The Recipe for an Impactful Women’s Heart Program: The Time Is Now

INTRODUCTION Minimally invasive cardiac surgery has been introduced for the surgical treatment of isolated valvular heart disease. Interest among cardiac surgeons is growing as the potential benefits to the patient have become more reproducible. Ten years ago, surgeons began to recognize the advantages of performing smaller incisions compared to the traditional median sternotomy.1 Our group at the Methodist DeBakey Heart & Vascular Center began our anatomic studies relating the cardiac valve position to the surface anatomy of the chest wall in 1998 as we launched our own efforts in this area.2 Since that time, experience with large numbers of cases has shown minimally invasive mitral valve surgery to be reproducible, reliable, and much better tolerated by our patients.3,4 Recently, the Methodist DeBakey Heart & Vascular Center robotic mitral valve surgery program was successfully launched by Dr. Gerald Lawrie and his team with outstanding early results.

Minimally invasive cardiac surgery has been introduced for the surgical treatment of isolated valvular heart disease. Interest among cardiac surgeons is growing as the potential benefits to the patient have become more reproducible. Ten years ago, surgeons began to recognize the advantages of performing smaller incisions compared to the traditional median sternotomy.1 Our group at the Methodist DeBakey Heart & Vascular Center began our anatomic studies relating the cardiac valve position to the surface anatomy of the chest wall in 1998 as we launched our own efforts in this area.2 Since that time, experience with large numbers of cases has shown minimally invasive mitral valve surgery to be reproducible, reliable, and much better tolerated by our patients.3,4 Recently, the Methodist DeBakey Heart & Vascular Center robotic mitral valve surgery program was successfully launched by Dr. Gerald Lawrie and his team with outstanding early results.

The Past 50 Years of Cardiovascular Surgery

Introduction: As of January 2013, medical marijuana (MM) is currently legal in 18 states across the United States. In thoracic transplantation, standardized polices do not exist regarding MM use. We surveyed 317 US thoracic transplant medical directors regarding their center’s policies surrounding both MM and recreational marijuana (RM) use. Methods: We obtained names of the medical directors for US heart and lung transplant centers through the United Network for Organ Sharing (UNOS). A survey regarding MM and RM policies was developed, approved by the Colorado Multiple Institutional Review Board, and emailed through SurveyMonkey from April 2012-October 2012. Descriptive statistics were used to determine overall percentage of responses. Results: The survey was sent to 317 directors; 82 surveys were returned (25.8% overall response). 67.1%, 28.0%, and 4.9% were from heart, lung, and heart-lung programs, respectively. 80.5% of respondents were directors of adult programs, while 12.2% were from pediatric programs and 7.3% were affiliated with both adult and pediatric programs. Table 1 summarizes center policies on contraindications. During the study period, MM was state legalized for 32.9% of the directors. 2.5% of programs allowed their patients to drive while using MM, 21.0% did not, and 33.3% had no policy regarding this subject. Only 5.0% of respondents believed that a drug-drug interaction existed between marijuana and a patient’s immunosuppressive medications, while 78.8% were unsure of an drug-drug interactions. Conclusions: There is substantial heterogeneity among thoracic transplant programs about the acceptability of both MM and RM as a contraindication for transplantation. Additional data about drug-drug interactions with marijuana and the influence of MM and RM on transplant outcomes is warranted; harmonization of state and federal laws would advance this agenda.

Bacterial permeability family member A1 (BPIFA1), also known as short palate, lung, and nasal epithelium clone 1 (SPLUNC1), is a protein involved in the antiinflammatory response. The goal of this study was to determine whether BPIFA1 expression in asthmatic airways is regulated by genetic variations, altering epithelial responses to type 2 cytokines (e.g., IL-13). Nasal epithelial cells from patients with mild to severe asthma were collected from the National Heart, Lung, and Blood Institute Severe Asthma Research Program centers, genotyped for rs750064, and measured for BPIFA1. To determine the function of rs750064, cells were cultured at air-liquid interface and treated with IL-13 with or without recombinant human BPIFA1 (rhBPIFA1). Noncultured nasal cells with the rs750064 CC genotype had significantly less BPIFA1 mRNA expression than the CT and TT genotypes. Cultured CC versus CT and TT cells without stimulation maintained less BPIFA1 expression. With IL-13 treatment, CC genotype cells secreted more eotaxin-3 than CT and TT genotype cells. Also, rhBPIFA1 reduced IL-13-mediated eotaxin-3. BPIFA1 mRNA levels negatively correlated with serum IgE and fractional exhaled nitric oxide. Baseline FEV1% levels were lower in the asthma patients with the CC genotype (n = 1,016). Our data suggest that less BPIFA1 in asthma patients with the CC allele may predispose them to greater eosinophilic inflammation, which could be attenuated by rhBPIFA1 protein therapy.

Since the introduction of percutaneous techniques for the relief of symptomatic obstructive atherosclerotic coronary artery disease in the late 1970s, the major Achilles heel was restenosis. After nearly 3 decades of study, the cellular and molecular biology of this complex response to injury is now far better understood and includes the role of thrombosis, cellular proliferation, inflammation, matrix production, and elastic recoil.1,2 Some 15 years ago there was enthusiastic interest in the concept of “site specific” or “direct delivery” of antiproliferative or anticoagulant therapies.3–6 Edelman et al reported on the inhibition of SMC proliferation after vascular injury by surgical placement of heparin-impregnated polymer matrix in the periadventitial tissue of rat carotid arteries.3 At that time a catheter-based porous balloon catheter became available for “site specific” delivery7 but failed to be effective in limiting restenosis in an atherosclerotic rabbit femoral artery injury model.4 Although labeled heparin could be demonstrated to be present in the injured vessel wall, retention time of the drug and potential additional injury created by a jet effect of the porous balloon catheter were cited as potential explanations for the lack of efficacy. Subsequently, the concept of local delivery remained dormant and a multitude of clinical trials using systemically administered pharmacological agents to reduce or prevent restenosis demonstrated no benefit.8 See accompanying article on page 1960 In the late 1980s and early 1990s, coronary stents, providing the necessary scaffolding to prevent elastic recoil become the new standard for the percutaneous treatment of obstructive …

Chylothorax following paediatric cardiac surgery is associated with significant morbidity, particularly those that are refractory to conservative therapy. It is our impression that there is important variability in the medical, surgical, and interventional therapies used to manage refractory chylothorax between congenital heart programmes. We therefore conducted a survey study of current practices for managing refractory chylothorax. The Chylothorax Work Group, formed with the support of the Pediatric Cardiac Critical Care Consortium, designed this multi-centre survey study with a focus on the timing and indication for utilising known therapies for refractory chylothorax. The survey was sent to one chylothorax expert from each Work Group centre, and results were summarised and reported as the frequency of given responses. Of the 20 centres invited to participate, 17 (85%) submitted complete responses. Octreotide (13/17, 76%) and sildenafil (8/17, 47%) were the most utilised medications. Presently, 9 (53%) centres perform pleurodesis, 15 (88%) perform surgical thoracic duct ligation, 8 (47%) perform percutaneous lymphatic interventions, 6 (35%) utilise thoracic duct decompression procedures, and 3 (18%) perform pleuroperitoneal shunts. Diagnostic lymphatic imaging is performed prior to surgical thoracic duct ligation in only 7 of the 15 (47%) centres that perform the procedure. Respondents identified barriers to referring and transporting patients to centres with expertise in lymphatic interventions. There is variability in the treatment of refractory post-operative chylothorax across a large group of academic heart centres. Few surveyed heart centres have replaced surgical thoracic duct ligation or pleurodesis with image-guided selective lymphatic interventions.

Improving, Enhancing and Evaluating Outcomes of Comprehensive Heart Health Care Programs for High Risk Women has funded six diverse centers to provide chronic disease risk factor screening and lifestyle interventions for women and focuses specifically on low-income, minority women. This article describes the rationale for these diverse programs across the country, all focusing on improving outcomes for women with or at risk for cardiovascular disease (CVD). The six programs include College of Physicians and Surgeons at Columbia University, Christ Community Health Services in Memphis, Women's Heart Center of Fox Valley Cardiovascular Consultants, University of Minnesota, University of California Davis Women's Cardiovascular Medicine Program, and Yale-New Haven Hospital's Women's Heart Advantage. We present six differing approaches to women's heart programs. Based on this experience, promoting CVD prevention in women is a feasible healthcare delivery strategy for health promotion and for delivering preventive strategies for high-risk women. It is possible to deliver heart-healthy programs through existing healthcare infrastructures. These programs provide important models for public health, voluntary, and other health organizations to develop networks for population-based, targeted, relatively low cost programs that support Healthy People 2010 objectives for lifestyle changes and cardiovascular health. Ongoing longitudinal analysis of the programs will provide information about clinical outcomes and sustainability of such programs beyond the funding period.

During August 30-31, 2017, the National Heart, Lung, and Blood Institute's Center for Translation Research and Implementation Science (CTRIS) hosted a two-day workshop with thought leaders and experts in the fields of implementation science, prevention science, health inequities research, and training and research workforce development. The workshop addressed critical challenges and compelling questions from the NHLBI Strategic Vision, as well as the Department of Health and Human Services' Action Plan to Reduce Racial and Ethnic Health Disparities. Participants discussed: best practices for designing and executing implementation research training programs; approaches to increase participation in implementation research to address health inequities; innovative training methods and models, including team science approaches; and best practices for developing and sustaining a cadre of mentors for individuals who conduct implementation research. As part of this workshop, the Saunders-Watkins Memorial Lecture, named posthumously for Dr. Elijah Saunders, a Baltimore cardiologist, and Dr. Levi Watkins, a Baltimore cardiothoracic surgeon, was established. Both men dedicated their lives to patient care, teaching, research, and community service. The lecture honors them for their pioneering efforts to advance health equity for medically underserved communities in the United States and around the globe, at a time when it was neither popular nor safe to do so. The lecture is also designed to stimulate a future generation of researchers committed to advancing health equity research and the elimination of health iniquities. The inaugural lecture was delivered by Lisa A. Cooper, MD, MPH, Bloomberg Distinguished Professor and James F. Fries Professor of Medicine at Johns Hopkins University, and inaugural recipient of the American Heart Association's Watkins-Saunders Award, which recognizes excellence in clinical, medical, and community work focused on diminishing health care disparities in Maryland. This article captures the essence of that lecture.

Efficacy of an exercise intervention among children with comorbid asthma and obesity

Purpose: Prenatal diagnosis of congenital heart disease (CHD) is associated with elevated maternal stress and anxiety. At our Fetal Heart Center, we have a structured peer support program for mothers with a fetal diagnosis of CHD called the Fetal Heart to Heart Program (FHTHP). Past studies have reported the maternal reaction to a fetal diagnosis of CHD, but this is the first study to evaluate the impact of a peer mentorship program on maternal coping mechanisms following fetal diagnosis of CHD. Our study explores the maternal reaction to fetal diagnosis of CHD, maternal support system, …

Physical inactivity: an easily modified risk factor?

The advent of transcatheter aortic valve replacement (TAVR) has directly impacted the lifelong management of patients with aortic valve disease. The U.S. Food and Drug Administration has approved TAVR for all surgical risk: prohibitive (2011), high (2012), intermediate (2016), and low (2019). Since then, TAVR volumes are increasing and surgical aortic valve replacements (SAVR) are decreasing. This study sought to evaluate trends in isolated SAVR in the pre- and post-TAVR eras. From January 2000 to June 2020, 3,861 isolated SAVRs were performed at a single academic quaternary care institution which participated in the early trials of TAVR beginning in 2007. A formal structural heart center was established in 2012 when TAVR became commercially available. Patients were divided into the pre-TAVR era (2000-2011, n = 2,426) and post-TAVR era (2012-2020, n = 1,435). Data from the institutional Society of Thoracic Surgeons National Database was analyzed. The median age was 66 years, similar between groups. The post-TAVR group had a statistically higher rate of diabetes, hypertension, dyslipidemia, heart failure, more reoperative SAVR, and lower STS Predicted Risk of Mortality (PROM) (2.0% vs. 2.5%, p < 0.0001). There were more urgent/emergent/salvage SAVRs (38% vs. 24%) and fewer elective SAVRs (63% vs. 76%), (p < 0.0001) in the post-TAVR group. More bioprosthetic valves were implanted in the post-TAVR group (85% vs. 74%, p < 0.0001). Larger aortic valves were implanted (25 vs. 23 mm, p < 0.0001) and more annular enlargements were performed (5.9% vs. 1.6%, p < 0.0001) in the post-TAVR era. Postoperatively, the post-TAVR group had less blood product transfusion (49% vs. 58%, p < 0.0001), renal failure (1.4% vs. 4.3%, p < 0.0001), pneumonia (2.3% vs. 3.8%, p = 0.01), shorter lengths of stay, and lower in-hospital mortality (1.5% vs. 3.3%, p = 0.0007). The approval of TAVR changed the landscape of aortic valve disease management. At a quaternary academic cardiac surgery center with a well-established structural heart program, patients undergoing isolated SAVR in the post-TAVR era had lower STS PROM, more implantation of bioprosthetic valves, utilization of larger valves, annular enlargement, and lower in-hospital mortality. Isolated SAVR continues to be performed in the TAVR era with excellent outcomes. SAVR remains an essential tool in the lifetime management of aortic valve disease.

The confluence of science, technology, and medicine in our dynamic digital era has spawned new data applications to develop prescriptive analytics, to improve healthcare personalization and precision medicine, and to automate the reporting of health data for clinical decisions.1 Data science in health care has seen recent and rapid progress along 3 paths: (1) through big data via the aggregation of large and complex data sets including electronic medical records, social media, genomic databases, and digitized physiological data from wireless mobile health devices2; (2) through new open-access initiatives that seek to leverage the availability of clinical trial, research, and citizen science data sources for data sharing3; and (3) in analytic techniques particularly for big data, including machine learning and artificial intelligence that may enhance the analyses of both structured and unstructured data.4 As new data sets are created, analyzed, and become increasingly available, several key questions emerge including the following: What is the quality of unstructured data generation? Will the use of nonstandardized methods in data processing with traditional software and hardware lead to data fragmentation and analyses that are nonreproducible? Will healthcare systems incorporate and use big data especially from new publically and patient-generated sources? How will physicians and researchers learn from new open-sourced data and big-data analytics? And ultimately, How can they acquire the skills to create a knowledge translation in data sciences?5 Practicing in an era of continuous payment reform and decline in research funding, early career investigators are challenged to keep up with the accelerating pace of change in medicine, all while being expected to provide meaningful contributions through productive clinical, educational, and research experiences.6 In this perspective, we aim to highlight how data science can catalyze professional advancement and discuss the implications of big data, open access, …

Municipal solid waste (MSW) generated in developing countries usually contains a high percentage of organic material. When not properly managed, organic waste is known for creating many environmental issues. Greenhouse gas (GHG) emissions, soil and water contamination, and air pollution are a few examples. On the other hand, proper and sustainable management of organic waste can not only bring economic gains but also reduce the waste volume that is sent for final disposal. Composting is one such recovery method, in which the end product – compost – eventually helps the agricultural industry, and other sectors, making the process an excellent example of nexus thinking in integrated management of environmental resources. The aim of this chapter is to discuss how Cajicá, a small city in Colombia, approached this issue in a methodical way to eventually became one of the leading organic waste composting examples in the whole world, as recognised by the United Nations Environment Programme in 2017. Cajicá launched a source separation and composting initiative called Green Containers Program (GCP) in 2008, based on a successful pilot project conducted in 2005. The organic waste separated at source collected from households, commercial entities, schools, and universities are brought to a privately operated composting plant chosen by the city to produce compost. The compost plant sells compost to the agricultural sector. The participants in the GCP could also receive a bag of compost every 2 months as a token of appreciation. The Cajicá case presents us with many lessons of good practice, not only in the sustainable management of waste but also in stakeholder engagement. It specifically shows how stakeholders should be brought together for long-lasting collaboration and the benefits to society. Finding the correct business model for the project, efforts made in educating the future generation, and technology adaptation to local conditions are also seen as positive experiences that others can learn from in the case of Cajicá’s GCP. Some of the concerns and potential threats observed include the high dependency GCP has on two institutions: the programme financially depends completely on the municipality, and the composting operation depends completely on one private facility. GCP will benefit from having contingency plans to reduce the risk of having these high dependencies.