Advocate Christ Medical Center Research Articles

Giancarlo Lyle-Edrosolo, DNP, RN, CENP, NEA-BC, FAONL

Giancarlo Lyle-Edrosolo is the Vice President and Chief Nursing Officer of Advocate Christ Medical Center in Oak Lawn, Illinois. He is a first-generation immigrant and was born and raised in the Philippines. Giancarlo has focused his career and professional activities on promoting leadership development, cultivating professional advancement, finding solutions and support for health care worker burnout, and addressing incivility and bullying.

Unintended consequences of achieving equity in the new heart allocation policy.

Journal of Cardiac SurgeryVolume 36, Issue 10 p. 3629-3630 COMMENTARY Unintended consequences of achieving equity in the new heart allocation policy Nikhil Narang MD, Nikhil Narang MD Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USASearch for more papers by this authorTeruhiko Imamura MD, PhD, Corresponding Author Teruhiko Imamura MD, PhD [email protected] orcid.org/0000-0002-7294-7637 Second Department of Internal Medicine, University of Toyama, Toyama, Japan Correspondence Teruhiko Imamura, MD, PhD, Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan. Email: [email protected]Search for more papers by this author Nikhil Narang MD, Nikhil Narang MD Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois, USASearch for more papers by this authorTeruhiko Imamura MD, PhD, Corresponding Author Teruhiko Imamura MD, PhD [email protected] orcid.org/0000-0002-7294-7637 Second Department of Internal Medicine, University of Toyama, Toyama, Japan Correspondence Teruhiko Imamura, MD, PhD, Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan. Email: [email protected]Search for more papers by this author First published: 09 July 2021 https://doi.org/10.1111/jocs.15799Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume36, Issue10October 2021Pages 3629-3630 RelatedInformation

Cardiopulmonary bypass on wheels: An evolving application of extracorporeal membrane oxygenation.

Journal of Cardiac SurgeryVolume 35, Issue 12 p. 3658-3659 INVITED COMMENTARY Cardiopulmonary bypass on wheels: An evolving application of extracorporeal membrane oxygenation Teruhiko Imamura MD, PhD, Corresponding Author Teruhiko Imamura MD, PhD teimamu@med.u-toyama.ac.jp orcid.org/0000-0002-7294-7637 Second Department of Internal Medicine, University of Toyama, Toyama, Japan Correspondence Teruhiko Imamura, MD, PhD, Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan. Email: teimamu@med.u-toyama.ac.jpSearch for more papers by this authorNikhil Narang MD, Nikhil Narang MD Advocate Christ Medical Center, Oak Lawn, Illinois, USASearch for more papers by this author Teruhiko Imamura MD, PhD, Corresponding Author Teruhiko Imamura MD, PhD teimamu@med.u-toyama.ac.jp orcid.org/0000-0002-7294-7637 Second Department of Internal Medicine, University of Toyama, Toyama, Japan Correspondence Teruhiko Imamura, MD, PhD, Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan. Email: teimamu@med.u-toyama.ac.jpSearch for more papers by this authorNikhil Narang MD, Nikhil Narang MD Advocate Christ Medical Center, Oak Lawn, Illinois, USASearch for more papers by this author First published: 10 October 2020 https://doi.org/10.1111/jocs.15101Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume35, Issue12December 2020Pages 3658-3659 RelatedInformation

1D2 Free Naloxone Discharge Kits: An Innovative Approach to the Prevention of Opioid Related Overdose Deaths

According to the CDC, opioids killed more than 49,000 people across the U.S. in 2017 (that's 5 times more deaths than in 1999). Our country saw an increase of greater than 15% opioid related deaths from 2016 to 2017. Furthermore, opioid-related overdoses claimed the lives of 2,199 Illinoisans in 2017, nearly 2 times the number of homicides in Chicago, and over 2 times the number of car accidents. This is a public health crisis that crosses all racial, ethnic, and socioeconomic boundaries. Statistics have shown that for every 1 fatal overdose there are 30 non-fatal overdoses and that one is at greater risk of a fatal overdose immediately after a non-fatal overdose. Since 2010, Advocate has served more than 30,000 patients in need of opioid overdose and addiction treatment and that number is projected to increase by 15%. The Emergency Department at Advocate Christ Medical Center and Advocate Children's Hospital, Oak Lawn are taking a major step to help prevent deaths by opioid overdose by providing free naloxone discharge kits. Our program is in partnership with the Chicago Recovery Alliance (CRA) who is donating the naloxone discharge kits as well as providing educational materials on how to inject the reversal agent. Before receiving a kit, patients and family members will be educated via a short video that outlines preventing, identifying, and responding to an overdose; rescue breathing; and the importance of still calling emergency services. This program is not designed to serve as a substitute for rehabilitation for patients, but rather allow a person experiencing an opioid overdose to live another day and hopefully seek the help they need. The chances of an addict or first-time user proactively filling a prescription for naloxone, should another overdose even occur, are relatively small. Any registered ED patient may request the kit.

Palliative Outpatient Inotrope in End Stage Heart Failure Patients is Safe with Moderate Survival Benefit: A Single Center Retrospective Study

Introduction With the advent of newer heart failure (HF) medications and devices such as implantable cardioverter-defibrillator (ICD), the survival benefits of long-term intravenous (IV) inotropes might be underestimated. 1-year mortality from outpatient IV inotropes (continuous and intermittent) have been reported between 25% to 47.6%. However, a study solely based on outpatient continuous inotropes for palliation has not been done in the past. This study hypothesizes that the survival rate of patients with end stage HF on palliative intravenous inotrope is better than previously expected (6 months) and may be a viable option for certain patients. Methods and Results We performed a single-center, retrospective chart review of HF patients who were discharged with an inotrope (milrinone or dobutamine) for palliation. Inclusion criteria included age > 18, diagnosis of HF, and patients discharged on inotropes after January 1, 2010. Exclusion criteria included patients who had received mechanical circulatory support (MCS) or patients who had received a heart transplant. Data were collected on 119 patients from the existing database of the Advocate Christ Medical Center's heart failure clinic. Primary outcome was survival on inotropes. Secondary outcomes included number of hospitalizations, number of clinic visits, infection rates and incidence of arrhythmia on inotrope. SAS software was used for statistical analysis. 87.38% of patients were discharged on Milrinone whereas 13.51% were discharged on dobutamine. Demographics, comorbidities, medications and devices are shown in table 1. The mean follow-up time was 255.36±23.93 days. 27.03% were alive on inotrope, 15.32% were alive but weaned off of inotrope, 18.92% were on hospice, 17.12% had expired, and 21.62% were lost to follow-up. Using product-limiting survival estimates, the unconditional probability of surviving beyond 6.5 months was 84%. Mean number of hospitalizations after discharge on inotrope was 1.92±0.25. Mean number of clinic visits in 3, 6 and 12 months were 2.61±0.26, 4.48±0.49, 7.92±0.95 respectively. The rate of peripherally inserted central catheter infection and arrhythmia were 8.11% and 9.91% respectively. Conclusions Palliative inotrope after diagnosis of end-stage heart failure is a safe option with moderate survival benefit in patients who opt out of or who do not meet criteria for MCS or transplant.

Psychosocial Characteristics and Outcomes in Patients with Ventricular Assist Device

Purpose Patient selection for durable ventricular assist device (VAD) involves a comprehensive medical and psychosocial evaluation. Although there are guidelines for evaluation of medical comorbidities, psychosocial risk assessment remains somewhat subjective. There is ongoing concern that patients may be denied VAD due to perceived high-risk psychosocial characteristics that may not impact survival after VAD implantation. The purpose of this study was to evaluate the patient psychosocial risk profile and its impact on outcomes after VAD implantation. Methods This study was a single center, retrospective analysis of 93 patients who underwent durable VAD implantation at Advocate Christ Medical Center in 2016. Psychosocial factors on outcomes were evaluated using the Student's t-test, Fischer's exact test, and one-way analysis of variance. Results Of 93 patients, mean age was 55 ± 13 years, 73% were males, 46% were African American, 69% had non-ischemic cardiomyopathy, and 60% received destination therapy. Most prevalent psychosocial factors were: 27% had a pre-existing psychiatric diagnosis, 53% were not married, 22% had no children, 11% lived alone, 19% did not complete a high school education, 26% were chronically unemployed, 55% formerly abused tobacco, 13% formerly abused alcohol, and 24% formerly abused illicit drug. Mean days on device was 589 ± 321, mean number of readmissions within the first year was 2.5 ± 2.6, and mean number of days to first readmission was 80 ± 91. Those with less than a high school education were 55% more likely to experience an adverse event (driveline infection, bacteremia, stroke, hemolysis, GI bleed, other bleed) compared to those with a graduate level education (p Conclusion These results suggest that certain psychosocial factors may not influence mortality or adverse event rates after VAD implantation. Although, education level impacted adverse event rates, further delineation is required. A larger sample size is needed to elucidate exactly which psychosocial characteristics affect VAD outcomes.

Academy of Nutrition and Dietetics Evidence-Based Practice Guideline for the Management of Heart Failure in Adults

Academy of Nutrition and Dietetics Evidence-Based Practice Guideline for the Management of Heart Failure in Adults

Impact of Chest Pain Protocol Targeting Intermediate Cardiac Risk Patients in an Observation Unit of an Academic Tertiary Care Center.

BackgroundChest pain (CP) is a frequent cause of emergency room visits in United States and adds a huge financial burden to our healthcare cost. With the addition of observation units, standard CP protocols have shown to decrease length of stay (LOS) and cost per discharge (CPD). We report our experience with the development and implementation of “CP protocol for intermediate cardiac risk patients” and its impact on healthcare resource utilization at our medical center.Methods and ResultsWe retrospectively analyzed 30 patients who presented to Advocate Christ Medical Center (ACMC) with CP and were considered to be at intermediate risk for acute coronary syndrome after obtaining IRB approval. Patients were treated with our standardized CP protocol and labeled as “protocol patients”. Our control group consisted of patients with similar demographics and diagnosis but not treated with our CP protocol admitted in the same time period and under our own faculty. This helped remove the bias of different treating attending. Our protocol algorithm consisted of medications, an electrocardiogram (EKG), cardiac troponin I level, and a stress test if indicated. Primary clinical endpoints for this study were LOS in hours and CPD for patients in our protocol group compared to control group. LOS in the protocol group was lower compared to the control but the difference was not statistically significant (P = 0.74). The average CPD in the control group (mean = $13,446) was almost $830 more than the protocol group (mean = $14,276, P = 0.827).ConclusionImplementation of standardized protocols for patients with CP has proven to be a cost effective strategy at several institutions across the country. Our study showed a reduction in CPD although not statistically significant. LOS was also reduced but did not meet statistical significance mainly due to our small sample size. Previous studies had demonstrated much larger savings between a protocol-driven group and a non-protocol-driven group. On further analysis of our data, our protocol group contained five patients who underwent invasive diagnostic tests including computed tomography for pulmonary embolism scans which were not present in the control group. This accounted for the small reduction in costs for the protocol group.

Potassium Shifts During Therapeutic Hypothermia Induced via Esophageal Heat Transfer in Swine

transfer in swine Patrick Shanley1, MS; Erik Kulstad2, MD, MS; Melissa Naiman3, PhD; D. Mark Courtney1, MD, MS; Anja Metzger4,6, PhD; Tim Matsuura4, PhD; Scott McKnite5, BS, Jennifer Rees6, PhD; Keith Lurie4,6, MD 1. Northwestern University; 2. Advocate Christ Medical Center; 3. U. of Illinois at Chicago; 4. U. of Minnesota; 5. Minneapolis Medical Research Foundation; 6. Advanced Circulatory Systems, Inc.

Invited Commentary

Historically, mechanical assist devices were used as an emergency bridge to support patients until a suitable donor organ could be found [1Delgado D.H. Rao V. Ross H.J. Verma S. Smedira N. Mechanical circulatory assistance: state of art.Circulation. 2002; 106: 2046-2050Crossref PubMed Scopus (40) Google Scholar]. As such, a decade ago most devices were implanted for less than a year and were not designed to provide prolonged support. The presence of a valvular pathologic condition at the time of ventricular assist device (VAD) implantation dictated surgical strategy, and significant aortic insufficiency required intervention [2Rao V. Slater J.P. Edwards N.M. Naka Y. Oz M.C. Surgical management of valvular disease in patients requiring left ventricular assist device support.Ann Thorac Surg. 2001; 71: 1448-1453Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar]. However, with increasing clinical experience and improved device technology, the concept of “destination” therapy became a reality, and prolonged support (>1 year) is now common. In many centers, including our own, the average support time, even in a bridge to transplantation population, exceeds 1 year. Often, clinical success breeds novel problems, and “acquired aortic insufficiency” (AI) has now become accepted among heart failure specialists. This report [2Rao V. Slater J.P. Edwards N.M. Naka Y. Oz M.C. Surgical management of valvular disease in patients requiring left ventricular assist device support.Ann Thorac Surg. 2001; 71: 1448-1453Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar] from Advocate Christ Medical Center, a leading enroller in the Destination Therapy (DT) trial, describes their experience with almost 80 patients supported by a HeartMate 2 device. During their period of follow-up, over half of their patients experienced significant AI (defined as mild or greater). Of interest, advanced age and a closed aortic valve were found to be independent predictors of AI progression. Strikingly, the mean time to AI development was just over 6 months in this cohort of predominantly DT patients (69 of 79). Surprisingly, despite the finding that a closed aortic valve was associated with AI, there were no significant differences in pump speeds between the patients who experienced AI and those with a competent valve. Thus, the clinician remains somewhat confused over formulating a strategy to militate against AI. We have found that maintaining low pump speeds (8600 rpm vs the mean of 9200 rpm in this series) allows the aortic valve to open intermittently. We intentionally “ramp down” pump speeds at early follow-up (1 to 3 months) to achieve aortic valve opening every three cardiac cycles. Although we initially used this strategy to preserve the aortic valve, we have, surprisingly, found a dramatic decrease in the incidence of gastrointestinal bleeding (data published in abstract form). We have insufficient follow-up time to determine whether this strategy will lead to long-term aortic valve competence. Other clinicians have advocated for either formal aortic valve closure or a repair suture to maintain long-term aortic valve competence [3Aggarwal A. Raghuvir R. Eryazici P. et al.The development of aortic insufficiency in continuous-flow left ventricular assist device-supported patients.Ann Thorac Surg. 2013; 95: 493-499Abstract Full Text Full Text PDF PubMed Scopus (94) Google Scholar, 4Park S.J. Liao K.K. Segurola R. Madhu K.P. Miller L.W. Management of aortic insufficiency in patients with left ventricular assist devices: a simple coaptation stitch method (Park's stitch).J Thorac Cardiovasc Surg. 2004; 127: 264-266Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar]. However, the impact of a permanently fused aortic valve on long-term clinical outcomes (especially gastrointestinal bleeding) has not been determined. The importance of the present report is to emphasize that aortic valve competence becomes an issue as early as 6 months after implantation, even in patients who had no aortic insufficiency at the time of VAD implantation. The long-term sequelae of either permanently fusing the aortic valve or lowering VAD support to facilitate intermittent aortic valve opening remains unknown and again will require vigilant clinical follow-up. The Development of Aortic Insufficiency in Continuous-Flow Left Ventricular Assist Device–Supported PatientsThe Annals of Thoracic SurgeryVol. 95Issue 2PreviewSignificant aortic insufficiency (AI) after left ventricular assist device (LVAD) placement affects device performance and end-organ perfusion. This study examined the development and progression of AI after implantation of continuous-flow LVAD. Full-Text PDF

117 Patient Selection for Ventricular Assist Device Therapy in the Elderly: Application of the HeartMate II Risk Score

Patient Selection for Ventricular Assist Device Therapy in the Elderly: Application of the HeartMate II Risk Score J.A. Cowger, K. Sundareswaran, J.G. Rogers, S.S. Kushwaha, F.D. Pagani, A. Tatooles, R.M. Adamson, M.S. Slaughter, D.J. Farrar. Univ. of Michigan Health System, Ann Arbor, MI; Thoratec Corporation, Pleasanton, CA; Duke University Medical Center, Durham, NC; Mayo Clinic, Rochester, MN; Advocate Christ Medical Center, Oak Lawn, IL; Sharp Memorial Hospital, San Diego, CA; Univ. of Louisville, Jewish Hospital, and St. Mary’s HealthCare, Louisville, KY.

333: Center experience and outcomes of left-ventricular assist device (LVAD) implantation as destination therapy (DT) – analysis of thoratec DT registry 1998-2005

CENTER EXPERIENCE AND OUTCOMES OF LEFTVENTRICULAR ASSIST DEVICE (LVAD) IMPLANTATION AS DESTINATION THERAPY (DT) – ANALYSIS OF THORATEC DT REGISTRY 1998-2005 K. Lietz, J. Long, A. Kfoury, M. Slaughter, M. Silver, C. Milano, J. Rogers, Y. Naka, D. Mancini, L. Miller, Cardiovascular Division, Georgetown University Washington Hospital Center, Washington, DC; Cardiovascular and Cardiothoracic Divisions, LDS Hospital, Salt Lake City, UT; Cardiovascular and Cardiothoracic Divisions, Advocate Christ Medical Center, Oak Lawn, IL; Cardiovascular and Cardiothoracic Divisions, Duke University Medical Center, Durham, NC; Cardiovascular and Cardiothoracic Divisions, Columbia-Presbyterian Medical Center, New York, NY

Role of Standard Small Bowel Follow-Through in the Evaluation of Anemia after a Negative Upper and Lower Gastrointestinal Tract Endoscopy

Purpose: It has been noted that standard small bowel follow through (SBFT) has become a common investigation in patients with anemia even if the suspicion of small bowel pathology or gastrointestinal (GI) blood loss is low. A review of the literature revealed few studies that looked directly at the utility of SBFT in this population and these studies had a small sample size. Our aim was to evaluate the usefulness of a standard SBFT in detecting significant pathology in asymptomatic patients with anemia and a negative endoscopic evaluation. Methods: We retrospectively reviewed the records of all inpatients referred to the gastroenterology service at Advocate Christ Medical Center, for evaluation of anemia (Hb <13 mg/dl in males and <12 mg/dl in females). Records were reviewed between January 2001 to December 2005. Inclusion criterion: all patients who had esophagogastroduodenoscopy (EGD) and colonoscopy for anemia followed by a standard SBFT. Exclusion criterion: patients with overt GI signs or symptoms (e.g. nausea, vomiting, abdominal distention, abdominal pain, early satiety or active GI bleeding), a history of, or a current GI malignancy, cirrhosis, inflammatory bowel disease, and those patients who were found to have an obvious source of anemia on endoscopic examination. Results: A total of 415 patients were referred to the gastroenterology service. 202 patients (69 men, 133 female) met the study criterion. Only 8 patients (3.9%) were found to have an abnormal SBFT. 194 patients (96.1%) had a negative study. The abnormal findings included diverticular disease in 6 patients, duodenitis in 1 patient and possible small bowel polyposis in 1 patient. Only the finding of possible small bowel polyposis was thought to be the cause of anemia by the attending gastroenterologist. In summary standard SBFT identified the possible cause of anemia in only 1/202 patients (0.5%). Conclusions: SBFT was not found to be useful in detecting a cause of anemia in asymptomatic patients with a prior negative upper and lower endoscopic evaluation. Consideration should be made to remove the standard SBFT as a part of the routine work up for patients in this population.

Systemic hypertension among women with uterine leiomyomata: potential final common pathways of target end-organ remodeling.

The uterus and the heart share a common structure and may remodel in a similar fashion, albeit temporally distinct. The authors investigated the prevalence of systemic hypertension in women with uterine leiomyomata (fibroids) and compared the prevalence in women undergoing hysterectomy for other reasons as well as in age-matched women from the National Health and Nutrition Examination Survey III (NHANES III). A total of 584 women, 205 with leiomyomata in 1999 (group A) and 379 who underwent hysterectomy for a variety of reasons in 2000 (group B) at Advocate Christ Medical Center were included. Presence of leiomyomata was confirmed by pathology. Hypertension was defined as blood pressure > or = 140/90 mm Hg or history of hypertension with or without medication use. The prevalence of hypertension in group A and B patients with leiomyomata compared with NHANES III overall was 48.6% vs. 24% (p<0.001), in African Americans 55.5% vs. 32.4% (p<0.001), and in Caucasians 51.1% vs. 23.3% (p<0.001). Leiomyomata were more frequent among hypertensive than normotensive women (57% vs. 27%). Caucasian and African-American women with leiomyomata were significantly younger and more likely to use hormone replacement therapy than others. Thus there appears to be an association between leiomyomata and hypertension, which needs to be explored in future prospective trials.

Advancing the Advances in Heart Failure: Updates on Newer Therapies

Marc A. Silver, MD, Co-Editor in Chief From the Department of Medicine and the Heart Failure Institute, Advocate Christ Medical Center, Oak Lawn, IL Address for correspondence: Marc A. Silver, MD, Chairman and Clinical Professor, Department of Medicine and the Heart Failure Institute, Advocate Christ Medical Center, 4440 West 95th Street, Suite 319 South, Oak Lawn, IL 60453-2600 E-mail: marc.silver@advocatehealth.com In January 2005, we issued a call for papers to focus on updates on some of the new and emerging therapies for patients with heart failure. We specifically asked potential authors to focus on biventricular resynchronization and left ventricular assist devices. This focus was prudent, because although clinical trial publications and early adoption of these strategies were of recent vintage, we felt that these were two key therapeutic areas where the field was evolving on a daily basis. Furthermore, as a heart failure community, we must test our tools every day. There is no room here for a strategy or therapy that does not provide continued significant improvement in heart failure outcomes for patients. So the call went out and authors responded. Included in this issue are four of these papers. One deals with updates on selecting responders to resynchronization therapy—a hot topic indeed. Two others deal with advances in patient selection and care for potential left ventricular assist device recipients and potential new complications to be aware of. We are also pleased to have the excellent paper by Faris and colleagues representing an important FDA perspective on both resynchronization and left ventricular assist devices. And as these papers are published, it is my hope that they soon become obsolete. We should push ourselves to test the methods and resources we use for heart failure patients every day. We should continue to speak among ourselves and to others about these advances. In that context, Congestive Heart Failure will continue to publish periodic focus issues like this. In an electronic age, we should be able to spread best practices liberally to those who provide the care; it is our pledge to be part of that dissemination of current knowledge.

Current and Emerging Issues With B‐Type Natriuretic Peptide

A brief panel discussion was held on March 23, 2005, in New York City following a live symposium for primary care physicians discussing the roles of B-type natriuretic peptide in a variety of cardiovascular diseases. The participants were Dr. Marc A. Silver, Advocate Christ Medical Center, Oak Lawn, IL; Dr. Clive Rosendorff, Mount Sinai School of Medicine, New York, NY and VA Medical Center, Bronx, NY; Dr. Robert Berkowitz, Hackensack University Medical Center, Hackensack, NJ; and Dr. W. Franklin Peacock IV, The Cleveland Clinic Department of Emergency Medicine, Cleveland, OH. Dr. Silver moderated the discussion. The panel gathered to review some of the questions that emerged from the symposium and the questions raised by the attendees. These are of interest and importance to all interested in heart failure and B-type natriuretic peptide.

Embol-X Intra-Aortic Filtration System: Capturing Particulate Emboli in the Cardiac Surgery Patient

We sought to evaluate the effectiveness of using an intra-aortic filtration system for the prevention of particulate emboli transport and the minimization of significant postoperative complications associated with particulate emboli. Between October of 2000 and October 2001, a total of 146 patients were enrolled at Advocate Christ Medical Center as part of the multi-institutional randomized trial (1289 patients at 22 centers). A total of 74 patients (51%) received the Embol-X intra-aortic filter and 72 patients (49%) were enrolled in the control group. Patients were evaluated for neurological deficit, myocardial infarction, renal insufficiency/failure, limb ischemia, and death at 12-hour, 24-hour, 72-hour, 7-day, and 30-day postoperative intervals. All filters received histological examination for particulate matter. Particulate matter was isolated in 70 (94.5%) of the filters successfully deployed. There was no statistically significant difference in the device related events between the filter and conventional cannulation groups (9/74 = 12.1% vs. 7/72 = 9.7%). Although not clinically evident, the primary event for both groups was ascending aortic intimal tears. There was one death in each of the groups not related to the filter or cannula used. The use of the Embol-X intra-aortic filter system has proven to be a safe and effective means to reduce the introduction of particulate emboli into the systemic circulation. Clearly, the reduction of particulate matter by as much as 95% justifies its use in cardiac surgery patients identified with an increased preoperative embolic risk.

Surgical Site Infection Prevention: Interventional Epidemiology

ISSUE: Advocate Christ Medical Center, Department of Epidemiology. noted an increase of Class I surgical site infections (SSIs) in January 2002, returned to baseline rates for 2 months, and then experienced an increase in rates again in April 2002. Neither outbreak investigation revealed a common source; however, many quality improvement initiatives were identified. PROJECT: In a effort to improve quality of care for patients and to decrease SSI rates to baseline or below, a 0.6 Infection Control Coordinator was reassigned from patient units to the surgical units and sterile processing. Included in her responsibilities were observations of surgical cases and cleaning processes, education, organization of a multidisciplinary surgical site task force, and review of policy and procedures. Utilizing the P.D.S.A. model of quality improvement, numerous initiatives were identified, and actions and measurements for improvement were put into place. The following are just a few examples of successful initiatives that were put into place: decrease in flash sterilization, purchase of new surgical instruments, strict use of clipping not shaving, appropriate timing of antibiotic usage, decrease of wet loads in sterile processing, improving traffic patterns in sterile processing, and decreasing weight of instrument trays. RESULTS: In July 2002, a marked reduction in SSI rates was noted, to below baseline rates with a continuation of the downward trend through the fourth quarter of 2003. The current rate of Class I SSIs remains below 1%. LESSONS LEARNED: Oftentimes conventional infection control programs focus on inpatient units, and problem-solving issues are identified in departments. This initiative demonstrates that assigning to a given department an interventional coordinator who is highly visible, accessible, and valued by the surgical team, can result in improved patient safety and reduce costs associated with infection levels above baseline. We could more than justify a 0.6 salary in epidemiology by initiating interventional programs.

The thoratec IVAD: a new implantable ventricular assist device

THE THORATEC IVAD: A NEW IMPLANTABLE VENTRICULAR ASSIST DEVICE M.S. Slaughter, S.S.L. Tsui, A. El-Banayosy, R.L. Kormos, T.B. Icenogle, J.D. Hill, Surgery, Cardiothoracic Division, Advocate Christ Medical Center, Oak Lawn, IL; Surgery, Papworth Hospital, Cambridge, United Kingdom; Surgery, Heart Center NRW, Bad Oeynhausen, Germany; Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Surgery, Sacred Heart Medical Center, Spokane, WA; Surgery, California Pacific Medical Center, San Francisco, CA

The effects of spironolactone on thiamine blood levels in patients with congestive heart failure on chronic high doses of loop-diuretics

Background: The nonpharmacological management of congestive heart failure (CHF) has been understudied. The importance of micronutrients such as vitamin B1 (thiamine) has long been known since its deficiency is associated with the development of high-output CHF. In the present study, we studied the relationship between adding to ACE inhibition further aldosterone suppression with spironolactone and thiamine blood levels (pmol/ml). Methods: A total of 22 patients (pts) with moderate to severe CHF symptoms (NYHA II/IV) were divided in two groups according to the use of spironolactone [group I-spironolactone 25 mg/qd (n 11) and group II no spironolactone (n 11)]. Thiamine blood levels were determined using the erythrocyte transketolase activity. The groups were compared regarding food intake, furosemide doses, demographics and thiamine blood levels (mean SD) using a student’s t test. Chi-square and Kruskal-Wallis tests were used to assess variables associated with thiamine levels. Results: Group I and II were similar regarding food intake, daily furosemide doses (110.9 30.2 and 105.5 26.9 mg, respectively; p 0.05), demographics (etiology of CHF, age, hypertension, diabetes, smoking, alcohol abuse, dyslipidemia and adjuvant drug CHF treatment). Patients in group I showed significantly higher thiamine blood levels when compared to patients in group II (277.2 89.8 and 154.7 35.7 pmol/ml, respectively) (p 0.001). None of the dependent variables cited above were associated with thiamine blood levels. Conclusion: In a cohort of ambulatory CHF patients (NYHAII/IV) on high doses of loop diuretics the use of spironolactone is associated with higher thiamine blood levels. The significance of this finding remains to be established by future studies with prospective design and larger sample sizes. Safety and Efficacy of Intermittent, Short-Term, Outpatient Nesiritide Infusions for the Treatment of Decompensated Heart Failure Ghaith M. Mulki, Carol Pisano, Gallagher Colleen, Cianci Pamela, Muhyaldeen Dia, Marc A. Silver1—Department of Medicine and the Heart Failure Institute, Advocate Christ Medical Center, Oak Lawn, IL