperative neuroprotection and neuromonitoring. Many strategies have been adopted as "standard of care." However, the strength of evidence for these practices and the relation-ship to long-term outcomes are unknown. We performed a systematic review (January 1, 1990 to July 30, 2010) of neuromonitoring and neuroprotection strategies during cardiopulmonary bypass (CPB) in in-fants of age 1 year or less. Papers were graded individu-ally and as thematic groups, assigning evidence-based medicine and American College of Cardiology/American Heart Association (ACC/AHA) level of evidence grades. Consensus scores were determined by adjudication. Literature search identified 527 manuscripts; 162 met inclusion criteria. Study designs were prospective obser-vational cohort (53.7%), case-control (21.6%), randomized clinical trial (13%), and retrospective observational co-hort (9.9%). Median sample size was 43 (range 3 to 2,481).The Annals of Thoracic Surgery 01/2012; 94:1365. · 3.74 Impact Factor
