102 results on '"Shahian D"'
Search Results
2. Variability in the measurement of hospital-wide mortality rates.
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Shahian, D M, Wolf, R E, Iezzoni, L I, Kirle, L, and Normand, S-LT
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- 2010
Catalog
3. ECHOCARDIOGRAPHIC MID-VENTRICULAR LINEAR DIMENSIONS ARE MORE ACCURATE THAN TRADITIONAL BASAL-LEVEL LINEAR DIMENSIONS: AN MRI VALIDATION STUDY
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Chetrit, M., primary, Roujol, S., additional, Timmins, L., additional, Levine, R., additional, Weyman, A., additional, Flynn, A., additional, Shahian, D., additional, Picard, M., additional, and Afilalo, J., additional more...
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- 2017
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4. Incremental value of the echocardiogram to predict short- and long-term mortality and morbidity after surgical aortic valve replacement
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Tan, T. C., primary, Flynn, A. W., additional, Mehrotra, P., additional, Nunes, M. P., additional, Shahian, D. M., additional, Picard, M. H., additional, and Afilalo, J., additional
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- 2013
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5. Weekend hospitalization and additional risk of death: An analysis of inpatient data
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Freemantle, N, primary, Richardson, M, additional, Wood, J, additional, Ray, D, additional, Khosla, S, additional, Shahian, D, additional, Roche, WR, additional, Stephens, I, additional, Keogh, B, additional, and Pagano, D, additional more...
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- 2012
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6. Measuring healthcare quality
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Shahian, D, primary
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- 2011
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7. Efficacy of short term versus long term tube thoracostomy drainage before tetracycline pleurodesis in the treatment of malignant pleural effusions.
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Villanueva, A G, primary, Gray, A W, additional, Shahian, D M, additional, Williamson, W A, additional, and Beamis, J F, additional
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- 1994
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8. Etiology and management of chronic valve disease in antiphospholipid antibody syndrome and systemic lupus erythematosus.
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Shahian, David M., Labib, Sherif B., Schneebaum, Andrea B., Shahian, D M, Labib, S B, and Schneebaum, A B
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- 1995
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9. In vitro decalcification of aortic valve leaflets with the Er:YSGG laser, Ho:YAG laser, and the Cavitron ultrasound surgical aspirator.
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Williamson, Warren A., Aretz, H. Thomas, Weng, Guoxing, Shahian, David M., Hamilton, William M., Pankratov, Michail M., Shapshay, Stanley M., Williamson, W A, Aretz, H T, Weng, G, Shahian, D M, Hamilton, W M, Pankratov, M M, and Shapshay, S M more...
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- 1993
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10. Cardiac Surgery Report Cards: Comprehensive Review and Statistical Critique
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Shahian, D. M., Normand, S.-L., Torchiana, D. F., Lewis, S. M., Pastore, J. O., Kuntz, R. E., and Dreyer, P. I.
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- 2001
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11. Reduction of Neurologic Injury After High-Risk Thoracoabdominal Aortic Operation
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Svensson, L. G., Hess, K. R., D'Agostino, R. S., Entrup, M. H., Hreib, K., Kimmel, W. A., Nadolny, E., and Shahian, D. M.
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- 1998
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12. Endarterectomy for Calcified Porcelain Aorta Associated With Aortic Valve Stenosis
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Svensson, L. G., Sun, J., Cruz, H. A., and Shahian, D. M.
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- 1996
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13. Relationship of hospital size, case volume, and cost for coronary artery bypass surgery: Analysis of 12,774 patients operated on in Massachusetts during fiscal years 1995 and 1996
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SHAHIAN, D
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- 2001
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14. Selection of a cardiac surgery provider in the managed care era
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SHAHIAN, D
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- 2000
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15. Applications of Statistical Quality Control to Cardiac Surgery
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Shahian, D. M., Williamson, W. A., Svensson, L. G., Restuccia, J. D., and D'Agostino, R. S.
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- 1996
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16. Anterior Ischemic Optic Neuropathy After Open Heart Operations
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Shapira, O. M., Kimmel, W. A., Lindsey, P. S., and Shahian, D. M.
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- 1996
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17. The Society of Thoracic Surgeons National Intermacs Database Risk Model for Durable Left Ventricular Assist Device Implantation.
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Pagani FD, Singletary B, Cantor R, Mehaffey JH, Nayak A, Teuteberg J, Shah P, Cowger J, Vega JD, Goldstein D, Kurlansky PA, Stehlik J, Jacobs J, Shahian D, Habib R, Dardas TF, and Kirklin JK
- Abstract
Background: Statistical risk models for durable left ventricular assist device (LVAD) implantation inform candidate selection, quality improvement, and evaluation of provider performance. This study developed a 90-day mortality risk model using The Society of Thoracic Surgeons National Intermacs Database (STS Intermacs)., Methods: STS Intermacs was queried for primary durable LVAD implants from January 2019 to September 2023. Multivariable logistic regression was used to derive a model based on preimplant risk factors by using derivation (2019-2021 implants) and validation (2022-2023 implants) cohorts. Model performance (derivation and validation cohorts) was assessed using C-statistics, Brier scores, and calibration plots. A refined model (all patients) was generated to calculate observed-to-expected (O/E; 95% CI) ratios for each center., Results: The study population consisted of 11,342 patients from 2019 to 2023 who were sequentially divided in time into derivation (n = 6775) and validation (n = 4567) cohorts. Ninety-day mortality was 8.0% (9.2% in the derivation cohort vs 7.4% in the validation cohort; P = .001). Logistic regression applied to derivation and validation cohorts produced similar discrimination (area under the curve [AUC], 0.714 [95% CI, 0.69-0.74]; and AUC, 0.707; [95% CI, 0.67-0.72], respectively) and calibration (Brier score, .08 vs .07), with overestimation of risk among patients with a predicted risk >0.4. The O/E analysis identified 22 (12.5%) centers with worse than expected mortality with a 95% CI >1.0 and 14 centers (8.0%) with better than expected mortality with a 95% CI <1.0 (all P < .05)., Conclusions: The STS Intermacs risk model demonstrated satisfactory discrimination and calibration. This tool may be used to inform candidate selection, facilitate quality improvement, and assess provider performance., Competing Interests: Disclosures Francis D. Pagani has served as a noncompensated ad hoc scientific advisor for Abbott, BrioHealth Solutions, Berlin Heals, FineHeart, and Medtronic; has served as a noncompensated medical monitor for Abiomed; has served as a member of the Data Safety Monitoring Board for Carmat; and has received travel support from BrioHealth Solutions. Aditi Nayak has served on the clinical advisory board of Pumpinheart; and has reported consulting for Alira Health. Jeffrey Teuteberg has reported consulting for Abbott, Broadview Ventures, and Medtronic; has served on the advisory board for Abiomed, Care Dx, Medtronic, and Takeda; and has served as a speaker for CareDx, Medtronic, and Paragonix. Palak Shah has reported consulting for Procyrion, Merck, Natera, Ortho Clinical Diagnostics, Tosoh Biosciences, and JVP Labs. J. David Vega has reported membership on the Clinical Events Committee for BrioHealth INNOVATE IDE clinical trial. Josef Stehlik has reported consulting for Medtronic, Natera, and TransMedics. All other authors declare that they have no conflicts of interest., (Copyright © 2025 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.) more...
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- 2025
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18. Revisiting performance metrics for prediction with rare outcomes.
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Adhikari S, Normand SL, Bloom J, Shahian D, and Rose S
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- Algorithms, False Positive Reactions, Humans, Postoperative Complications, Predictive Value of Tests, Benchmarking, Machine Learning, ROC Curve
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Machine learning algorithms are increasingly used in the clinical literature, claiming advantages over logistic regression. However, they are generally designed to maximize the area under the receiver operating characteristic curve. While area under the receiver operating characteristic curve and other measures of accuracy are commonly reported for evaluating binary prediction problems, these metrics can be misleading. We aim to give clinical and machine learning researchers a realistic medical example of the dangers of relying on a single measure of discriminatory performance to evaluate binary prediction questions. Prediction of medical complications after surgery is a frequent but challenging task because many post-surgery outcomes are rare. We predicted post-surgery mortality among patients in a clinical registry who received at least one aortic valve replacement. Estimation incorporated multiple evaluation metrics and algorithms typically regarded as performing well with rare outcomes, as well as an ensemble and a new extension of the lasso for multiple unordered treatments. Results demonstrated high accuracy for all algorithms with moderate measures of cross-validated area under the receiver operating characteristic curve. False positive rates were < 1%, however, true positive rates were < 7%, even when paired with a 100% positive predictive value, and graphical representations of calibration were poor. Similar results were seen in simulations, with the addition of high area under the receiver operating characteristic curve ( > 90%) accompanying low true positive rates. Clinical studies should not primarily report only area under the receiver operating characteristic curve or accuracy. more...
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- 2021
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19. I-PASS handover system: a decade of evidence demands action.
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Shahian D
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- Continuity of Patient Care, Humans, Patient Handoff
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Competing Interests: Competing interests: None declared.
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- 2021
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20. Updating an Empirically Based Tool for Analyzing Congenital Heart Surgery Mortality.
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Jacobs ML, Jacobs JP, Thibault D, Hill KD, Anderson BR, Eghtesady P, Karamlou T, Kumar SR, Mayer JE, Mery CM, Nathan M, Overman DM, Pasquali SK, St Louis JD, Shahian D, and O'Brien SM
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- Bayes Theorem, Female, Heart Defects, Congenital mortality, Hospital Mortality trends, Humans, Male, Survival Rate trends, United States epidemiology, Cardiac Surgical Procedures mortality, Heart Defects, Congenital surgery, Risk Assessment methods
- Abstract
Objectives: STAT Mortality Categories (developed 2009) stratify congenital heart surgery procedures into groups of increasing mortality risk to characterize case mix of congenital heart surgery providers. This update of the STAT Mortality Score and Categories is empirically based for all procedures and reflects contemporary outcomes., Methods: Cardiovascular surgical operations in the Society of Thoracic Surgeons Congenital Heart Surgery Database (January 1, 2010 - June 30, 2017) were analyzed. In this STAT 2020 Update of the STAT Mortality Score and Categories, the risk associated with a specific combination of procedures was estimated under the assumption that risk is determined by the highest risk individual component procedure. Operations composed of multiple component procedures were eligible for unique STAT Scores when the statistically estimated mortality risk differed from that of the highest risk component procedure. Bayesian modeling accounted for small denominators. Risk estimates were rescaled to STAT 2020 Scores between 0.1 and 5.0. STAT 2020 Category assignment was designed to minimize within-category variation and maximize between-category variation., Results: Among 161,351 operations at 110 centers (19,090 distinct procedure combinations), 235 types of single or multiple component operations received unique STAT 2020 Scores. Assignment to Categories resulted in the following distribution: STAT 2020 Category 1 includes 59 procedure codes with model-based estimated mortality 0.2% to 1.3%; Category 2 includes 73 procedure codes with mortality estimates 1.4% to 2.9%; Category 3 includes 46 procedure codes with mortality estimates 3.0% to 6.8%; Category 4 includes 37 procedure codes with mortality estimates 6.9% to 13.0%; and Category 5 includes 17 procedure codes with mortality estimates 13.5% to 38.7%. The number of procedure codes with empirically derived Scores has grown by 58% (235 in STAT 2020 vs 148 in STAT 2009). Of the 148 procedure codes with empirically derived Scores in 2009, approximately one-half have changed STAT Category relative to 2009 metrics. The New STAT 2020 Scores and Categories demonstrated good discrimination for predicting mortality in an independent validation sample (July 1, 2017-June 30, 2019; sample size 46,933 operations at 108 centers) with C-statistic = 0.791 for STAT 2020 Score and 0.779 for STAT 2020 Category., Conclusions: The updated STAT metrics reflect contemporary practice and outcomes. New empirically based STAT 2020 Scores and Category designations are assigned to a larger set of procedure codes, while accounting for risk associated with multiple component operations. Updating STAT metrics based on contemporary outcomes facilitates accurate assessment of case mix. more...
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- 2021
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21. Interdisciplinary Patient Tracers: Routine, Systematic Safety Surveillance.
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Logan M, Seguin C, Snydeman C, Deen J, Liu X, Shahian D, and Mort E
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- Ambulatory Care Facilities, Humans, Interdisciplinary Studies, Patient Safety, Leadership, Quality Improvement
- Abstract
Patient tracers and leadership WalkRounds proactively identify quality and safety issues. However, these programs have been inconsistent in application, results, and sustainability. The goal was to identify a more consistent and efficient approach to survey health care facilities. The authors developed a Peer-to-Peer Interdisciplinary Patient Tracer program to assess compliance with National Patient Safety Goals and to proactively identify areas of inpatient, ambulatory, and procedural risk. The program has been operational for more than 5 years, with continued expansion annually. In all, 96% of frontline leadership reported satisfaction; 100% reported that they would recommend the program to others (Kirkpatrick level 1 results). Mean absolute change in performance scores from 2014 to 2018 was 15%. All survey findings triggered the development of an improvement project. This novel integrated program advanced institutional improvement by strengthening internal peer-to-peer surveillance, engaging leadership, and creating an accountability structure for internal improvement efforts., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.) more...
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- 2021
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22. Concomitant carotid endarterectomy and cardiac surgery does not decrease postoperative stroke rates.
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Klarin D, Patel VI, Zhang S, Xian Y, Kosinski A, Yerokun B, Badhwar V, Thourani VH, Sundt TM, Shahian D, and Melnitchouk S
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- Aged, Cardiopulmonary Bypass adverse effects, Carotid Stenosis diagnostic imaging, Carotid Stenosis mortality, Coronary Artery Bypass mortality, Coronary Artery Bypass, Off-Pump adverse effects, Coronary Artery Disease diagnostic imaging, Coronary Artery Disease mortality, Databases, Factual, Endarterectomy, Carotid mortality, Female, Humans, Incidence, Ischemic Attack, Transient diagnosis, Ischemic Attack, Transient mortality, Male, Middle Aged, Retrospective Studies, Risk Assessment, Risk Factors, Stroke diagnosis, Stroke mortality, Time Factors, Treatment Outcome, United States epidemiology, Carotid Stenosis surgery, Coronary Artery Bypass adverse effects, Coronary Artery Disease surgery, Endarterectomy, Carotid adverse effects, Ischemic Attack, Transient epidemiology, Stroke epidemiology
- Abstract
Objective: The timing of operative revascularization for patients with concomitant carotid artery stenosis and coronary artery disease remains controversial. We examined the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database to evaluate the association of combined carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG) with postoperative outcomes., Methods: All patients undergoing CABG with known carotid stenosis of >80% were identified from 2011 to 2016. Individuals were stratified by use of cardiopulmonary bypass and whether a concomitant CEA was performed at the time of CABG. Multivariate logistic regression was used to model the probability of combined CABG and CEA. The resulting propensity scores were used to match individuals on the basis of clinical and operative characteristics to evaluate primary (30-day mortality and in-hospital transient ischemic attack and stroke) and secondary (STS morbidity composite events and length of stay) end points, with P < .05 required to declare statistical significance., Results: After propensity score matching, 994 off-pump CABG patients (497 CABG only and 497 CABG-CEA) and 5952 on-pump CABG patients (2976 CABG only and 2976 CABG-CEA) were identified. For patients who received on-pump operations, those undergoing CABG-CEA had no observed difference in rate of in-hospital stroke (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.72-1.21; P = .6), higher incidence of STS morbidity composite events (OR, 1.15, 95% CI, 1.01-1.31; P = .03), longer length of stay (7.0 [interquartile range, 5.0-9.0] days vs 6.0 [interquartile range, 5.0-9.0] days; P < .005), and no observed difference in 30-day mortality (OR, 1.28; 95% CI, 0.97-1.69; P = .08) compared with those undergoing CABG only. For off-pump procedures, CABG-CEA patients had no observed difference in rate of in-hospital stroke (OR, 0.80; 95% CI, 0.37-1.69; P = .56) compared with those undergoing CABG only., Conclusions: Whereas the differences are relatively small, these data suggest that a combined CABG-CEA approach is unlikely to provide significant stroke reduction benefit compared with CABG only. However, comparison with staged approaches merits further investigation., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.) more...
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- 2020
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23. Improving cardiac surgical quality: lessons from the Japanese experience.
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Shahian D
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- Accreditation, Humans, Japan, Data Management, Quality Improvement
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Competing Interests: Competing interests: None declared.
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- 2020
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24. Bilateral internal thoracic artery versus radial artery multi-arterial bypass grafting: a report from the STS database†.
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Schwann TA, Habib RH, Wallace A, Shahian D, Gaudino M, Kurlansky P, Engoren MC, Tranbaugh RF, Schwann AN, and Jacobs JP
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- Aged, Coronary Artery Bypass adverse effects, Coronary Artery Bypass methods, Coronary Artery Disease surgery, Female, Humans, Male, Middle Aged, Retrospective Studies, Coronary Artery Bypass mortality, Mammary Arteries transplantation, Radial Artery transplantation
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Objectives: Multi-arterial bypass grafting with bilateral internal thoracic (BITA-MABG) or radial (RA-MABG) arteries improves long-term survival, but its increased complexity raises perioperative safety concerns. We compared perioperative outcomes of RA-MABG and BITA-MABG using the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD)., Methods: We analysed the 2004-2015 BITA-MABG and RA-MABG experience in STS-ACSD. Primary end points were operative mortality (OM) and deep sternal wound infections (DSWI). Risk-adjusted odds ratios [AOR (95% confidence interval)] were derived via multivariable logistic regression. Sensitivity analyses were done in patient sub-cohorts and based on institutional BITA-utilization rates (<5%, 5-10%, 10-20%, 20-40% and >40%)., Results: Eighty-five thousand nine hundred five RA-MABG (82.5% men; 61 years) and 61 336 BITA-MABG (85.1% men; 59 years) patients were analysed; 41.6% of BITA-MABG and 27.3% of RA-MABG cases came from institutions with low MABG utilization rates (<10%). Unadjusted OM was equivalent for both techniques (BITA-MABG versus RA-MABG: 1.3% vs 1.2%, P = 0.79), while DSWI was lower for RA-MABG (1.0% vs 0.6%, P < 0.001). RA-MABG was associated with lower adjusted OM [AOR = 0.80 (0.69-0.96)] and DSWI [AOR = 0.39 (0.32-0.46)]. Sensitivity analyses confirmed robustness of these findings. Equivalent outcomes were observed at high BITA-use institutions where BITA cases comprised >20% of all cases for OM and ≥40% for DSWI., Conclusions: This analysis of the STS-ACSD showed that RA-MABG is a generally safer form of multi-arterial coronary artery bypass grafting surgery. However, this advantage is mitigated at institutions with substantial BITA experience., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.) more...
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- 2019
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25. Transcatheter Aortic Valve Replacement in Patients With End-Stage Renal Disease.
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Szerlip M, Zajarias A, Vemalapalli S, Brennan M, Dai D, Maniar H, Lindman BR, Brindis R, Carroll JD, Hamandi M, Edwards FH, Grover F, O'Brien S, Peterson E, Rumsfeld JS, Shahian D, Tuzcu EM, Holmes D, Thourani VH, and Mack M more...
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- Aged, Aged, 80 and over, Aortic Valve Stenosis complications, Aortic Valve Stenosis mortality, Comorbidity, Female, Follow-Up Studies, Hospital Mortality, Humans, Kidney Failure, Chronic complications, Kidney Failure, Chronic mortality, Male, Reference Values, Registries, Renal Dialysis, Risk, Transcatheter Aortic Valve Replacement mortality, Treatment Outcome, Aortic Valve Stenosis surgery, Kidney Failure, Chronic physiopathology, Transcatheter Aortic Valve Replacement methods
- Abstract
Background: In patients with end-stage renal disease (ESRD), surgical aortic valve replacement is associated with higher early and late mortality, and adverse outcomes compared with patients without renal disease. Transcatheter aortic valve replacement (TAVR) offers another alternative, but there are limited reported outcomes., Objectives: The purpose of this study was to determine the outcomes of TAVR in patients with ESRD., Methods: Among the first 72,631 patients with severe aortic stenosis (AS) treated with TAVR enrolled in the Society of Thoracic Surgeons (STS)/American College of Cardiology (ACC) TVT (Transcatheter Valve Therapies) registry, 3,053 (4.2%) patients had ESRD and were compared with patients who were not on dialysis for demographics, risk factors, and outcomes., Results: Compared with the nondialysis patients, ESRD patients were younger (76 years vs. 83 years; p < 0.01) and had higher rates of comorbidities leading to a higher STS predicted risk of mortality (median 13.5% vs. 6.2%; p < 0.01). ESRD patients had a higher in-hospital mortality (5.1% vs. 3.4%; p < 0.01), although the observed to expected ratio was lower (0.32 vs. 0.44; p < 0.01). ESRD patients also had a similar rate of major vascular complications (4.5% vs. 4.6%; p = 0.86), but a higher rate of major bleeding (1.4% vs. 1.0%; p = 0.03). The 1-year mortality was significantly higher in dialysis patients (36.8% vs. 18.7%; p < 0.01)., Conclusions: Patients undergoing TAVR with ESRD are at higher risk and had higher in-hospital mortality and bleeding, but similar vascular complications, when compared with those who are not dialysis dependent. The 1-year survival raises concerns regarding diminished benefit in this population. TAVR should be used judiciously after full discussion of the risk-benefit ratio in patients on dialysis., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.) more...
- Published
- 2019
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26. Transcatheter Versus Surgical Aortic Valve Replacement: Propensity-Matched Comparison.
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Brennan JM, Thomas L, Cohen DJ, Shahian D, Wang A, Mack MJ, Holmes DR, Edwards FH, Frankel NZ, Baron SJ, Carroll J, Thourani V, Tuzcu EM, Arnold SV, Cohn R, Maser T, Schawe B, Strong S, Stickfort A, Patrick-Lake E, Graham FL, Dai D, Li F, Matsouaka RA, O'Brien S, Li F, Pencina MJ, and Peterson ED more...
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- Aged, Aged, 80 and over, Aortic Valve Stenosis mortality, Female, Follow-Up Studies, Heart Valve Prosthesis Implantation methods, Humans, Male, Propensity Score, Risk Factors, Survival Rate trends, Treatment Outcome, United States, Aortic Valve surgery, Aortic Valve Stenosis surgery, Registries, Risk Assessment methods, Transcatheter Aortic Valve Replacement methods
- Abstract
Background: Randomized trials support the use of transcatheter aortic valve replacement (TAVR) for the treatment of aortic stenosis in high- and intermediate-risk patients, but the generalizability of those results in clinical practice has been challenged., Objectives: The aim of this study was to determine the safety and effectiveness of TAVR versus surgical aortic valve replacement (SAVR), particularly in intermediate- and high-risk patients, in a nationally representative real-world cohort., Methods: Using data from the Transcatheter Valve Therapy Registry and Society of Thoracic Surgeons National Database linked to Medicare administrative claims for follow-up, 9,464 propensity-matched intermediate- and high-risk (Society of Thoracic Surgeons Predicted Risk of Mortality score ≥3%) U.S. patients who underwent commercial TAVR or SAVR were examined. Death, stroke, and days alive and out of the hospital to 1 year were compared, as well as discharge home, with subgroup analyses by surgical risk, demographics, and comorbidities., Results: In a propensity-matched cohort (median age 82 years, 48% women, median Society of Thoracic Surgeons Predicted Risk of Mortality score 5.6%), TAVR and SAVR patients experienced no difference in 1-year rates of death (17.3% vs. 17.9%; hazard ratio: 0.93; 95% confidence interval [CI]: 0.83 to 1.04) and stroke (4.2% vs. 3.3%; hazard ratio: 1.18; 95% CI: 0.95 to 1.47), and no difference was observed in the proportion of days alive and out of the hospital to 1 year (rate ratio: 1.00; 95% CI: 0.98 to 1.02). However, TAVR patients were more likely to be discharged home after treatment (69.9% vs. 41.2%; odds ratio: 3.19; 95% CI: 2.84 to 3.58). Results were consistent across most subgroups, including among intermediate- and high-risk patients., Conclusions: Among unselected intermediate- and high-risk patients, TAVR and SAVR resulted in similar rates of death, stroke, and DAOH to 1 year, but TAVR patients were more likely to be discharged home., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.) more...
- Published
- 2017
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27. Gait Speed Predicts 30-Day Mortality After Transcatheter Aortic Valve Replacement: Results From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry.
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Alfredsson J, Stebbins A, Brennan JM, Matsouaka R, Afilalo J, Peterson ED, Vemulapalli S, Rumsfeld JS, Shahian D, Mack MJ, and Alexander KP
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- Acute Kidney Injury epidemiology, Aged, Aged, 80 and over, Female, Frail Elderly statistics & numerical data, Hospital Mortality, Humans, Male, Postoperative Complications mortality, Postoperative Hemorrhage epidemiology, Prognosis, Prospective Studies, Registries statistics & numerical data, Stroke epidemiology, Gait, Mobility Limitation, Postoperative Complications epidemiology, Transcatheter Aortic Valve Replacement mortality
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Background: Surgical risk scores do not include frailty assessments (eg, gait speed), which are of particular importance for patients with severe aortic stenosis considering transcatheter aortic valve replacement., Methods and Results: We assessed the association of 5-m gait speed with outcomes in a cohort of 8039 patients who underwent transcatheter aortic valve replacement (November 2011-June 2014) and were included in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry. We evaluated the association between continuous and categorical gait speed and 30-day all-cause mortality before and after adjustment for Society of Thoracic Surgeons-predicted risk of mortality score and key variables. Secondary outcomes included in-hospital mortality, bleeding, acute kidney injury, and stroke. The overall median gait speed was 0.63 m/s (25th-75th percentile, 0.47-0.79 m/s), with the slowest walkers (<0.5 m/s) constituting 28%, slow walkers (0.5-0.83 m/s) making up 48%, and normal walkers (>0.83 m/s) constituting 24% of the population. Thirty-day all-cause mortality rates were 8.4%, 6.6%, and 5.4% for the slowest, slow, and normal walkers, respectively (P<0.001). Each 0.2-m/s decrease in gait speed corresponded to an 11% increase in 30-day mortality (adjusted odds ratio, 1.11; 95% confidence interval, 1.01-1.22). The slowest walkers had 35% higher 30-day mortality than normal walkers (adjusted odds ratio, 1.35; 95% confidence interval, 1.01-1.80), significantly longer hospital stays, and a lower probability of being discharged to home., Conclusions: Gait speed is independently associated with 30-day mortality after transcatheter aortic valve replacement. Identification of frail patients with the slowest gait speeds facilitates preprocedural evaluation and anticipation of a higher level of postprocedural care., Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01737528., (© 2016 American Heart Association, Inc.) more...
- Published
- 2016
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28. Transapical and Transaortic Transcatheter Aortic Valve Replacement in the United States.
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Thourani VH, Jensen HA, Babaliaros V, Suri R, Vemulapalli S, Dai D, Brennan JM, Rumsfeld J, Edwards F, Tuzcu EM, Svensson L, Szeto WY, Herrmann H, Kirtane AJ, Kodali S, Cohen DJ, Lerakis S, Devireddy C, Sarin E, Carroll J, Holmes D, Grover FL, Williams M, Maniar H, Shahian D, and Mack M more...
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- Aged, 80 and over, Aortic Valve Stenosis mortality, Cardiac Catheterization statistics & numerical data, Female, Follow-Up Studies, Humans, Incidence, Male, Postoperative Complications epidemiology, Risk Factors, Survival Rate trends, Treatment Outcome, United States epidemiology, Aortic Valve Stenosis surgery, Cardiac Catheterization methods, Registries, Risk Assessment, Transcatheter Aortic Valve Replacement statistics & numerical data
- Abstract
Background: When transcatheter aortic valve replacement (TAVR) cannot be carried out through transfemoral access, alternative access TAVR is indicated. The purpose of this study was to explore inhospital and 1-year outcomes of patients undergoing alternative access TAVR through the transapical (TA) or transaortic (TAo) techniques in the United States., Methods: Clinical records of 4,953 patients undergoing TA (n = 4,085) or TAo (n = 868) TAVR from 2011 to 2014 in The Society of Thoracic Surgeons (STS)/American College of Cardiology Transcatheter Valve Therapy Registry were linked to Centers for Medicare and Medicaid Services hospital claims. Inhospital and 1-year clinical outcomes were stratified by operative risk; and the risk-adjusted association between access route and mortality, stroke, and heart failure repeat hospitalization was explored., Results: Mean age for all patients was 82.8 ± 6.8 years. The median STS predicted risk of mortality was significantly higher among patients undergoing TAo (8.8 versus 7.4, p < 0.001). When compared with TA, TAo was associated with an increased risk of unadjusted 30-day mortality (10.3% versus 8.8%) and 1-year mortality (30.3% versus 25.6%, p = 0.006). There were no significant differences between TAo and TA for inhospital stroke rate (2.2%), major vascular complications (0.3%), and 1-year heart failure rehospitalizations (15.7%). Examination of high-risk and inoperable subgroups showed that 1-year mortality was significantly higher for TAo patients classified as inoperable (p = 0.012)., Conclusions: Patients undergoing TAo TAVR are older, more likely female, and have significantly higher STS predicted risk of mortality scores than patients operated on by TA access. There were no risk-adjusted differences between TA and TAo access in mortality, stroke, or readmission rates as long as 1 year after TAVR., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.) more...
- Published
- 2015
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29. Standardized Outcome Measurement for Patients With Coronary Artery Disease: Consensus From the International Consortium for Health Outcomes Measurement (ICHOM).
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McNamara RL, Spatz ES, Kelley TA, Stowell CJ, Beltrame J, Heidenreich P, Tresserras R, Jernberg T, Chua T, Morgan L, Panigrahi B, Rosas Ruiz A, Rumsfeld JS, Sadwin L, Schoeberl M, Shahian D, Weston C, Yeh R, and Lewin J more...
- Subjects
- Aged, Cause of Death, Coronary Artery Bypass methods, Coronary Artery Disease mortality, Coronary Artery Disease physiopathology, Female, Health Status, Humans, Male, Middle Aged, Percutaneous Coronary Intervention methods, Risk Factors, Treatment Outcome, Consensus, Coronary Artery Disease diagnosis, Coronary Artery Disease therapy, Hospitalization statistics & numerical data, Surveys and Questionnaires standards
- Abstract
Background: Coronary artery disease (CAD) outcomes consistently improve when they are routinely measured and provided back to physicians and hospitals. However, few centers around the world systematically track outcomes, and no global standards exist. Furthermore, patient-centered outcomes and longitudinal outcomes are under-represented in current assessments., Methods and Results: The nonprofit International Consortium for Health Outcomes Measurement (ICHOM) convened an international Working Group to define a consensus standard set of outcome measures and risk factors for tracking, comparing, and improving the outcomes of CAD care. Members were drawn from 4 continents and 6 countries. Using a modified Delphi method, the ICHOM Working Group defined who should be tracked, what should be measured, and when such measurements should be performed. The ICHOM CAD consensus measures were designed to be relevant for all patients diagnosed with CAD, including those with acute myocardial infarction, angina, and asymptomatic CAD. Thirteen specific outcomes were chosen, including acute complications occurring within 30 days of acute myocardial infarction, coronary artery bypass grafting surgery, or percutaneous coronary intervention; and longitudinal outcomes for up to 5 years for patient-reported health status (Seattle Angina Questionnaire [SAQ-7], elements of Rose Dyspnea Score, and Patient Health Questionnaire [PHQ-2]), cardiovascular hospital admissions, cardiovascular procedures, renal failure, and mortality. Baseline demographic, cardiovascular disease, and comorbidity information is included to improve the interpretability of comparisons., Conclusions: ICHOM recommends that this set of outcomes and other patient information be measured for all patients with CAD., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.) more...
- Published
- 2015
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30. Clinical outcomes at 1 year following transcatheter aortic valve replacement.
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Holmes DR Jr, Brennan JM, Rumsfeld JS, Dai D, O'Brien SM, Vemulapalli S, Edwards FH, Carroll J, Shahian D, Grover F, Tuzcu EM, Peterson ED, Brindis RG, and Mack MJ
- Subjects
- Aged, Aged, 80 and over, Aortic Valve surgery, Female, Follow-Up Studies, Heart Failure epidemiology, Heart Failure etiology, Heart Valve Diseases surgery, Humans, Incidence, Male, Outcome Assessment, Health Care, Patient Readmission statistics & numerical data, Product Surveillance, Postmarketing, Registries, Risk Factors, Stroke epidemiology, Transcatheter Aortic Valve Replacement mortality, Stroke etiology, Transcatheter Aortic Valve Replacement adverse effects
- Abstract
Importance: Introducing new medical devices into routine practice raises concerns because patients and outcomes may differ from those in randomized trials., Objective: To update the previous report of 30-day outcomes and present 1-year outcomes following transcatheter aortic valve replacement (TAVR) in the United States., Design, Setting, and Participants: Data from the Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) Transcatheter Valve Therapies Registry were linked with patient-specific Centers for Medicare & Medicaid Services (CMS) administrative claims data. At 299 US hospitals, 12 182 patients linked with CMS data underwent TAVR procedures performed from November 2011 through June 30, 2013, and the end of the follow-up period was June 30, 2014., Exposure: Transcatheter aortic valve replacement., Main Outcomes and Measures: One-year outcomes including mortality, stroke, and rehospitalization were evaluated using multivariate modeling., Results: The median age of patients was 84 years and 52% were women, with a median STS Predicted Risk of Operative Mortality (STS PROM) score of 7.1%. Following the TAVR procedure, 59.8% were discharged to home and the 30-day mortality was 7.0% (95% CI, 6.5%-7.4%) (n = 847 deaths). In the first year after TAVR, patients were alive and out of the hospital for a median of 353 days (interquartile range, 312-359 days); 24.4% (n = 2074) of survivors were rehospitalized once and 12.5% (n = 1525) were rehospitalized twice. By 1 year, the overall mortality rate was 23.7% (95% CI, 22.8%-24.5%) (n = 2450 deaths), the stroke rate was 4.1% (95% CI, 3.7%-4.5%) (n = 455 stroke events), and the rate of the composite outcome of mortality and stroke was 26.0% (25.1%-26.8%) (n = 2719 events). Characteristics significantly associated with 1-year mortality included advanced age (hazard ratio [HR] for ≥95 vs <75 years, 1.61 [95% CI, 1.24-2.09]; HR for 85-94 years vs <75 years, 1.35 [95% CI, 1.18-1.55]; and HR for 75-84 years vs <75 years, 1.23 [95% CI, 1.08-1.41]), male sex (HR, 1.21; 95% CI, 1.12-1.31), end-stage renal disease (HR, 1.66; 95% CI, 1.41-1.95), severe chronic obstructive pulmonary disease (HR, 1.39; 95% CI, 1.25-1.55), nontransfemoral access (HR, 1.37; 95% CI, 1.27-1.48), STS PROM score greater than 15% vs less than 8% (HR, 1.82; 95% CI, 1.60-2.06), and preoperative atrial fibrillation/flutter (HR, 1.37; 95% CI, 1.27-1.48). Compared with men, women had a higher risk of stroke (HR, 1.40; 95% CI, 1.15-1.71)., Conclusions and Relevance: Among patients undergoing TAVR in US clinical practice, at 1-year follow-up, overall mortality was 23.7%, the stroke rate was 4.1%, and the rate of the composite outcome of death and stroke was 26.0%. These findings should be helpful in discussions with patients undergoing TAVR. more...
- Published
- 2015
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31. Population trends in rates of coronary revascularization.
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Yeh RW, Mauri L, Wolf RE, Romm IK, Lovett A, Shahian D, and Normand SL
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- Cohort Studies, Coronary Artery Bypass statistics & numerical data, Humans, Massachusetts, Myocardial Infarction surgery, Retrospective Studies, Percutaneous Coronary Intervention statistics & numerical data
- Published
- 2015
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32. International participation in the Society of Thoracic Surgeons National Database.
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Shapira OM, Badhwar V, Shahian D, Jacobs JP, Izhar U, Bao Y, Korach A, Lattouf OM, Grover FL, and Puskas JD
- Subjects
- Israel, Databases, Factual, Internationality, Societies, Medical, Thoracic Surgery
- Abstract
In 2011 The Society of Thoracic Surgeons (STS) Workforce on National Databases established the International Database Task Force devoted to expanding participation in the STS National Database internationally. The vision for this initiative was to assist in the globalization of outcomes data and share knowledge, facilitating a worldwide quality collaborative in cardiac surgery. The Department of Cardiothoracic Surgery at Hadassah Medical Center, Jerusalem, Israel, was among the first of several international sites to join the collaborative. This report outlines the rationale behind clinical databases outside of North America submitting data to the STS National Database and reviews the unique challenges and practical steps of integration through experiences by Hadassah Medical Center. Our hope is that this procedural learning will serve as a template to assist future international program integration., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.) more...
- Published
- 2014
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33. Outcomes following transcatheter aortic valve replacement in the United States.
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Mack MJ, Brennan JM, Brindis R, Carroll J, Edwards F, Grover F, Shahian D, Tuzcu EM, Peterson ED, Rumsfeld JS, Hewitt K, Shewan C, Michaels J, Christensen B, Christian A, O'Brien S, and Holmes D
- Subjects
- Aged, Aged, 80 and over, Aortic Valve surgery, Bicuspid Aortic Valve Disease, Cardiac Catheterization, Cohort Studies, Female, Femoral Artery, Heart Valve Prosthesis, Heart Valve Prosthesis Implantation adverse effects, Heart Valve Prosthesis Implantation instrumentation, Humans, Incidence, Length of Stay, Male, Patient Satisfaction, Patient Selection, Product Surveillance, Postmarketing, Registries statistics & numerical data, Treatment Outcome, Heart Defects, Congenital surgery, Heart Valve Diseases surgery, Heart Valve Prosthesis Implantation methods, Heart Valve Prosthesis Implantation mortality, Hospital Mortality, Stroke epidemiology
- Abstract
Importance: Transcatheter aortic valve replacement (TAVR) was approved by the US Food and Drug Administration for the treatment of severe, symptomatic aortic stenosis and inoperable status (in 2011) and high-risk but operable status (starting in 2012). A national registry (the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy [STS/ACC TVT] Registry) was initiated to meet a condition for Medicare coverage and also facilitates outcome assessment and comparison with other trials and international registries., Objective: To report the initial US commercial experience with TAVR., Design, Setting, and Participants: We obtained results from all eligible US TAVR cases (n=7710) from 224 participating registry hospitals following the Edwards Sapien XT device commercialization (November 2011-May 2013)., Main Outcomes and Measures: Primary outcomes included all-cause in-hospital mortality and stroke following TAVR. Secondary analyses included procedural complications and outcomes by clinical indication and access site. Device implantation success was defined as successful vascular access, deployment of a single device in the proper anatomic position, appropriate valve function without either moderate or severe AR, and successful retrieval of the delivery system. Thirty-day outcomes are presented for a representative 3133 cases (40.6%) at 114 centers with at least 80% complete follow-up reporting., Results: The 7710 patients who underwent TAVR included 1559 (20%) cases that were inoperable and 6151 (80%) cases that were high-risk but operable. The median age was 84 years (interquartile range [IQR], 78-88 years); 3783 patients (49%) were women and the median STS predicted risk of mortality was 7% (IQR, 5%-11%). At baseline, 2176 patients (75%) were either not at all satisfied (1297 patients [45%]) or mostly dissatisfied (879 patients [30%]) with their symptom status; 2198 (72%) had a 5-m walk time longer than 6 seconds (slow gait speed). The most common vascular access approach was transfemoral (4972 patients [64%]), followed by transapical (2197 patients [29%]) and other alternative approaches (536 patients [7%]); successful device implantation occurred in 7069 patients (92%; 95% CI, 91%-92%). The observed incidence of in-hospital mortality was 5.5% (95% CI, 5.0%-6.1%). Other major complications included stroke (2.0%; 95% CI, 1.7%-2.4%), dialysis-dependent renal failure (1.9%; 95% CI, 1.6%-2.2%), and major vascular injury (6.4%; 95% CI, 5.8%-6.9%). Median hospital stay was 6 days (IQR, 4-10 days), with 4613 (63%) discharged home. Among patients with available follow-up at 30 days (n=3133), the incidence of mortality was 7.6% (95% CI, 6.7%-8.6%) (noncardiovascular cause, 52%); a stroke had occurred in 2.8% (95% CI, 2.3%-3.5%), new dialysis in 2.5% (95% CI, 2.0%-3.1%), and reintervention in 0.5% (95% CI, 0.3%-0.8%)., Conclusions and Relevance: Among patients undergoing TAVR at US centers in the STS/ACC TVT Registry, device implantation success was achieved in 92% of cases, the overall in-hospital mortality rate was 5.5%, and the stroke rate was 2.0%. Although these postmarket US approval findings are comparable with prior published trial data and international experience, long-term follow-up is essential to assess continued efficacy and safety., Trial Registration: clinicaltrials.gov Identifier: NCT01737528. more...
- Published
- 2013
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34. Regulatory and ethical considerations for linking clinical and administrative databases.
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Dokholyan RS, Muhlbaier LH, Falletta JM, Jacobs JP, Shahian D, Haan CK, and Peterson ED
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- Biomedical Research ethics, Clinical Trials as Topic ethics, Clinical Trials as Topic legislation & jurisprudence, Ethics Committees, Research ethics, Ethics Committees, Research legislation & jurisprudence, Ethics, Clinical, Ethics, Research, Government Regulation, Health Insurance Portability and Accountability Act ethics, Health Insurance Portability and Accountability Act legislation & jurisprudence, Humans, Informed Consent ethics, Informed Consent legislation & jurisprudence, Quality Assurance, Health Care, United States, Confidentiality ethics, Confidentiality legislation & jurisprudence, Databases as Topic ethics, Databases as Topic legislation & jurisprudence, Registries ethics
- Abstract
Clinical data registries are valuable tools that support evidence development, performance assessment, comparative effectiveness studies, and the adoption of new treatments into routine clinical practice. Although these registries do not have important information on long-term therapies or clinical events, administrative claims databases offer a potentially valuable complement. This article focuses on the regulatory and ethical considerations that arise from the use of registry data for research, including linkage of clinical and administrative data sets. (1) Are such activities primarily designed for quality assessment and improvement, research, or both, as this determines the appropriate ethical and regulatory standards? (2) Does the submission of data to a central registry, which may subsequently be linked to other data sources, require review by the institutional review board (IRB) of each participating organization? (3) What levels and mechanisms of IRB oversight are appropriate for the existence of a linked central data repository and the specific studies that may subsequently be developed using it? (4) Under what circumstances are waivers of informed consent and Health Insurance Portability and Accountability Act authorization required? (5) What are the requirements for a limited data set that would qualify a research activity as not involving human subjects and thus not subject to further IRB review? The approaches outlined in this article represent a local interpretation of the regulations in the context of several clinical data registry projects and focuses on a specific case study of the Society of Thoracic Surgeons National Database. more...
- Published
- 2009
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35. The Society of Thoracic Surgeons practice guideline series: Antibiotic prophylaxis in cardiac surgery, part II: Antibiotic choice.
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Engelman R, Shahian D, Shemin R, Guy TS, Bratzler D, Edwards F, Jacobs M, Fernando H, and Bridges C
- Subjects
- Cardiac Surgical Procedures methods, Female, Humans, Male, Sensitivity and Specificity, United States, Anti-Bacterial Agents administration & dosage, Antibiotic Prophylaxis standards, Cardiac Surgical Procedures adverse effects, Surgical Wound Infection prevention & control
- Published
- 2007
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36. Effectiveness of early implantation of cardioverter defibrillator for postoperative ventricular tachyarrhythmia.
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Bolad I, MacLellan C, Karanam S, Parrella F, Michaud G, D'Agostino R, Shahian D, John R, and Martin D
- Subjects
- Aged, Cardiac Surgical Procedures methods, Electrocardiography, Female, Follow-Up Studies, Humans, Male, Middle Aged, Postoperative Complications prevention & control, Probability, Retrospective Studies, Risk Assessment, Severity of Illness Index, Survival Analysis, Tachycardia, Ventricular diagnosis, Tachycardia, Ventricular mortality, Time Factors, Treatment Outcome, Cardiac Surgical Procedures adverse effects, Defibrillators, Implantable, Tachycardia, Ventricular therapy
- Abstract
The effectiveness of implantable cardioverter defibrillators (ICDs) implanted in the early postoperative period after cardiac surgery for ventricular tachyarrhythmias is unknown, because all of the major trials excluded this patient population. Thus, a 10-year retrospective study was conducted of patients who had ICDs implanted for de novo postoperative ventricular tachyarrhythmias during the index admission for cardiac surgery. There was a high rate of early recurrence of ventricular tachyarrhythmia treated by defibrillators, and this finding questions the exclusion of this important patient population from large trials. more...
- Published
- 2004
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37. Papillary fibroelastomas.
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Shahian DM
- Subjects
- Echocardiography, Transesophageal, Endothelium, Vascular metabolism, Humans, Immunohistochemistry, Neoplastic Cells, Circulating, Stroke etiology, Fibroma diagnosis, Fibroma etiology, Fibroma surgery, Heart Neoplasms diagnosis, Heart Neoplasms etiology, Heart Neoplasms surgery
- Abstract
Papillary fibroelastomas are rare benign neoplasms, predominantly involving cardiac valves, that have been discovered with increasing frequency through the use of echocardiography. Most are papillary lesions, less than 1 cm in size, connected to the valve or mural endocardium by a small stalk. Although often asymptomatic, embolization from the lesion or attached thrombus may cause serious neurological or cardiac events. All symptomatic papillary fibroelastomas should be removed unless there are compelling contraindications, in which case anticoagulation is an acceptable but unreliable alternative. Surgical removal is safe, simple, effective, and permanent. Asymptomatic lesions of the left side of the heart should be removed because of their potentially serious or fatal consequences, whereas those arising from the right side of the heart may be observed. more...
- Published
- 2000
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38. A prospective randomized study of neurocognitive function and s-100 protein after antegrade or retrograde brain perfusion with hypothermic arrest for aortic surgery.
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Svensson LG, Husain A, Penney DL, Swanson RA, Margolis DS, Kimmel WA, Nadolny E, and Shahian DM
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- Aortic Diseases surgery, Biomarkers blood, Cognition Disorders blood, Electroencephalography, Humans, Hypothermia, Induced, Linear Models, Mood Disorders diagnosis, Mood Disorders etiology, Neuropsychological Tests, Perfusion methods, Postoperative Complications diagnosis, Prospective Studies, Brain blood supply, Cognition Disorders diagnosis, Cognition Disorders etiology, Heart Arrest, Induced adverse effects, S100 Proteins blood
- Published
- 2000
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39. Readmission after cardiac operations: prevalence, patterns, and predisposing factors.
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D'Agostino RS, Jacobson J, Clarkson M, Svensson LG, Williamson C, and Shahian DM
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- Aged, Causality, Female, Humans, Male, Middle Aged, Postoperative Complications epidemiology, Postoperative Period, Prevalence, Risk Factors, Time Factors, Cardiac Surgical Procedures, Patient Readmission statistics & numerical data
- Abstract
Objectives: This study was undertaken (1) to determine the prevalence of hospital readmission within 1 month of discharge after cardiac operations, (2) to categorize diagnoses responsible for readmission, and (3) to examine predischarge patient factors that influenced readmission., Methods: Data at 1 month after discharge were obtained for 1665 (98.4%) of 1692 patients who underwent cardiac operations between January 1996 and July 1998., Results: Two hundred twenty-five patients (13.5%) were readmitted to a hospital within a 1-month period after discharge. Forty-eight percent of readmissions were to other hospitals. The most common readmission problems were congestive heart failure (15.6%), atrial fibrillation (12.9%), chest pain (12.0%), wound problems (10.2%), and gastrointestinal problems (8.0%). Hospital discharge on or before the fifth postoperative day was associated with a lower prevalence of subsequent readmission. The independent predictors of a readmission for congestive heart failure were postoperative stay longer than 5 days, diabetes, New York Heart Association functional class IV, preoperative congestive heart failure, total blood product use, the need for postoperative inotropes, body mass index greater than 28 kg/m(2), and reoperation for bleeding., Conclusions: The prevalence of rehospitalization during the first month after discharge is not trivial. Other than postoperative atrial fibrillation, readmission is probably the single most likely adverse event to befall a patient in the early postoperative period. Patients who are discharged early do not appear to be at increased risk. Patterns in readmission diagnoses suggest opportunities for preventive strategies. more...
- Published
- 1999
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40. Coronary artery bypass risk prediction using neural networks.
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Lippmann RP and Shahian DM
- Subjects
- Bayes Theorem, Calibration, Chi-Square Distribution, Confidence Intervals, Female, Humans, Logistic Models, Male, Pattern Recognition, Automated, ROC Curve, Risk Assessment, Survival Analysis, Coronary Artery Bypass mortality, Neural Networks, Computer
- Abstract
Background: Neural networks are nonparametric, robust, pattern recognition techniques that can be used to model complex relationships., Methods: The applicability of multilayer perceptron neural networks (MLP) to coronary artery bypass grafting risk prediction was assessed using The Society of Thoracic Surgeons database of 80,606 patients who underwent coronary artery bypass grafting in 1993. The results of traditional logistic regression and Bayesian analysis were compared with single-layer (no hidden layer), two-layer (one hidden layer), and three-layer (two hidden layer) MLP neural networks. These networks were trained using stochastic gradient descent with early stopping. All prediction models used the same variables and were evaluated by training on 40,480 patients and cross-validation testing on a separate group of 40,126 patients. Techniques were also developed to calculate effective odds ratios for MLP networks and to generate confidence intervals for MLP risk predictions using an auxiliary "confidence MLP.", Results: Receiver operating characteristic curve areas for predicting mortality were approximately 76% for all classifiers, including neural networks. Calibration (accuracy of posterior probability prediction) was slightly better with a two-member committee classifier that averaged the outputs of a MLP network and a logistic regression model. Unlike the individual methods, the committee classifier did not overestimate or underestimate risk for high-risk patients., Conclusions: A committee classifier combining the best neural network and logistic regression provided the best model calibration, but the receiver operating characteristic curve area was only 76% irrespective of which predictive model was used. more...
- Published
- 1997
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41. Screening carotid ultrasonography and risk factors for stroke in coronary artery surgery patients.
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D'Agostino RS, Svensson LG, Neumann DJ, Balkhy HH, Williamson WA, and Shahian DM
- Subjects
- Adult, Aged, Aged, 80 and over, Carotid Stenosis diagnostic imaging, Cerebrovascular Disorders diagnostic imaging, Female, Humans, Male, Middle Aged, Multivariate Analysis, Risk Factors, Ultrasonography, Doppler, Carotid Arteries diagnostic imaging, Cerebrovascular Disorders etiology, Coronary Artery Bypass adverse effects, Postoperative Complications
- Abstract
Background: The role of noninvasive carotid artery screening in relation to other clinical variables in identifying patients at increased risk of stroke after coronary artery bypass grafting was examined., Methods: Preoperative, intraoperative, and postoperative clinical data were prospectively collected for 1,835 consecutive patients undergoing first-time isolated coronary artery bypass grafting between March 1990 and July 1995, 1,279 of whom had screening carotid ultrasonography. All patients with postoperative neurologic events were identified and reviewed in detail. Average patient age was 65.3 years (range, 33 to 92 years), and 9.3% (171 patients) had a prior permanent stroke or transient ischemic attack. Hospital and 30-day mortality was 2.2% (41 patients). Forty-five patients (2.5%) had a transient or permanent postoperative neurologic event. The data were analyzed by stepwise logistic regression to determine the independent predictors of both significant carotid stenosis and stroke., Results: On multivariate analysis, the clinical predictors of significant carotid stenosis were age (p < 0.0001), diabetes (p = 0.0123), female sex (p = 0.0026), left main coronary stenosis greater than 60% (p < 0.0001), prior stroke or transient ischemic attack (p = 0.0008), peripheral vascular disease (p = 0.0001), prior vascular operation (p = 0.0068), and smoking (p < 0.0001). When all variables were evaluated for those patients who underwent noninvasive carotid artery screening, the independent predictors of postoperative neurologic event were prior stroke or transient ischemic attack (p < 0.0001), peripheral vascular disease (p = 0.0037), postinfarction angina pectoris (p = 0.0319), postoperative atrial fibrillation (p = 0.0014), carotid stenosis greater than 50% (p = 0.0029), cardiopulmonary bypass time (p = 0.0006), significant aortic atherosclerosis (p = 0.0054), postoperative amrinone or epinephrine use (p = 0.0054), and left ventricular ejection fraction less than 0.30 (p = 0.0744)., Conclusions: The etiology of postoperative stroke is multifactorial. Selective use of carotid ultrasonography is of value in identifying patients who are at greater risk of postoperative stroke independent of other variables and should be considered before coronary artery bypass grafting, particularly in patients with a history of neurologic event or peripheral vascular disease. more...
- Published
- 1996
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42. Timing of surgery after acute myocardial infarction.
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Svensson LG, Cruz H, Sun J, D'Agostino S, Williamson WA, and Shahian DM
- Subjects
- Hemodynamics, Humans, Logistic Models, Myocardial Infarction mortality, Myocardial Infarction physiopathology, Prospective Studies, Risk Factors, Survival Rate, Time Factors, Treatment Outcome, Myocardial Infarction surgery
- Abstract
Objective: We wished to determine if timing of surgery, when other co-morbid variables are controlled, influenced outcome after operations for acute myocardial infarction., Design: Between 3/20/1990 and 6/17/1994, data was prospectively collected on 338 patients undergoing operation for either evolving infarcts (n=73) or up to 21 days after infarction (mean 7.9 days)., Setting: Tertiary hospital referral center., Patients: Infarction was diagnosed by CK enzymes or EKG Q-waves preoperatively in 338 patients undergoing surgery. The mean age of the patients was 66.1 years (SD+/-10.5 years), 76 had emergency operations immediately after catheterization (50 following PTCA complications), 223 had urgent operations, and 39 were elective., Interventions: Seventy-three had preoperative ballon pumps, and 259 had one or more mammary artery bypasses with a mean of 3.27 (SD+/-1.0) distal anastomoses., Results: In-hospital and 30-day survival rate was 95.6% (323/338). Of the 73 variables evaluated by step-wise logistic regression analysis, the multivariate independent preoperative predictors of death were: aortic valve regurgitation, chronic pulmonary disease, preoperative diuretic administration, preoperative balloon pump, preoperative inotropes, and the need for additional concomitant noncardiac surgery. Including the operative variables, the predictors were: preoperative balloon pump, preoperative inotropes, the presence of left main stenosis, preoperative renal failure, chronic pulmonary disease, valve disease, ischemic arrhythmia, pump perfusion time, valve surgery, and homologous blood transfusion volume required. When the postoperative variables were included, the predictors were: preoperative inotropes, postoperative balloon pump, postoperative epinephrine, postoperative permanent stroke, and postoperative acute renal failure. The time between infarction and operation was not an independent prediction (p>0.4) in any of the logistic regression models., Conclusion: Early operation after acute infarction is not in itself a risk factor, rather comorbid disease and preoperative hemodynamic status determine outcome after surgery. more...
- Published
- 1996
43. Circadian variation in defibrillation energy requirements.
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Venditti FJ Jr, John RM, Hull M, Tofler GH, Shahian DM, and Martin DT
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- Aged, Differential Threshold, Electrophysiology, Female, Humans, Male, Middle Aged, Arrhythmias, Cardiac physiopathology, Circadian Rhythm, Electric Countershock, Heart physiopathology
- Abstract
Background: Reports have demonstrated a circadian variation in the incidence of acute myocardial infarction, ventricular arrhythmias, and sudden cardiac death. We tested the hypothesis that a similar circadian variation exists for defibrillation energy requirements in humans., Methods and Results: We reviewed the time of defibrillation threshold (DFT) measurements in 134 patients with implantable cardioverter-defibrillators (ICDs) who underwent 345 DFT measurements. The DFT was determined in 130 patients at implantation, in 121 at a 2 months, and in 94 at 6 months. All patients had nonthoracotomy systems. The morning DFT (8 AM to 12 noon) was 15.1 +/- 1.2 J compared with 13.1 +/- 0.9 J in the midafternoon (12 noon to 4 PM) and 13.0 +/- 0.7 J in the late afternoon (4 to 8 PM), P < .02. In a separate group of 930 patients implanted with an ICD system with date and time stamps for each therapy, we reviewed 1238 episodes of ventricular tachyarrhythmias treated with shock therapy. To corroborate the hypothesis that energy requirements for arrhythmia termination vary during the course of the day, we plotted the failed first shock frequency for all episodes per hour. There was a significant peak in failed first shocks in the morning compared with other time intervals (P = .02)., Conclusions: There is a morning peak in DFT and a corresponding morning peak in failed first shock frequency. This morning peak resembles the peaks seen in other cardiac events, specifically sudden cardiac death. These findings have important implications for appropriate ICD function, particularly in patients with marginal DFTs. more...
- Published
- 1996
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44. The role of coronary revascularization in recipients of an implantable cardioverter-defibrillator.
- Author
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Shahian DM, Williamson WA, Venditti FJ Jr, Martin DT, and Ellis JR
- Subjects
- Adult, Aged, Aged, 80 and over, Arrhythmias, Cardiac etiology, Arrhythmias, Cardiac therapy, Coronary Disease complications, Coronary Disease mortality, Coronary Disease surgery, Female, Humans, Male, Middle Aged, Multivariate Analysis, Postoperative Complications, Risk Factors, Survival Rate, Coronary Artery Bypass, Defibrillators, Implantable
- Abstract
The impact of adjuvant coronary revascularization was studied in a group of 138 recipients of an implantable cardioverter-defibrillator, all of whom had ischemic heart disease as the cause of their arrhythmias. Patients chosen for revascularization had more severe anatomic, symptomatic, or physiologic evidence of active ischemia. There were no operative deaths among 23 patients who actually underwent coronary artery bypass combined with cardioverter-defibrillator implantation; however, operative mortality by the intention-to-treat principle was 8% (2/25). Total cardiac survival was better for patients who underwent revascularization than for those patients who had "high-risk" characteristics and did not undergo revascularization. Stratified subgroup analysis demonstrated significant survival advantages favoring revascularization in patients with three-vessel or left main coronary artery disease, class III or IV angina, and an ejection fraction greater than 25%. Multivariate analysis revealed that low ejection fraction and left main coronary artery disease were independent predictors of decreased survival. more...
- Published
- 1995
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45. Transvenous versus transthoracic cardioverter-defibrillator implantation. A comparative analysis of morbidity, mortality, and survival.
- Author
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Shahian DM, Williamson WA, Svensson LG, D'Agostino RS, Martin DT, Ellis JR, and Venditti FJ
- Subjects
- Aged, Atrial Fibrillation epidemiology, Death, Sudden, Cardiac epidemiology, Electrodes, Implanted, Female, Hospital Mortality, Humans, Incidence, Length of Stay statistics & numerical data, Logistic Models, Male, Morbidity, Respiration Disorders epidemiology, Retrospective Studies, Sternum surgery, Survival Analysis, Venous Cutdown, Arrhythmias, Cardiac therapy, Defibrillators, Implantable, Postoperative Complications epidemiology, Thoracotomy
- Abstract
The hypothesis that transvenous implantation of a cardioverter-defibrillator is associated with less morbidity than use of a transthoracic approach was investigated in a retrospective series of 146 patients. None of these patients had concomitant heart procedures, and the preoperative characteristics of the two groups were similar. When analyzed by actual technique used (transvenous, 57 patients; transthoracic, 89 patients) and by the intention-to-treat method (transvenous, 65 patients, 8 of whom actually underwent thoracotomy; thoracotomy, 81 patients), transvenous implantation was associated with a lower incidence of postoperative respiratory complications and atrial fibrillation. Total cardiac mortality and freedom from sudden cardiac death in the transvenous and transthoracic groups were comparable at 2 years. more...
- Published
- 1995
- Full Text
- View/download PDF
46. Anti-Jkb delayed hemolytic transfusion reaction after coronary bypass surgery.
- Author
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Shahian DM, Weiner NJ, and Kurtz SR
- Subjects
- Aged, Erythrocytes immunology, Female, Humans, Postoperative Complications, Coronary Artery Bypass adverse effects, Erythrocyte Transfusion adverse effects, Hemolysis, Isoantibodies blood, Kidd Blood-Group System immunology
- Abstract
Delayed hemolytic transfusion reaction occurred in a 74-year-old woman after coronary bypass. Antibodies were not detected during preoperative screening but did appear late after exposure to Jkb-positive red blood cells, probably as an anamnestic response to previous exposure during childbirth or remote transfusion. The incidence, pathophysiology, clinical presentation, diagnosis, and management of this syndrome are discussed. more...
- Published
- 1995
47. Transvenous cardioverter defibrillators: cost implications of a less invasive approach.
- Author
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Venditti FJ Jr, O'Connell M, Martin DT, and Shahian DM
- Subjects
- Aged, Convalescence, Cost-Benefit Analysis, Female, Hospital Charges statistics & numerical data, Humans, Length of Stay, Male, Methods, Middle Aged, Thoracotomy, Veins, Defibrillators, Implantable economics
- Abstract
To assess the economic impact of a transvenous lead system for an implantable cardioverter defibrillator (ICD), we evaluated the hospital charges for two groups of patients: group I patients (n = 23) underwent implantation of an ICD generator with an epicardial lead system via a thoracotomy and group II patients (n = 25) underwent implantation of the same generator using transvenous leads. There was no difference in demographics between the two groups. There was a 15% decrease in total charges for the transvenous group compared to the thoracotomy group ($54,142 vs $63,359, P < 0.05). Evaluation of the component charges revealed that the decline could be attributed to a reduction in implant ($27,328 vs $29,285, P < 0.02) and convalescent charges ($7,703 vs $15,179, P < 0.01) for the transvenous group. There was a corresponding decrease in length of stay for the transvenous group (22 vs 29 days, P < 0.05) largely secondary to a 38% reduction in convalescent length of stay (8 vs 13 days, P < 0.05). We conclude that the use of transvenous lead systems for the ICD results in a significant reduction in hospital charges as well as hospital length of stay. more...
- Published
- 1995
- Full Text
- View/download PDF
48. Cardiac papillary fibroelastoma.
- Author
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Shahian DM, Labib SB, and Chang G
- Subjects
- Aged, Humans, Male, Fibroma diagnosis, Heart Neoplasms diagnosis
- Abstract
Papillary fibroelastomas are rare cardiac tumors, but they are the most common primary tumor of the heart valves. These lesions occur on any of the valves or endothelial surfaces of the heart and may be detected by echocardiography, cardiac catheterization, during open heart operation for other conditions, or at autopsy. Because of their potential for cerebral and coronary embolization, even small papillary fibroelastomas should be excised. more...
- Published
- 1995
- Full Text
- View/download PDF
49. Replacement of entire aorta from aortic valve to bifurcation during one operation.
- Author
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Svensson LG, Shahian DM, Davis FG, Entrup MH, Kimmel WA, McGrath DM, Jewel ER, and Gray AW Jr
- Subjects
- Aged, Aortic Aneurysm, Abdominal surgery, Aortic Aneurysm, Thoracic surgery, Humans, Male, Aorta surgery, Aortic Aneurysm surgery, Blood Vessel Prosthesis methods
- Abstract
A 68-year-old patient presented with an extensive aortic aneurysm extending from the aortic valve to the aortic bifurcation associated with severe continuous pain, dysphagia, and hoarseness. Because of the risk of impending rupture and an "elephant trunk" procedure not being an option, the entire aorta from the aortic valve to the aortic bifurcation was replaced during one operation using deep hypothermia with circulatory arrest and retrograde perfusion of the brain through the jugular veins. Seven months after the operation the patient walks more than 3 km a day and lives a normal life. The operative repair is presented. more...
- Published
- 1994
- Full Text
- View/download PDF
50. Total aortic replacement.
- Author
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Svensson LG and Shahian DM
- Subjects
- Aged, Anastomosis, Surgical methods, Aorta, Abdominal surgery, Aorta, Thoracic surgery, Aortic Aneurysm surgery, Heart Arrest, Induced, Humans, Male, Survival Rate, Aorta surgery, Blood Vessel Prosthesis
- Published
- 1994
- Full Text
- View/download PDF
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