VOLUME 1 •
NUMBER 2 •
SUMMER 2019 •
www.japacvs.org
APACVS J
Journal of The Association of PAs in Cardiothoracic and Vascular Surgery
Official Journal of The Association of Physician Assistants in Cardiothoracic and Vascular Surgery
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
JAPACVS
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Editor-in-Chief David J. Bunnell, MSHS, PA-C Washington DC VA Medical Center Associate Editor Stafford Scott Balderson, BS, PA-C, FAPACVS Duke University Medical Center - Durham, NC Editor Emeritus Doug Condit, PA-C Montefiore Medical Center – New York, NY Editorial Board Anitha Chandrasekhar, BS, PA-C Fortis Malar Hospital – Chennai, India Steven Harrington, MD, MBA Henry Ford Macomb – Clinton Township, MI Marcus Hoffman, MD Stuttgart, Germany Kimberly Mackey, MPAS, PA-C Children’s Healthcare of Atlanta JoAnn Montecalvo, MPAS, PA-C Winthrop University Hospital—Mineola, NY Aaron Morton, MMSc, PA-C, ATC, FAPACVS Emory University Medical Center – Atlanta, GA Mitesh Patel, MSHS, PA-C Baylor Scott and White – The Heart Hospital – Plano, TX David Tecchio, MPAS, MBA, PA-C Vassar Brothers Medical Center Poughkeepsie, NY Publisher David E. Lizotte, MS, PA-C, FAPACVS Executive Director APACVS – Simpsonville, KY
EDITORIAL MISSION: The JAPACVS is the official clinical journal of the Association of PAS in Cardiothoracic and Vascular Surgery. The mission of the JAPACVS is to improve Cardiac, Vascular and Thoracic Surgical and CVT Critical Care patient care by publishing the most innovative, timely, practice-proven educational information available for the physician assistant profession. PUBLISHED CONTENT IN THE JAPACVS: Statements and opinions expressed in the articles and communications herein are those of the authors and not necessarily those of the Publisher or the Association of PAS in Cardiothoracic and Vascular Surgery (APACVS). The Publisher and the APACVS disclaim any responsibility or liability for such material, including but not limited to any losses or other damage incurred by readers in reliance on such content. Neither Publisher nor APACVS verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damage incurred by readers in reliance on thereon. Neither Publisher nor APACVS guarantees, warrants, or endorses any product or service advertised in this publication, nor do they guaranty any claim made by the manufacturer of such product or service. SALES OFFICE APACVS 1435 Taylor Wood Rd. Simpsonville, KY 40067 Phone (502) 321-6155 admin@apacvs.org JAPACVS/Journal of the Association of PAs in Cardiothoracic and Vascular Surgery is published quarterly (4 issues per volume, one volume per year) by APACVS 1435 Taylor Wood Rd., Simpsonville, KY 40067. Volume 1, Number 1, Spring 2019. One year subscription rates: $40 in the United States and Possessions. Single copies (prepaid only): $10 in the United States
© 2019 APACVS, INC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including by photocopy, recording, or information storage and retrieval system, without permission in writing from the publisher. 2
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Editorial Caring for Vulnerable Patients: Schizophrenia and Lung Cancer in Veterans.
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David J. Bunnell, MSHS, PA-C – Editor-in-Chief Case Report Left Atrial Mass Resection for Pleomorphic Fibroblastic Myofibroblastic Sarcoma.
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Evan T. Markell, MMS, PA-C; Michael Magarakis, MD, Alvaro Montoya, MD Department of Cardiothoracic Surgery, Miami VA Medical Center, Miami, FL Case Report APACVS Special Section ERAS Cardiac Guidelines Commentary
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Rawn Salenger, MD Assistant Professor of Surgery, Division of Cardiac Surgery, University of Maryland Saint Joseph Medical Center
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Questions and Answers Mitesh Patel, MSHS, PA-C; David J. Bunnell, MSHS, PA-C The Interview
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Five Questions for Kendra Thomsen, MPAS, PA-C, Chair-Elect NCCPA.
The 39th Annual Meeting of the APACVS will be April 16-19, 2020 at the Miami Downtown Hilton. Registration will open soon!
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
David J. Bunnell, MSHS, PA-C, Editor-in-Chief
Caring for Vulnerable Patients: Schizophrenia and Lung Cancer in Veterans. In my time caring for veterans I noticed we had more than a few individuals who struggled with schizophrenia for whom we were able to resect low stage non-small cell lung cancers. This has always been a source of satisfaction because I felt we were good at engaging vulnerable individuals and saving them from the most common cause of worldwide cancer death.1 I do not have data to support my anecdotal feelings. However, I am grateful to work in the Veterans Health Administration where there were resources to support vulnerable patients. This is why I read with interest the findings of “Disparities in lung cancer outcomes for veterans with comorbid mental conditions� which reviewed the VA Cancer Registry from 2000 to 2011 published in the Journal of Clinical Oncology. 55,315 individuals were evaluated based on their mental disorder, survival, and the impact of VA treatment programs on survival.2 The first finding may not be surprising. Patients with schizophrenia and dementia had higher rates of all-cause mortality. (hazard ratio HR 1.10; 95% CI, 1.03-1.16; p < 0.005 and 1.11, 95% CI, 1.08-1.18; p < 0.005). However, the study discovered participation in programs to support those struggling with mental illness, substance abuse, and homelessness significantly improved all-cause mortality and cancer deaths. (HR 0.71; 95% CI, 0.690.77; p < 0.0001 and HR 0.73; 95% CI, 0.69-0.77; p v 0.001) Supporting vulnerable patients saves lives. It is not enough to simply be a good diagnostician, surgeon, or oncologist. Blaming the patient for their life circumstance as an explanation for poor outcomes solves nothing. However, recognizing the context in which a patient is living with their cancer improves survival. Think about that for one moment. Look at the hazard ratios. Supporting these individuals not only improved outcomes to even with those not suffering from these issues but actually improved their outcomes overall.
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How is your team identifying and supporting vulnerable patients? Do you know the resources available to them? How does your team approach no-shows for appointments for people you know are struggling? What is your relationship with your social work and psychiatry colleagues? Finding the right answers to these questions will save lives. The PA community is uniquely positioned on the team to be experts in identifying vulnerable patients, connecting them to support, and following to make sure the plan is working. We are empowered to make good things happen if we are open to the full scope of what we can accomplish.
1. Bray, Ferlay, Soerjomataram, Siegel, Torre, Jemal. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. Vol 68, Iss 6, Nov/Dec 2018. pp 394424. https://doi.org/10.3322/caac.21492
2. Berchuck, Meyer, Zhang, Triveldi, Cohen, Wang. Disparities in lung cancer outcomes for veterans with comorbid mental conditions.Journal of Clinical Oncology 37. No. 15 suppl (May 20, 2019) 6577-6577. https://ascopubs.org/doi/abs/10.1200/ JCO.2019.37.15_suppl.6577
JAPACVS publishes invited commentary and letters to the editor in response to published articles in which the authors are given the opportunity to respond
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Left Atrial Mass Resection for Pleomorphic Fibroblastic Myofibroblastic Sarcoma. Evan T. Markell, MMS, PA-C; Michael Magarakis, MD; Alvaro Montoya, MD Department of Cardiothoracic Surgery, Miami VA Medical Center, Miami, FL Introduction
The discovery of a primary cardiac tumor is rare. In a study performed of greater than 12,000 autopsies, fewer than 0.1% were identified. Cardiac tumors can be either symptomatic in nature, or found incidentally. Imaging will include: echocardiography, cardiac magnetic resonance imaging, and/or computed tomography. MRI is the preferred study for a cardiac tumor. A left atrial tumor will typically present with heart failure symptoms, such as dyspnea, leg swelling and orthopnea. The most frequent tumor seen in the left atrium is a benign myxoma. Resection of these tumors is necessary to prevent embolization and heart failure symptoms. Malignant tumors make up roughly 15 percent of primary cardiac tumors. The most frequently seen primary malignant cardiac tumor is a sarcoma, but these are quite uncommon. Diagnosis also involves echocardiography, magnetic resonance imaging and computed tomography. A positron emission tomography (PET) should be used to evaluate for metastatic disease. The most commonly found sarcomas include: angiosarcomas, rhabdomyosarcoma and fibrosarcoma Angiosarcomas are the most prevalent type of cardiac sarcoma, as 40% sarcoma incidence has been reported as an angiosarcoma.3 They are more often discovered in the right atrium and are composed of malignant cells forming vascularity. Rhabdomyosarcomas are reported in 20% of cardiac malignant tumors found.4 They tend to arise more so on the ventricular wall. Fibrosarcomas are white, fleshy tumors that are composed of spindle cells and may have extensive areas of necrosis and hemorrhage. 5 Fibrosarcomas are known to heavily intrude myocardial tissue. The incidence of cardiac fibrosarcoma is quite rare with 11% of cases, however, they were previously categorized malignant fibrous histiocytomas.6 Literature review with this terminology is more common, with one article quoting 46 case reports.7 The report concluded benefit for surgery, despite high recurrence rates, for histological information and symptomatic relief. The mean survival was a year, with range of one month to 6 years. A sarcoma will typically multiply quickly, and lead to mortality secondary to myocardial infiltration, blood flow obstruction and metastatic disease. Although treatment is total resection of the sarcoma, most will develop recurrent disease and die from malignancy.8 Average survival for sarcoma is 6-12 months, with improved outcome when complete resection is performed.9 There have been studies showing possible survival benefits with adjuvant chemotherapy. Radiation therapy is primarily reserved for metastatic disease. A study done at Mayo clinic with 34 patients during a 32-year period showed median survival was improved (17 months) when complete resection was performed, versus 6 months when resection was not accomplished.10 Additionally, there is mention of cardiac transplantation. However, a case review of heart transplantation for non-metastatic cardiac sarcoma concluded that heart transplant was not indicated. The majority of the cases for this review 7
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
were angiosarcomas. It should be noted there was greater survival benefit with lower grade sarcomas post-transplantation, as grade 2 mean survival for this study was 85 months.11 Cardiac transplantation has been seen in conjunction with neoadjuvant chemotherapy/radiation. A 21-case review of patient undergoing this treatment showed 12 month mean survival, but seven of these patients survived to 27 month follow up.12 Cardiac auto transplant is advantageous with ex vivo tumor resection, and without the need for antirejection medication required for cardiac transplant. Our case involves a patient who was found to have a fibrosarcoma, treated with surgical resection and adjuvant therapy. Case Report
A 70-year-old male with history of hypertension, chronic obstructive pulmonary disease, hyperlipidemia, diabetes mellitus type 2, diabetic neuropathy, current tobacco use, who underwent CT abdomen and pelvis as follow up for treatment of pancreatitis. The 3month follow up scan showed an enlarged subcarinal lymph node. A CT of the chest was recommended for further evaluation. The CT chest with contrast showed a mass extending into the left atrium causing mass effect on the atrium and right main bronchus and right pulmonary veins measuring 3.4 cm transverse and 2.9 cm in AP dimension. There was mild dilatation of pulmonary arteries. The mass appeared to be extrinsic from the left atrium causing mass effect. Additionally, right hilar lymph nodes measuring 1.2 cm. Transesophageal echocardiogram revealed results consistent with large 3-4 centimeter left atrial mass thought most likely to be left atrial myxoma versus clot. Given the size of the mass, the patient was then urgently referred to cardiac surgery for evaluation. Upon presentation to cardiac surgery the patient stated that he clinically felt well. No complaints of chest pain, dyspnea, cough, hemoptysis, or leg swelling. No evidence of embolization, as he denied history of stroke, or focal weakness. Cardiac catheterization documented nonobstructive coronary artery disease. Transthoracic echocardiogram showed ejection fraction 55-60%, mild left ventricular hypertrophy, and no significant valvular disease. The case was presented in chest conference and tumor board. Consensus was to proceed with surgical resection. Surgery was performed via median sternotomy incision. A soft tip cannula was entered in the ascending aorta and connected to the pump. Bi-caval cannulation was implemented and he was placed on cardiopulmonary bypass. Aorta was cross clamped. Myocardial protection was accomplished antegrade with cold blood cardioplegic solution. Palpation of the posterior wall of the heart revealed a hard mass. The left atrium was entered via incision in the interatrial groove. Immediately seen was a greyish, hard surface mass. It was somewhat round and also within a superior right pulmonary artery. With blunt dissection, this mass was easily detached from both pulmonary veins. Once the mass came out in one piece without fracture or damage, no other signs of tumor were detected. There was no evidence of residual tissue from the tumor left behind. The mitral valve was intact and there were no other tumors in the left atrial cavity. The mitral valve remained intact. Initial frozen section diagnosis showed Spindle Cell neoplasm of uncertain malignant potential. The left atrium was closed with continuous 3-0 Prolene and reinforced with Afrin pledgets. Cross clamp on the aorta was released. The heart contracted spontaneously. Air from inside the heart was evacuated. Hemodynamics were stable. Cardiopulmonary bypass was terminated. The heart was decannulated in the usual 8
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
fashion. Protamine was given. Temporary pacing leads were sutured to the right ventricular wall and 2 chest tubes were left in place. The sternum was approximated in the interrupted stainless steel wires and tissue closure as per normal routine. Estimated blood loss 500mL. The patient tolerated the procedure well and was taken to Intensive Care Unit in satisfactory condition with minimal vasopressor support. The patient developed post-operative atrial fibrillation requiring initiation of anticoagulation, otherwise he recovered quite well. He was sent home on postoperative day three in stable/improved condition. Final pathology diagnosis was pleomorphic fibroblastic myofibroblastic sarcoma, high-grade, grade 3/3. The pathologist further noted type of neoplasm had the potential to behave in a very aggressive fashion and should be treated accordingly. PET scan one-month post-op showed no focal intensely hypermetabolic areas to suggest FDG avid malignancy. He was then referred to oncology for further management and surveillance. The decision was made for no adjuvant chemotherapy or radiation post-resection. Over the next several months, the patient developed increasing shortness of breath with minimal exertion. He was admitted 6 months post-op with presumed COPD versus heart failure exacerbation. Chest radiograph at that time revealed vague right hilar mass. Subsequent PET CT demonstrated a large hypermetabolic mass in the left atrium compatible with recurrence of Stage IV sarcoma. Additionally, there were several enlarged mediastinal lymph nodes that were worrisome for possible metastatic disease. There was further discussion in tumor board with recommendation for palliative chemotherapy. He underwent four chemotherapy sessions without significant improvement in symptoms. Repeat chest imaging post chemotherapy showed extensive tumor infiltration into the mediastinum encasing the right pulmonary artery, resulting in hypoperfusion of the right lung. At this point, he required continuous home oxygen and was experiencing dyspnea with minimal exertion. He had loss of appetite, twenty-pound unintentional weight loss, and became wheelchair bound due to fatigue and weakness. He described extreme symptom burden. His oncologist discussed further treatment options, including heart transplant, additional chemotherapy and palliative care. He was referred to palliative hospice care and passed away within several months due to sepsis and pneumonia. Care was withdrawn per the patient’s wishes. Discussion Primary cardiac tumors are not reported as a common finding and when discovered in the left atrium it is most often a benign myxoma. Symptomatic etiology of these tumors is related to the obstructing nature that can emulate mitral valve disease with heart failure and pulmonary hypertension burden. Additionally, there is concern for embolic events related to thrombi from the tumor. Although a myxoma is the expected pathology, it is important to establish diagnosis and rule out true malignant tumors that mimic a myxoma on echocardiography such as a sarcoma.13 An angiosarcoma is the most frequently seen sarcoma, followed by rhabdomyosarcoma and fibrosarcoma. There is quite limited reporting of fibrosarcoma upon literature review, but a study with 46 cases was found when utilizing the term malignant fibrous histiocytomas.6,7 For a primary intracardiac sarcoma without evidence of metastatic disease, the treatment is surgical excision for symptom relief, establishing diagnosis and avoiding complications.13 For our patient, his left atrial mass was incidentally found and he did not complain of expected heart failure symptoms. Work up showed no evidence of metastatic spread, and decision was therefore made for surgical removal. In retrospect, there could have been benefit from
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
cardiac MRI to understand more detailed anatomy prior to surgery.14 The technical aspects of the surgery went quite well, and there was no evidence of tumor fragments left behind as it was removed with ease and in one piece. Intra-operatively, the initiation of cardiopulmonary bypass and antegrade cardioplegia was performed with minimal tissue manipulation. That being said, there is hypothesized in a report the concept of cardiopulmonary bypass attributing to tumor spread.13 Additional treatment seen for sarcoma with fluctuant success include heart transplant with versus without adjuvant chemotherapy, and surgical resection followed by chemotherapy. It appears the survival benefit of heart transplant is directly correlated with sarcoma grade, with lower grade showing greater longevity.11 Overall, an increase in survival is seen with surgical intervention, as without resection the lifespan expected is less than a year.9 Additionally, there is report of increased survival with neoadjuvant chemotherapy followed by resection for cardiac sarcoma.15 The cause of death for patients is related to malignancy. With our patient, after undergoing surgical resection, he was not initially given adjuvant treatment as his one-month postresection PET scan did not show evidence of malignancy. He was found to have recurrence at 6 months as well as heavy symptom burden and at that time he was then offered palliative chemotherapy. Overall, this patient was found to have a rare and fatal cardiac tumor and when compared to literature and case reports reviewed, he did have a survival benefit with 24-month lifespan post tumor discovery. References 1. Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Lam KY, Dickens P, Chan AC. Arch Pathol Lab Med. 1993;117(10):1027 2. Primary cardiac tumors: experience at the University of Minnesota. Molina JE, Edwards JE, Ward HB Thorac Cardiovasc Surg. 1990;38 Suppl 2:183 3. Surgical Treatment of Primary Cardiac Sarcomas: Review of a Single-Institution Experience. Ramlawi B, Leja MJ, Abu Saleh WK, Al Jabbari O, Benjamin R, Ravi V, Shapira OM, Blackmon SH, Bruckner BA, Reardon MJ Ann Thorac Surg. 2016 Feb;101(2):698-702. Epub 2015 Oct 21. 4. Primary cardiac rhabdomyosarcoma of the left atrium: an unusual presentation. Castorino F, Masiello P, Quattrocchi E, Di Benedetto G Tex Heart Inst J. 2000;27(2):206. 5. Survival following treatment of a cardiac malignant fibrous histiocytoma. Schena S, Caniglia A, Agnino A, Caruso G, Ferlan G. Chest. 2000;118(1):271. 6. Fletcher CDM, Bridge JA, Hogendoorn PCW, Mertens F. World Health Organization Classification of tumours of soft tissue and bone, 4th ed, IARC Press, Lyon 2013. 7. Primary cardiac tumors: early and late results of surgical treatment in 91 patients. Centofanti P, Di Rosa E, Deorsola L, Dato GM, PatanèF, La Torre M, Barbato L, Verzini A, Fortunato G, di Summa M. Ann Thorac Surg. 1999;68(4):1236. 10
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8. Malignant fibrous histiocytoma of the heart: case report and review of 46 cases in the literature. Okamoto K, Kato S, Katsuki S, Wada Y, Toyozumi Y, Morimatsu M, Aoyagi S, Imaizumi T Intern Med. 2001;40(12):1222. 9. Primary sarcomas of the heart. Burke AP, Cowan D, Virmani R. Cancer. 1992;69(2):387. 10. Malignant primary cardiac tumors: review of a single institution experience. Simpson L, Kumar SK, Okuno SH, Schaff HV, Porrata LF, Buckner JC, Moynihan TJ. Cancer. 2008;112(11):2440. 11. Survival after heart transplantation for non-metastatic primary cardiac sarcoma. Li H, Yang S, Chen H, Yang Z, Hong T, Hou Y, et al. J Cardiothorac Surg. 2016 Oct 3. 11 (1):145. 12. Therapy for primary cardiac tumors: is there a role for heart transplantation? Gowdamarajan A, Michler RE Curr Opin Cardiol. 2000;15(2):121. 13. Metastatic left atrial synovial sarcoma mimicking a myxoma. Kumar S, Chaudhry MA, Khan I, Duthie DJ, Lindsay S, Kaul P J. Thorac Cardiovasc Surg. 2004;128(5):756. 14. Usefulness of magnetic resonance imaging of cardiac and paracardiac masses. U. Hoffmann, S. Globits, W. Schima. Am J Cardiol, 92 (7) (2003), pp. 890-895. 15. Improved Outcomes With the Evolution of a Neoadjuvant Chemotherapy Approach to Right Heart Sarcoma. Abu Saleh WK, Ramlawi B, Shapira OM, Al Jabbari O, Ravi V, Benjamin R, Durand JB, Leja MJ, Blackmon SH, Bruckner BA, Reardon MJ. Ann Thorac Surg. 2017;104(1):90.
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ERAS Cardiac Guidelines Commentary Rawn Salenger, MD Assistant Professor of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, University of Maryland Saint Joseph Medical Center Enhanced Recovery After Surgery (ERAS) is a movement to rigorously apply evidence-based best practice to all phases of perioperative care.1 ERAS programs have demonstrated significant benefit in reducing complications and costs outside of cardiac surgery.2-4 Application of ERAS principles to cardiac surgical care is gaining widespread enthusiasm and evidence specific to cardiac patients continues to emerge.5-8 In May 2019 the first ever guidelines for Cardiac ERAS were published in JAMA Surgery.9 The guidelines were issued by the ERAS® Cardiac Society and were the result of extensive collaboration by leading cardiac surgeons, anesthesiologists, and intensivists reviewing the available evidence for perioperative care of the cardiac surgery patient. An exhaustive review yielded support for 22 interventions or “care bundles” divided into preoperative, intraoperative, and post-operative phases of care. Each recommendation is graded according to the American College of Cardiology/American Heart Association clinical practice guidelines to grade class of recommendation (strength of treatment effect) and level of evidence (certainty of treatment effect) (Table 1).10,11 The guidelines are meant to reduce practice variability in the perioperative care of all cardiac surgical patients.
Table 1: Class of Recommendations and Level of Evidence Explained
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Summary of Recommendations The guidelines are organized according to of preoperative, intraoperative, and postoperative phases of patient care: PREOPERATIVE Measurement of Hemoglobin A1C Class IIa, level C-LD The evidence supports measurement a risk stratification method. Those with Hemoglobin A1C > 7% are at greater long- and short-term risk. Evidence is equivocal regarding whether preoperative optimization of hemoglobin A1C will ameliorate this risk. Measurement of Albumin Class IIa, level C-LD This is also for risk stratification. Hypoalbuminemia is associated with increased risk, including prolonged mechanical ventilation, acute kidney injury, infection, prolonged length of stay, and increased mortality. Correction of Nutritional Deficiency Class IIa, level C-LD Intensive nutritional therapy for patients undergoing cardiac surgery with a serum albumin < 3.0 g/dl may improve outcomes. Enteral nutrition has the greatest effect.
Consumption of Clear Liquids Before General Anesthesia Class IIB, level C-LD Encouraging clear liquids up to two hours before surgery is a component of all noncardiac ERAS programs and has been shown to provide quicker return of normal gut function. The benefit for cardiac surgery patients is largely extrapolated from these noncardiac data, although the safety of this practice has been demonstrated in the cardiac surgery population. Carbohydrate Loading Class IIb, Level C-LD A 12-ounce carbohydrate drink administered two hours prior to surgery has been shown to reduce insulin resistance, improve glucose control, and speed the return of gut function postoperatively in the non-cardiac population. Similar to above this recommendation is largely extrapolative, although safety has been demonstrated in the cardiac surgery population.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Patient Engagement Tools Class IIa, level C-LD Patient education and counseling has the potential to decrease patient anxiety, fatigue, and discomfort, enhance recovery, and provide earlier discharge. Novel digital platforms are now becoming available that have the potential to extend this patient learning and further improve results. These same platforms may enhance our ability to learn from our patients by collecting patient reported outcomes. Prehabilitation Class IIa, level B-NR Although not always feasible, prehabilitation has been shown to decrease complications and improve readiness for discharge. An ideal prehabilitation program should provide education, nutrition, exercise, social support, and anxiety reduction to improve physical and psychological preparedness. Smoking and Hazardous Alcohol Consumption Class I, level C-LD Further cardiac-specific studies are needed but cessation of smoking and hazardous alcohol consumption for one month prior to surgery has been shown to reduce respiratory, wound, bleeding, infectious, and metabolic complications. Intraoperative
Surgical Site Infection Reduction This important topic has also been extensively reviewed in prior surgical guidelines. Evidence supports topical therapy to eradicate Staphylococcus aureus nasal colonization, weight-based cephalosporin infusion within sixty minutes of incision, intraoperative re-dosing of antibiotics after four hours, skin preparation, depilation protocols, and removal of dressing after 48 hours. Table 2 lists the classification of recommendations for the surgical site infection reduction bundle and the levels of evidence for each element as reviewed by Lazar et al, and as included in the ERAS Cardiac guidelines statement.
Table 2: Surgical Site Infection Bundle with Class of Recommendations and Level of Evidence
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Hyperthermia Class III, level B-R Avoid hyperthermia when rewarming on cardiopulmonary bypass and for at least 24 hours after surgery. Core temperatures above 37.90 C have been associated with cognitive deficits, infection, and renal dysfunction Rigid Sternal Fixation Class IIa, level B-R Rigid sternal fixation has been associated with accelerated sternal healing and decreased wound complications. This technique may be of particular value for high risk patients such as those with high body mass index, previous chest wall irradiation, chronic obstructive pulmonary disease, or steroid use. Tranexamic Acid or Epsilon Aminocaproic Acid Class I, level A Total blood management is a large topic beyond the scope of the ERAS Cardiac guidelines. However, a large randomized clinical trial in patients undergoing coronary bypass surgery demonstrated decreased total blood transfusion, major hemorrhage, and tamponade in patients receiving an anti-fibrinolytic agent. Based on this evidence, the ERAS Cardiac Society has given a strong recommendation for the use of Tranexamic Acid or Epsilon Aminocaproic Acid for on-pump cardiac surgery.
Postoperative
Perioperative Glycemic Control Class I, level B-R Perioperative glycemic control has been shown to improve outcomes for diverse groups of patients and is recommended based on randomized trials and high-quality observational studies, although not specific to cardiac surgery patients.
Insulin Infusion Class IIa, level B-NR Randomized trials, not specific to cardiac surgery, support the use of continuous insulin infusion for optimal perioperative glycemic control.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Pain Management Class I, level B-NR Evidence is mounting that multimodal opioid-sparing regimens have the potential to speed recovery and decrease opioid-related adverse events. No single multimodal path way has emerged as optimal for cardiac surgery. However, recommendations include preoperative counseling to set expectations and adjunctive acetaminophen. Some additional adjunctive agents with potential benefit include dexmedetomidine, gabapentin or pregabalin, and ketamine. Postoperative Systematic Delirium Screening Class I, level B-NR Delirium is associated with reduced in-hospital and long-term survival, increased read mission, and impaired cognitive and functional recovery. Delirium pathogenesis is complex and unlikely to be solved by a single agent or intervention. Early detection, however, is critical to identifying and treating reversible factors such as pain, hypoxia, low cardiac output, and sepsis. A systematic delirium screening tool such as the Confusion Assessment Method for the Intensive Care Unit or the Intensive Care Unit Delirium Screening Checklist should be used at least once per nursing shift. Persistent Hypothermia Class I, level B-NR Temperature < 360 C beyond 2-5 hours after surgery is associated with increased bleeding, infection, prolonged length of stay, and mortality. ERAS Cardiac guidelines recommend using forced air blankets, increasing ambient room temperature, and warming intravenous fluids in the early postoperative period to avoid hypothermia. Chest Tube Patency Class I, level B-NR Active chest tube clearance methods have been demonstrated to maintain chest tube patency without breaking the sterile field. This same method has been shown to reduce the need for subsequent interventions to treat pleural and pericardial effusions and decrease the incidence of atrial fibrillation. The alternative techniques of stripping or breaking the sterile field to clear chest tubes is not recommended (class IIIa, level B-R). Chemical Thromboprophylaxis Class IIa, level C-D All patients benefit from mechanical thromboprophylaxis with compression stockings and/or intermittent pneumatic compression devices. Daily prophylactic anticoagulation should also be considered starting on the first postoperative day.
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Extubation Strategy Class IIa, level B-NR Prolonged mechanical ventilation is associated with longer length of stay, higher morbidity, and increased mortality. ERAS Cardiac guidelines recommend time-directed protocols to achieve extubation within 6 hours of ICU arrival time. This method has been demonstrated to be safe and is associated with decreased ICU time, hospital length of stay, and decreased cost. This goal aligns with the ERAS principle of returning patients to normal function as quickly as possible after surgery. Acute Kidney Injury Class IIa, level B-R Urinary biomarkers such as tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 can detect kidney stress as early as one hour postcardiopulmonary bypass. Randomized trials have demonstrated that patients with positive urinary biomarkers for kidney stress assigned to an intervention arm had reduced rates of acute kidney injury. Interventions included avoiding nephrotoxic agents, discontinuance of ACE-I and ARB agents for 48 hours, and more intensive hemodynamic monitoring. Based on these trials, biomarkers are recommended for early identification of patients at risk for acute kidney injury. Goal-Directed Fluid Therapy Class I, level B-R Goal-directed fluid therapy trials consistently demonstrate reduced complications and length of stay.
Best available evidence was utilized by the ERAS Cardiac working group in assembling the guidelines. Adjustments were made to the Level of Evidence grade and Class of Recommendation when warranted due to limited applicable evidence. The relative paucity of cardiac surgery specific trials belies the rich opportunities for further cardiac ERAS research. There are also a number of important areas of interest to ERAS investigators for which there was not enough cardiac specific data to include in this initial set of guidelines. These topics include the treatment of preoperative anemia, optimization of diabetes to achieve a hemoglobin A1C <7%, comprehensive protective lung ventilation, regional/local anesthetic blocks, goal-directed perfusion, early enteral nutrition, and early ambulation. More research delineating the impact of these strategies specifically on the recovery of cardiac surgery patients is critical.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Conclusion The publication of ERAS guidelines for Cardiac Surgery provides engaged programs with a framework for applying well-established ERAS principles to the field of cardiac surgery. The 22 components contained in this initial set of guidelines set the standard for team-based multidisciplinary Cardiac ERAS. Importantly, we also look to the ERAS Cardiac Society to help our specialty establish standard metrics for measuring success with each care bundle. These standards will create the pathway for meaningful comparative research and benchmarks that can further advance the field. Future creation of ERAS Cardiac Centers of Excellence, based on commitments to research, teaching and multidisciplinary engagement as well as proven outcomes, will help aspiring cardiac surgery programs model successful ERAS programs. This team-based approach will potentially enhance the perioperative care of our patients and allow quicker recovery with fewer complications.
References 1. Ljungqvist O, ScottM, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017; 152(3):292-298. doi:10.1001/jamasurg.2016.4952 2. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. 2011;(2): CD007635. 3. Stone AB, Grant MC, Pio Roda C, et al. Implementation costs of an enhanced recovery after surgery program in the united states: a financial model and sensitivity analysis based on experiences at a quaternary academic medical center. J AmColl Surg. 2016;222(3):219-225. doi:10. 1016/j.jamcollsurg.2015.11.021 4. Thiele RH, Rea KM, Turrentine FE, et al. Standardization of care: impact of an enhanced recovery protocol on length of stay, complications, and direct costs after colorectal surgery. J Am Coll Surg. 2015;220(4):430-443. doi:10.1016/j. jamcollsurg.2014.12.042 5. Fleming IO, Garratt C, Guha R, et al. Aggregation of marginal gains in cardiac surgery: feasibility of a perioperative care bundle for enhanced recovery in cardiac surgical patients. J Cardiothorac Vasc Anesth. 2016;30(3):665-670. doi:10.1053/j.jvca.2016.01.017 6. Brown JK, Singh K, Dumitru R, Chan E, Kim MP. The Benefits of Enhanced Recovery After Surgery Programs and Their Application in Cardiothoracic Surgery. Methodist Debakey Cardiovasc J. 2018;14(2):77-88. 7. Noss C, Prusinkiewicz C, Nelson G, Patel PA, Augostides JG, Gregory AJ. Enhanced Recovery for Cardiac Surgery. J Cardiothorac Vasc Anesth. 2018:1-11. doi:10.1053/ j.jvca.2018.01.045
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
8. Li M, Zhang J, Gan TJ, Qin G, Wang L, Zhu M, et al. Enhanced Recovery After Surgery Pathway for Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial. Eur J Cardiothorac Surg 2018. doi:10.1093/ejcts/ezy 100 9. Engelman D, Walid BA, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM. Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. Jama Surg. Doi: 10.1001/ jamasurg.2019.1153. 10. Bakaeen FG, Svensson LG, Mitchell JD, Keshavjee S, Patterson GA,Weisel RD. The American Association for Thoracic Surgery/Society of Thoracic Surgeons position statement on developing clinical practice documents. J Thorac Cardiovasc Surg. 2017; 153(4):9991005. doi:10. 1016/j.jtcvs.2017.01.003 11. Jacobs AK, Anderson JL, Halperin JL, et al; ACC/AHA TASK FORCE MEMBERS. The evolution and future of ACC/AHA clinical practice guidelines: a 30-year journey: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014;130 (14):1208-1217. doi:10.1161/CIR. 90
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Q&A is a recurring JAPACVS feature where you can submit practice-based questions, answers, and explanations. Submit your Q&A to editor@japacvs.org to see your name in the author heading. Mitesh Patel, MSHS, PA-C; David J. Bunnell, MSHS, PA-C PA Patel You are completing a redo sternotomy aortic root replacement on a 78-year-old female with a known medical history of diabetes, hypertension, hyperlipidemia and previous aortic valve replacement 6 years prior. The case went well however it was a long cardiopulmonary bypass run, 290 minutes to be exact. Prior to placing sternal wires and closing the chest, you notice that the blood around the suture lines is still serosanguineous and there isn’t much clot formation. You ask anesthesia to send a coagulation panel and the following is reported: Hemoglobin/Hematocrit: 12g/dl/36%, PT/INR: 14 seconds /1.0 seconds, aPTT: 38 seconds, fibrinogen: 124 mg/dl, and platelets: 145,000 ¾l. You notice that the patient is becoming hypotensive with a blood pressure of 98/67. What is the next appropriate action? A: Order 2 units of platelets to be given when ready. B: Ask anesthesia to titrate up the levophed drip to keep the systolic blood pressure above 110mmHg. C: Order 50 mg of protamine to be given now. D: Order 10 units of cryoprecipitate to be given now. E: Continue to close the chest and monitor the chest tubes while you wait in the OR.
Answer D Order 10 units of cryoprecipitate to be given now. The reason is because the coagulation panel shows the fibrinogen is low. Normal fibrinogen is between 150-400 mg/dl and in a patient that is bleeding keeping a fibrinogen above 200 mg/dl is ideal. The other answer choices would not result in appropriate correction of the coagulation results and could cause the patient harm. Answer choice A platelets is incorrect because keeping platelets above 100,000 is the goal in a bleeding patient. Answer choice B is incorrect because although titrating levophed would help the BP it would not help bleeding and could potentially worsen the bleeding. Answer choice C administering protamine is not the correct answer as PTT is within normal limits. Answer choice E is not correct because the patient is bleeding and hypotensive and closing the chest could cause profound hypotension and cardiac tamponade.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
PA Patel For which of the following conditions would the use of positive inotropic drugs be appropriate? A. Hypertrophic Cardiomyopathy B. Restrictive Cardiomyopathy C. Dilated Cardiomyopathy D. Pericarditis
Answer C: Dilated cardiomyopathy is associated with a low ejection fraction due to thinned out and weak left ventricle. These types of cardiomyopathies benefit from inotropic support to help end organ perfusion. Option A, hypertrophic cardiomyopathy typically has a normal or above average ejection fraction and the left ventricle is often hyper-dynamic. Restrictive cardiomyopathies do not improve with inotropic support and these medications can be harmful in patients with this condition. With regards to pericarditis, it is important to treat the underlying cause which could be viral, bacterial, or a whole host of other causes. Schoen FJ, Padera RF. Cardiovascular Pathology. In: Cohn LH, Adams DH. eds. Cardiac Surgery in the Adult, 5e New York, NY: McGrawHill; . http://accesssurgery.mhmedical.com/content.aspx?bookid=2157§ionid=164288089. Accessed July 09, 2019.
PA Bunnell An 82-year-old woman with occasional palpitations presents with this 12-lead electrocardiogram. She has a past medical history of well controlled hypertension and diabetes for which she has been prescribed lisinopril and metformin.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
What initial approach is appropriate to reduce symptoms and prevent complications? A. Pacemaker insertion B. Anticoagulation and Heart Rate control C. Left Heart Catheterization D. Holter monitoring Answer B: Rate control and anticoagulation can be helpful to reduce palpitation symptoms and to prevent complication of thromboembolism.
The electrocardiogram has atrial flutter with variable atrioventricular conduction and a tachycardic rate as calculated by computer as 101 beats per minute. Atrial flutter is important to consider because it is often missed. One common reason to miss atrial flutter is when the rate is 140 to 150/min because it may represent a 2:1 conduction which is not demonstrated in this tracing. While there are a few shorter R to R intervals which have only one flutter wave visible, you have the benefit from variable conduction which reveals more than one flutter wave. A pacemaker is not indicated from information available because there is no evidence of atrioventricular block, bradycardia, dizziness, or syncope. There is variable ventricular conduction but this can be a normal finding in atrial flutter. Initial treatments for atrial flutter are anticoagulation and heart rate control. The patient has a CHA2DS2-VASC score1 of 5 for age (2 points for age greater than or equal to 75, female sex (1 point), hypertension (1 point), and diabetes (1 point). She has a HAS-BLED score2 of 1 for age. It is notable she does not get a point for hypertension because her blood pressure was noted to be well controlled. HAS-BLED assigns a point for uncontrolled hypertension greater than 160 mmHg systolic. Heart rate control is indicated for patients with atrial fibrillation and atrial flutter which is made more evident on this tracing with the tachycardic ventricular response. While calcium channel blockers and beta blockers are equally effective, you might consider betablockade for this patient with cardiac risk factors of hypertension and diabetes. While cardiac risk factors are noted, there is no evidence pointing towards initial evaluation of coronary arteries through catheterization. She does have occasional palpitations but no chest pains, ischemic EKG changes, or elevation in cardiac biomarkers have been presented. While not a part of this question, you may consider evaluation of left ventricular function which, if decreased, may lead to questions of etiology which would include ischemic studies. Also, it is notable that a decreased ejection fraction may also occur with prolonged tachycardia which accompany atrial flutter and may resolve with treatment. Holter monitoring is frequently utilized for patients with symptoms to identify arrhythmias. A patient with palpitations without known arrhythmia would benefit from cardiac monitoring to identify a causal arrhythmia. If this individual had concerning symptoms of dizziness or syncope a Holter may be indicated to identify a cause of the dizziness. This question was specific in asking for initial treatment because cardioversion and cavo tricuspid isthmus ablation needs to be considered for rhythm control. There are some patients 22
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
who may opt for medical management along with a cardioversion with a plan to follow symptoms to see if the arrhythmia recurs. However, performing radiofrequency ablation along the cavo tricuspid isthmus (CTI ABL) in the right atrium is an attractive approach to prevent recurrence. This specific location for ablation is advantageous because the vena cava and tricuspid valve annulus do not conduct electrical impulses so it feasible ablate conducting myocardium without the concern that the electrical impulse would simply find another path. The patient who presented with this tracing was prescribed metoprolol and apixaban. The individual was taken to the electrophysiology laboratory where typical counter clockwise atrial flutter pattern was identified. The arrhythmia was easily ablated and converted to sinus rhythm during the procedure. Note – The actual patient had a different history which was changed for this question to highlight key take home points. However, feedback on the electrophysiology study was warranted because; while there are typical “saw tooth” pattern atrial flutter waves in leads II, III, and aVF; there are also flutter waves in lead V1 which could make some experts question if this flutter had atypical features which would make ablation less effective. 1. Atrial fibrillation: CHA2DS2-VASC Risk Assessment Calculator. Heart Rhythm Society. http://resources.hrsonline.org/chads2-vasc-calculator.html. Accessed 7/20/2019. 2. HAS-BLED Score for Major Bleeding Risk. MD Calc. http://resources.hrsonline.org/
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Kendra Thomsen, MPAS, PA-C, Chair-Elect NCCPA.
Five Questions for PA Kendra Thomsen, MPAS, PA-C, Chair-Elect NCCPA. Kendra Thomsen, MPAS, PA-C is a practicing cardiothoracic surgery PA at Baylor Scott & White (BSW) in Texas and is Chair-Elect for the National Commission on Certification of Physician Assistants (NCCPA). She will assume responsibilities of NCCPA Chair in 2020. I met her at the AAPA Leadership and Advocacy Summit and it was quickly apparent she is a member of our tribe in that she knows and lives the life of a cardiothoracic surgery PA. Her unique clinical specialty perspective informs her work with NCCPA and her work with the Commission can inform members of the cardiac, thoracic, vascular, and critical care community. She graciously agreed to answer our five questions. JAPACVS All PAs have a working knowledge of NCCPA from the perspective of test takers and certification maintenance. What have you learned about the Commission that perhaps you did not know before you served as a member? KT I’ve learned that assessment leading to certification and maintenance of certification strategies rely on well-established industry standard principles. There is a real science to test development, scoring and interpretation of the results. The science is called psychometrics and the NCCPA employs psychometricians. Certification exams like those created by the NCCPA and other certifying bodies are based on practice analysis (or job task analysis) findings. PAs are involved in all aspects of NCCPA’s work. PAs are on exam teams, focus groups and the Board, to name just a few. They write and review test items and come from all practice disciplines and settings. I’ve also learned that NCCPA is well respected in the certification organization space
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
PAs from specialties frequently cite the need to take a generalist exam as a source of frustration and anxiety. What are your thoughts on generalist exams for those whose clinical life exists in a specialty? Starting this year (2019), NCCPA has shifted PANRE from a generalist PANRE to one that focuses on core medical knowledge. That is the content that all PAs must know as we practice across all disciplines. PAs value the ability to change disciplines and maintaining a core body of knowledge helps us to do that. I think most PAs keep up with their specialty through CME. I wanted to work in surgery, but didn’t start in CT Surgery because I had young children when I graduated from PA school and a husband who worked varying hours. But 5 years into my career, I was able to make the jump to CT Surgery. I love working in CT Surgery but also like the idea that I can change disciplines if I want to and maintaining core medical knowledge and my PA-C helps make that possible. NCCPA recently decided to continue the Cardiovascular and Thoracic Certificate of Added Qualification (CVT CAQ). What is your perspective on the benefit of a PA earning this certificate? What do you believe have been the barriers to the CVT CAQ becoming more widely sought in the PA community? Some PAs want an additional credential that documents their work in a specialty area. Earning a CAQ helps in that regard. NCCPA surveyed CAQ holders to ask why they chose to obtain a CAQ. The most common reply was that they wanted professional satisfaction and something to attest to their knowledge and skills in their practice areas. However, the biggest reason the CVT CAQ has not been widely sought seems to be that PAs are not getting financial gain or promotions based on the CAQ. Some specialties are requiring the CAQ more such as Psychiatry and Emergency Medicine, but that generally is not true in Cardiothoracic Surgery. There is not much incentive in the CT Surgery world at this point for people to pay money and take another exam. NCCPA is piloting an online home test which includes 25 questions per quarter over a two-year period as an alternative to the PA National Recertifying Exam (PANRE). What can you share about the progress of the pilot program so far? More than 58% of PAs who were eligible for the PANRE Pilot chose to enroll. Q2 just finished, and the feedback has been positive. PAs have indicated that the platform used to answer questions is easy to use, the content is mostly core medical knowledge, and they like the idea of getting immediate feedback and being able to look things up, if time permits.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
I am actually participating in the PANRE pilot myself. I don’t feel as stressed taking the exam and like that I can schedule for the exam when it is convenient to me. I can do 1 question or 25 questions in one sitting. I decided not to study ahead of time as the test is designed to test core medical knowledge. I’ve missed 3 questions out of 25 in Q1 and Q2, so not too bad given I work in a surgical subspecialty. I appreciate the immediate feedback and definitely see a trend in the in the areas I’m weaker (GI and neurology!). I also like that I can go back and review questions later. Resources are available with each question if I can’t find the answer or question the answer. As a whole, it has been a good experience so far. NCCPA Research has been publishing data on certified PAs which has been helpful to me in understanding the profession in ways that I did not before reading the work. Can you provide insight into the work done by NCCPA research and are their opportunities for PA researchers to collaborate with NCCPA to continue publish on the PA profession? NCCPA is in a unique position in that we can gather information from most PAs because we interact with most PAs. We appreciate the practice information that PAs share when completing their PA profile. That data is vital in helping to inform thinking about the profession. Actual numbers and facts matter. NCCPA has a director of research and staff that help to analyze the findings. NCCPA has published policies and processes for researchers interested in working with NCCPA to conduct research on the profession while protecting personal or identifying information of individual PAs.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery