Francis D Pagani

• MD PhD
• Professor (Full) at University of Michigan

Background: New postoperative atrial fibrillation (POAF) occurs in about 40% after cardiac surgery. Mineralocorticoid receptor antagonists (MRA) are known to reduce chronic atrial fibrillation (AF) development and burden. We examined the impact of preoperative MRA use on POAF and also examine the atrial cell type impacted by MRA treatment during co...

Background Infections following durable left ventricular assist device (dLVAD) implantation are common and associated with increased morbidity and mortality. Despite documented interhospital variability, few studies have identified strategies to mitigate their occurrence. This national study uses a multistage mixed methods design to develop a custo...

Importance The Aspirin and Hemocompatibility Events With a Left Ventricular Assist Device in Advanced Heart Failure (ARIES-HM3) study demonstrated that aspirin may be safely eliminated from the antithrombotic regimen after HeartMate 3 (HM3 [Abbott Cardiovascular]) left ventricular assist device (LVAD) implantation. This prespecified analysis explor...

BACKGROUND Safety in cardiac surgical procedures is predicated on effective team dynamics. This study associated operative team familiarity (ie, the extent of clinical collaboration among surgical team members) with procedural efficiency and Society of Thoracic Surgeons (STS) adjudicated patient outcomes. METHODS Institutional STS adult cardiac su...

Introduction: Cardiac rehabilitation (CR) is a clinically effective and underused service for patients with recent cardiac events, and insurance coverage is an important, yet understudied, mediator. The objective of this study was to evaluate the relationship between insurance type and CR participation. Methods: Data from the Michigan Value Collabo...

Background: Despite well-known morbidity and mortality benefits, implementation of guideline-directed medical therapy (GDMT) for HFrEF patients remains suboptimal. Understanding the center-level variation in observed-to-expected GDMT prescribing could support targeted improvement initiatives. Hypothesis: The risk-adjusted observed to expected (O/E)...

Adverse events (AEs) experienced by children and adults with congenital heart disease (CHD) on ventricular assist devices (VADs) are sometimes unique to these populations. The Advanced Cardiac Therapies Improving Outcomes Network (ACTION) and the Academic Research Consortium (ARC) aimed to harmonize definitions of pediatric and CHD AEs for use in c...

While mixed methods research is increasingly used to examine determinants of unwarranted variability in healthcare delivery and outcomes, novel integrative approaches are required to meet the needs of mixed methods healthcare delivery research. This article describes novel refining strategies that enhance the linkage between qualitative and quantit...

BACKGROUND Home health care (HHC) has been increasingly used to improve care transitions and avoid poor outcomes, but there is limited data on its use and efficacy following coronary artery bypass grafting. The purpose of this study was to describe HHC use and its association with outcomes among Medicare beneficiaries undergoing coronary artery byp...

Objective Cardiac surgeons experience unpredictable overnight operative responsibilities, with variable rest before same-day, first-start scheduled cases. This study evaluated the frequency and associated impact of a surgeon's overnight operative workload on the outcomes of their same-day, first-start operations. Methods A statewide cardiac surger...

Background Adult patients surviving with congenital heart disease (ACHD) is growing. We examine the factors associated with heart transplant outcomes in this challenging population with complex anatomy requiring redo-surgeries. Methods We reviewed the United Network for Organ Sharing-Standard Transplant Analysis and Research database and analyzed...

Background Over 20% of patients are discharged to a skilled nursing facility (SNF) after coronary artery bypass graft surgery, but little is known about specific drivers for postdischarge SNF use. The purpose of this study was to evaluate hospital variation in SNF use and its association with postoperative outcomes after coronary artery bypass graf...

IMPORTANCE Left ventricular assist devices (LVADs) enhance quality and duration of life in advanced heart failure. The burden of nonsurgical bleeding events is a leading morbidity. Aspirin as an antiplatelet agent is mandated along with vitamin K antagonists (VKAs) with continuous-flow LVADs without conclusive evidence of efficacy and safety. OBJE...

Introduction: Increased frailty before cardiovascular procedures is associated with poorer outcomes. While underutilized, cardiac rehabilitation (CR) is guideline-recommended for patients undergoing cardiovascular procedures and may help mitigate frailty through individualized, monitored exercise and risk factor reduction. Research Question/Hypothe...

Objective Professional standards recommend stopping cardiotomy suction at the termination of cardiopulmonary bypass before protamine administration based on perceived safety concerns. This study evaluated a multidisciplinary collaborative quality-improvement intervention promoting this agreed-upon cardiotomy suction practice during coronary artery...

Background Although disparities in cardiac rehabilitation (CR) participation are well documented, the role of community-level distress is poorly understood. This study evaluated the relationship between community-level distress and CR participation, access to CR facilities, and clinical outcomes. Methods A retrospective cohort study was conducted...

Objective To associate surgeon-anesthesiologist team familiarity with cardiac surgery outcomes. Background Team Familiarity (TF), a measure of repeated team member collaborations, has been associated with improved operative efficiency; however, examination of its relationship to clinical outcomes has been limited. Methods This retrospective cohor...

BACKGROUND Skilled nursing facility (SNF) care is frequently used after cardiac surgery, but the patterns and determinants of use have not been well understood. The objective of this study was to evaluate determinants and outcomes associated with SNF use after isolated coronary artery bypass grafting. METHODS A retrospective analysis of Medicare F...

Objective This study evaluated interhospital variability and determinants of failure-to-rescue for patients undergoing surgical aortic valve replacement. Methods An observational study was conducted among 28,842 patients undergoing aortic valve replacement with or without coronary artery bypass grafting between July 2011 and June 2017 across 90 ho...

Background: Evaluating the research productivity of cardiothoracic (CT) surgery residents during their training and early career is crucial for tracking their academic development. To this end, the training pathway of residents and the characteristics of their program in relation to their productivity was evaluated. Methods: Alumni lists from in...

The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS), a pioneer in initiating and nurturing quality improvement strategies in statewide cardiothoracic surgery, has been running the Quality Collaborative (MSTCVS-QC) program since 2001. This initiative has significantly grown over the years, facilitating at least 4 in-person meetings...

Introduction: Right heart output in heart failure can be compensated through increasing systemic venous pressure. We determined whether this "Passive Cardiac Output" magnitude can predict LVAD outcomes. Methods: Retrospective review of 383 patients who received a continuous flow LVAD at the University of Michigan from 2012 to 2021. Pre-LVAD card...

In June 2021, HVAD™ System distribution ceased due to observational data demonstrating increased mortality and neurological events compared to another commercial device, and a device malfunction with delay or failure to restart, especially in certain subpopulations. To assess ongoing risk for patients on support following subsequent device recalls,...

Background: Cardiac rehabilitation (CR) is a supervised outpatient exercise and risk reduction program offered to patients who have undergone coronary revascularization procedures. Multiple professional societal guidelines support the use of CR after CABG based on studies in combined PCI and CABG populations with surrogate outcomes. This statewide...

Background: Information about health-related quality of life (HRQOL) among caregivers of older patients with heart failure who receive heart transplantation (HT) and mechanical circulatory support (MCS) is sparse. We describe differences and factors associated with change in HRQOL before and early post-surgery among caregivers of older heart failu...

Background: Conflicting evidence exists regarding the risks and benefits of inotropic therapies during cardiac surgery, and the extent of variation in clinical practice remains understudied. Therefore, the authors sought to quantify patient-, anesthesiologist-, and hospital-related contributions to variation in inotrope use. Methods: In this obs...

Background Inflammation has been associated with progression and complications of chronic heart failure (HF) but no effective therapy has yet been identified to treat this dysregulated immunologic state. The selective cytopheretic device (SCD) provides extracorporeal autologous cell processing to lessen the burden of inflammatory activity of circul...

Background: Caregiving for heart failure (HF) patients is burdensome. We examined differences in caregiver burden for three groups of older advanced HF patients: (1) supported with mechanical circulatory support (MCS) before heart transplantation (HT MCS), (2) awaiting transplant without MCS (HT non-MCS), and (3) prior to long-term MCS and factors...

Importance: There is a need to better assess the cumulative effect on morbidity and mortality in patients undergoing durable left ventricular assist device (LVAD) implantation. This study evaluates a patient-centered performance metric (days alive and out of hospital [DAOH]) for durable LVAD therapy. Objective: To determine the incidence of perc...

Preservation quality of donor hearts is a key determinant of transplant success. Preservation duration beyond 4 hours is associated with primary graft dysfunction (PGD). Given transport time constraints, geographical limitations exist for donor-recipient matching, leading to donor heart underutilization. Here, we showed that metabolic reprogramming...

Background Reliable diagnosis of heart failure during preoperative evaluation is important for perioperative management and long-term care. We aimed to quantify preoperative heart failure diagnostic accuracy and explore characteristics of patients with heart failure misdiagnoses. Methods We performed an observational cohort study of adults undergo...

Objectives: To examine whether fragmentation of care is associated with worse in-hospital and 90-day outcomes following durable ventricular assist device (VAD) implant. Study design: Cohort study. Methods: This study was conducted using Medicare claims linked to the Society of Thoracic Surgeons (STS) Interagency Registry for Mechanically Assis...

Background: Despite the known benefits for patients undergoing coronary revascularization, cardiac rehabilitation (CR) use remains low, with few studies evaluating geographic barriers to care. In this analysis, we examined geographic access (i.e. distance) to a CR facility and its relationship to CR participation and completion. Methods: A cohort o...

Introduction: Participation in cardiac rehabilitation (CR) is poor, with disparities across patient demographic and clinical subgroups. Lower CR participation and completion rates may be associated with patients residing in socioeconomically distressed communities. Hypothesis: Patients undergoing surgical and percutaneous coronary revascularization...

Introduction: Home health care (HHC) use after discharge may improve short-term outcomes and reduce expenditures for patients undergoing coronary artery bypass grafting (CABG), but there is limited data describing utilization patterns of HHC and its association with longer-term outcomes. Thus, we investigated the utilization patterns of HHC and its...

Introduction: Ventricular arrhythmias (VA) are a common complication after left ventricular assist device (LVAD) implantation and contribute to increased mortality. The VT LVAD Score was created to help stratify patients into four risk categories: Low Risk, Moderate Risk, High Risk, and Very High Risk. Hypothesis: We sought to assess the performanc...

Introduction: Advanced data analytics are needed to reliably predict bleeding and thrombotic risk in ambulatory left ventricular assist device (LVAD) patients. Hypothesis: Machine learning techniques can be used to predict risk of gastrointestinal bleeding (GIB), stroke, or death in ambulatory LVAD patients. Methods: HeartMate 3 TM LVAD recipients...

Importance: In 2020, the Centers for Medicare & Medicaid Services revised its national coverage determination, removing the requirement to obtain review from a Medicare-approved heart transplant center to implant a durable left ventricular assist device (LVAD) for bridge-to-transplant (BTT) intent at an LVAD-only center. The association between ce...

Centers for Medicare and Medicaid Services created a five-star quality rating system to evaluate skilled nursing facilities (SNFs). Patient discharge to lower-star quality SNFs has been shown to adversely impact surgical outcomes. Recent data has shown that over 20% of patients are discharged to an SNF after CABG, but the link between SNF quality a...

Background Aortic regurgitation (AR) is common and detrimental in patients with left ventricular assist devices (LVADs). Off-label use of transcatheter aortic valve replacement (TAVR) has emerged as a potential treatment option. Further data are required regarding the feasibility and outcomes of TAVR to treat AR in LVAD recipients. Methods A retro...

Functional mitral regurgitation (MR) in the setting of heart failure results from progressive dilatation of the left ventricle (LV) and mitral annulus. This leads to leaflet tethering with posterior displacement. Contrary to common assumptions, MR often does not resolve with LVAD decompression of the LV alone. The negative impact of significant (mo...

Objective: Health Professional Shortage Areas (HPSA) were created by the Health Resources and Services Administration to identify communities with a shortage of clinical providers. For medical conditions, these designations are associated with worse outcomes. However, far less is known about patients undergoing high complexity surgical procedures,...

Women with advanced heart failure receive advanced surgical therapies such as durable left ventricular assist device (LVAD) implantation or heart transplantation at a rate much lower compared to males. Reasons for this discrepancy remain largely unknown. Much of what is understood reflects outcomes of those patients who ultimately receive device im...

Background: Restoring health-related quality of life (HRQOL) is a therapeutic goal for older patients with advanced heart failure. We aimed to describe change in HRQOL in older patients (60-80 years) awaiting heart transplantation (HT) with or without pretransplant mechanical circulatory support (MCS) or scheduled for long-term MCS, if ineligible...

Purpose Articulated hand pose tracking is an under-explored problem that carries the potential for use in an extensive number of applications, especially in the medical domain. With a robust and accurate tracking system on surgical videos, the motion dynamics and movement patterns of the hands can be captured and analyzed for many rich tasks. Meth...

Rationale There are limited therapeutic options for patients with coronavirus disease (COVID-19)-related acute respiratory distress syndrome with inflammation-mediated lung injury. Mesenchymal stromal cells offer promise as immunomodulatory agents. Objectives Evaluation of efficacy and safety of allogeneic mesenchymal cells in mechanically-ventila...

BACKGROUND Care fragmentation is associated with higher rates of infection after durable left ventricular assist device (LVAD) implant. Less is known about the relationship between care fragmentation and total spending, and whether this relationship is mediated by infections. METHODS Total payments were captured from admission to 180 days post-dis...

Background Systems level barriers to heart failure (HF) care limit access to HF advanced therapies (transplantation, left ventricular assist devices). There is a need for automated systems that can help clinicians ensure patients with HF are evaluated for HF advanced therapies at the appropriate time to optimize outcomes. Methods We performed a re...

Importance: While left ventricular assist devices (LVADs) increase survival for patients with advanced heart failure (HF), racial and sex access and outcome inequities remain and are poorly understood. Objectives: To assess risk-adjusted inequities in access and outcomes for both Black and female patients and to examine heterogeneity in treatmen...

Background Improved health-related quality of life (HRQOL) is an important outcome following durable left ventricular assist device (LVAD) implant. However, half of pre-implant HRQOL data are incomplete in The Society of Thoracic Surgeons’ Intermacs registry. Pre-implant HRQOL incompleteness may reflect patient status or hospital resources to captu...

BACKGROUND Durable ventricular assist device (VAD) therapy is reserved for patients with advanced heart failure who have a poor estimated 1-year survival. However, despite highly protocolized management processes, patients are at a unique risk for developing a health care-associated infection (HAI). Few studies have examined optimal strategies for...

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Background: Despite reported benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR participation. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and su...

BACKGROUND Defects in energetics are thought to be central to the pathophysiology of hypertrophic cardiomyopathy (HCM); yet, the determinants of ATP availability are not known. The purpose of this study is to ascertain the nature and extent of metabolic reprogramming in human HCM, and its potential impact on contractile function. METHODS We conduc...

Background: Payment reform efforts have sought to minimize the use of skilled nursing facilities (SNF) after coronary artery bypass grafting (CABG). Little is known about the characteristics and long-term consequences of CABG patients that are discharged to SNF. The purpose of this study was to identify clinical predictors and long-term outcomes as...

Intro: Despite providing benefit in the setting of aortic valve replacement (AVR), cardiac rehabilitation (CR) utilization remains low, with few studies evaluating hospital and patient-level variation in CR enrollment. We explored determinants of CR variability during AVR episodes of care: transcatheter aortic valve replacement (TAVR) and surgical...

Objectives Unsupervised statistical determination of optimal allograft ischemic time (IT) on heart transplant outcomes among ABO donor heart types. Methods We identified 36,145 heart transplants (2000–2018) from the United Network for Organ Sharing database. Continuous and categorical variables were analyzed with parametric and nonparametric testi...