VOLUME 3 •
NUMBER 1 •
WINTER 2021 •
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 Frostburg State University, Hagerstown, MD 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, FAPACVS Fortis Malar Hospital – Chennai, India Steven Harrington, MD, MBA Henry Ford Macomb – Clinton Township, MI Marcus Hoffman, MD, President EuroPAC 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
© 2020 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 4 Cardiothoracic and Vascular Surgery PA Scholarship at a Crossroads David J. Bunnell, MSHS, PA-C – Editor-in-Chief
7 Thoracic Aortic Dissection: A Case Report Debra L. Priore, PA-C, MHS 14 Robotic Assisted Left Lower Lobectomy: A Review of Critical Anatomy & Bedside Assisting Skills Matthew S. Vercauteren, MPAS, PA-C Inderpal S. Sarkaria, MD, MBA 15 APACVS – Top Articles from 2020
APACVS is the only association representing Cardiac, Thoracic and Vascular Surgery and CTV Critical Care PAs. By PAs, For PAs!
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Cardiothoracic and Vascular Surgery PA Scholarship at a Crossroads
David J. Bunnell, MSHS, PA-C, Editor-in-Chief
Origins A few in our community have had a vision and passion for scholarship in the cardiothoracic and vascular surgery PA community throughout our history. We have documented and explored our professional universe through CardioVISION as a quarterly and now weekly touch point for our community, the journal Surgical Physician Assistant has been widely credited for being a shared scholarly work, and now the Journal of the APACVS is working to define our place and contribute to knowledge and understanding of our profession. Path so far We have had a promising start with five issues that have included original peer reviewed manuscripts, editorial comments, education, stories about our contributions to the health and wellbeing of our patients, and interviews with notable PAs. This has happened through the work of authors, peer reviewers, and APACVS professional staff. I have had an opportunity to guide this effort by keeping a close eye on content by working with authors and peer reviewers to ensure our work is something that is worthy of being considered contributing to the scholarship of our field. Pandemic Experience There is not one person on the planet who has not been affected by the Sars-Cov-2 Pandemic. Most in our community have faced this virus head on with their patients since day one. While much is behind us, it is clear there is much more in front of us in terms of what is being asked of our teams as we staff critical care units overflowing with people suffering from the virus. The collective effect of the personal toll this continues to take on how we process our daily work and personal lives cannot be underestimated. We need to continue to work to find personal space for our own mental health and the health of our team members. 4
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
One effect of this universal stress is that people have been unable to find the opportunity to contribute to the journal. Without content from our community and participation in all aspects of this endeavor, we will struggle to explore our world. We are in a place where we have proven success but will need something more to build and grow this fledgling effort. Ground Effect Pilots are familiar with the concept of ground effect. When airplanes are close to the ground the vectors of airflow around the wings are such that a pilot can get the plane off the ground before enough velocity has been generated to climb to gain altitude. From a distance it can appear that a plane floating in ground effect is flying. However, the smart pilot knows the difference. I had the opportunity to become a private pilot and I understand the difference between floating in ground effect and flying. Right now, our wheels are off the ground and we are going to need some time and energy before we can fly. What is next? One thing in which there is general agreement about with all stakeholders is that JAPACVS is a worthwhile endeavor which needs to continue to provide a venue for scholarship in our community. The Editorial Board is working on what needs to happen for JAPACVS to succeed over the long term. I am committed to solutions which arise from a team which involve engagement from those involved. I want to give time and space for the Editorial Board to discern a path forward. However, here are some of the pieces we will need from our community for us to continue to serve our community as a journal. Authors – Are you an established writer? We need you now. Do you have an idea but aren’t confident in your ability to generate a manuscript? Talk to us so we can help connect people. Peer Reviewers – Do you have a clinical expertise and have the time to critically read one or two manuscripts a year in a way that provides timely, productive feedback? We need you. Do you have an interest in being a peer reviewer but need to learn more to be confident? We can help. Editorial Board – Do you have a network of PA professionals you can encourage to write, time to contribute as a team member, and a desire to contribute to your profession while building your CV? Talk to us. Associate Editors – Do you have specialty care expertise, comfort with scholarly manuscripts, the ability to coordinate with a team on a deadline, and a desire to contribute in a larger way? Talk to us.
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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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
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Peer Reviewed Content Thoracic Aortic Dissection: A Case Report Debra L. Priore, PA-C, MHS Penn-Presbyterian Medical Center, Department of Cardiac Surgery, Philadelphia, PA
Abstract Thoracic aortic dissections are relatively uncommon and sometimes difficult to diagnose. Fifty percent of patients with a Type A dissection die within 24-48 hours without the appropriate surgical intervention and even then, their mortality may exceed 25-30% in cases with critical malperfusion. Therefore, early, and accurate diagnoses and treatment are crucial for the survival of this potentially lethal condition. Introduction The natural history of a thoracic aortic aneurysm (TAA) is that of progressive expansion of the aorta, to greater than 50% of its normal diameter. Patients initially present with symptoms related to the rapid expansion of the TAA and/or compression of adjacent structures. Such symptoms include hoarseness, shortness of breath, sharp chest pain and back pain which increases the risk of rupture or aortic dissection.[1] Complications of TAA disease, such as rupture or dissection of the aorta, are a leading cause of death in the United States, particularly in individuals over 55 years of age. The incidence of thoracic aortic dissection is approximately 3 per 100,000 personyears. Males are five times more likely to have an aortic dissection than women.[2] A thoracic aortic dissection is an intimal tear in the wall of the aorta, allowing blood to surge through the tear, causing the intimal and medial layers to separate, creating a false lumen.[3] The dissection may propagate proximally and/or distally along the length of the aorta. This can lead to rupture or decreased blood flow to organs (malperfusion). Thoracic aortic dissections are associated with several risk factors for atherosclerosis such as: smoking, hypertension, and hypercholesterolemia.[4]
Other risk factors include connective tissue disorders (Marfan syndrome), bicuspid aortic valve, pre-existing aneurysm, inflammatory or infectious conditions (giant cell arteritis), and abnormal aortic arch anatomy.[5] The differential diagnosis includes acute coronary syndrome, aortic aneurysm, cardiac tamponade, esophageal rupture, pneumothorax, pulmonary embolism, and stroke. [6,7] Symptoms of a thoracic aortic dissection include sudden onset of severe sharp or tearing chest or back pain, dyspnea, and loss of consciousness. Computed Tomographic Angiography (CTA) is the most widely used definitive study when suspecting an aortic dissection. Aortic dissections are classified anatomically, using the Stanford or DeBakey classification systems. A Stanford Type A dissection involves the origin of the intimal tear to be in the ascending aorta, requiring emergent surgical intervention. This is to avoid the three main reasons for early death: severe aortic valve insufficiency, aortic rupture, and stroke. A Stanford Type B dissection involves the intimal tear origin to be in the descending aorta, distal to the left subclavian artery. It can be medically managed, unless the patient has increased pain or there is propagation of the tear, then surgical
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
intervention is required (endovascular stent). [6] Ascending aortic dissections are almost twice as common as descending dissections and aortic arch involvement occurs in up to 30% of patients. [8] Early mortality ranges have been reported from 10 to 35% with high stroke rates, prolonged ventilation, and renal failure. [9,10] CASE REPORT A 67-year-old female presented to an outside hospital with five days of worsening acute chest and abdominal pain, as well as dyspnea. Her past medical history was significant for hypertension, active smoker (40 pack-year history), moderate alcohol consumption, hypothyroidism, breast cancer and peripheral arterial disease. She was diagnosed with an acute Type A aortic dissection by a CTA and she was transferred to Penn-Presbyterian Medical Center given the complexity of the anatomy and for circulatory management. See Figure 1. Figure 1: CTA showed an acute Type A aortic dissection in the ascending aorta with a focally contained rupture. The ascending aorta measured 9 cm. The aortic arch was also dilated at 7cm, with the descending thoracic aorta at 6cm.
In the OR, bilateral radial arterial lines and a left femoral arterial line were placed for monitoring. The patient was then induced with general anesthesia. The right axillary artery was cut down upon and cannulated, using an 8mm Dacron graft. Then, using Transesophageal Echo (TEE) guidance, a right femoral vein venous cannula was placed into the right atrium. Heparin was given and Cardiopulmonary Bypass (CPB) was instituted. The heart was exposed via a full sternotomy, revealing the aneurysmal ascending aortic dissection with a contained rupture. See Figure 2. 8
Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Figure 2. 9 cm Aneurysmal Ascending Aortic Dissection with contained Rupture
Given the size of the aorta, a cross-clamp was unable to be placed. Therefore, the patient was cooled to 28 degrees Celsius and hypothermic circulatory arrest was instituted with antegrade cerebral perfusion via the right axillary cannulation. The aorta was transected to allow for direct right and left coronary osteal cannulation for cardioplegia to achieve electrical silence. Additional cardioplegia was given antegrade intermittently throughout the case. See Figure 3.
Figure 3. Ascending Aorta with separation of all layers, clot in false lumen.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
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1. Hussaini BE, Lu HG, Wolf JA, Thatte HS. Evaluation of endoscopic vein extraction on structural and functional viability of saphenous vein endothelium. J Thorac Cardiovasc Surg 2011;10(6):82 ©2021 Terumo Cardiovascular Systems Corporation. January 2021. 899969. Terumo® and VirtuoSaph® are a registered trademarks of Terumo Corporation.
Next, we turned our attention to the 7cm aneurysmal arch. There was no dissection distally in the descending thoracic aorta. The decision was made to proceed with a total arch reconstruction with a trifurcated Siena graft and antegrade deployment of the FET (frozen elephant trunk) TEVAR (thoracic endovascular aortic repair) into the distal arch, with the help of a guidewire. The guidewire had been placed via the left femoral artery retrograde with TEE guidance prior to the sternotomy. Antegrade delivery of the stent into the descending aorta promotes false lumen thrombosis and subsequent aortic remodeling. Using the trifurcated graft, the distal anastomosis beyond the left subclavian artery was performed in an end-to-end fashion. The anastomosis included the Siena graft, as well as the circumference of the distal arch, incorporating the TEVAR graft. Following the distal anastomosis, we went back on CPB and terminated hypothermic circulatory arrest. See Figure 4. Figure 4. Trifurcated Siena Graft: Innominate Artery, Left Common Carotid and Arterial graft to CPB.
The three head vessels were then reconstructed individually with the three branches of the Siena graft (left subclavian, left common carotid and innominate arteries). The aortic root was completely dissected and destroyed, with extension of the primary tear down to the root level. Therefore, an aortic root replacement was required. The left coronary button was intact; however, the right coronary button was dissected and distorted. A segment of greater saphenous vein was harvested from the left leg and grafted to the RCA (right coronary artery). The right coronary ostium was over sewn (Bentall technique). The patient was rewarmed. Temporary pacing wires were placed in the right atrium and right ventricle. The patient was weaned from CPB in NSR (normal sinus rhythm) with the aid of Inotropes. Post-op TEE showed a left ventricular ejection fraction (LVEF) of 60%, with normal right ventricular function and no aortic insufficiency. The frozen elephant trunk (FET) procedure facilitates staged treatment of patients with extensive aortic aneurysms and chronic dissections that involve the ascending aorta, aortic arch, and descending aorta. This hybrid approach combines open surgical and endovascular techniques, as well as minimizing hypothermic circulatory arrest, decreasing coagulopathies and neurologic complications. [11, 12] See Figure 5.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Figure 5. Total arch replacement with re-implantation of arch vessels, aortic root replacement with biologic prosthesis, coronary artery bypass graft to right coronary artery, and TEVAR .
REFERENCES 1. Elefteriades, JA. Indications for Aortic Replacement. J Thorac Cardiovasc Surg 2010 Dec;140 (6 Suppl): S5-9; discussion S45-51.
2. http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html (accessed Jan 2020). 3. Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection. Eur Heart J 2001 Sept;22(18):1642-1681. 4. Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation 2005; 111(6):816. 5. Alspach J. Core Curriculum for Critical Care. 6 ed. Phila, PA: W.B. Saunders Co; 2006. th
6. Bojar R. Manual of Peri-operative Care in Adult Cardiac Surgery. 5 ed. Wiley-Blackwell publishing; 2011. th
7. Hawkins RB, Mehaffey JH, Downs EA, et al. Regional practice patterns and outcomes of surgery for acute type A aortic dissection. Ann Thorac Surg 2017; 104:1275-81. 8. Nienbor CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management. Circulation 2003;108(6):772.
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
9. Pape LA, Awais M, Woznicki EM, et al. Presentation, diagnoses and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection. J Am Coll Cardiol 2015; 66:350-8. 10. Arsalon M, Squiers JJ, Herbert MA, et al. Comparison of outcomes of operative therapy for acute type A aortic dissection provided at high-volume vs low-volume medical centers in North Texas. Am J Cardiol 2017; 119:323-7.
Keep up With APACVS and Specialty News Every Friday. http:// www.multibriefs.com/ briefs/APACVS/
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
CTV Images and Movies
Robotic Assisted Left Lower Lobectomy: A Review of Critical Anatomy & Bedside Assisting Skills Matthew S. Vercauteren, MPAS, PA-C Surgical Services Division, Section of Thoracic Surgery Veteran Affairs Pittsburgh Healthcare System Inderpal S. Sarkaria, MD, MBA Assistant Professor of Cardiothoracic Surgery Vice Chairman, Clinical Affairs Director, Robotic Thoracic Surgery Co- Director, Esophageal and Lung Surgery Institute UPMC Department of Cardiothoracic Surgery
Robotic surgery has been an important technological advancement that has been accepted by many patients and surgical subspecialty communities around the world. In the past two decades, the use of robotics in thoracic surgery has increased significantly and has been shown to be as safe and effective as other minimally invasive surgical techniques. Due to the nature of robotic surgery, the physician assistant may serve as the primary surgical bedside assistant while the surgeon and trainee work at their respective operating consoles. To work independently at the bedside, the Physician Assistant must have a firm grasp of complex thoracic anatomy and have specialized surgical skills to ensure safe and efficient surgery. In this video I will review the steps of a left lower lobectomy, identify critical pulmonary anatomy (including variant vasculature), and demonstrate essential robotic bedside techniques.
Click on the image To view this video
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
APACVS – Top Articles from 2020
Some Of Latest Illinois Coronavirus Deaths Involved People In 20s And 30s; Expert Weighs In WBBM-TV
From April 3: Jenn Orozco, MMS, PA-C, Director of Advanced Practice Providers at Rush University Medical Center, is among experts interviewed in Chicago about hospital COVID-19 response. READ MORE
APACVS 2020 Compensation and Benefits Survey Report Now Available! APACVS From Nov. 20: As the 2020 Pandemic has reshaped the way many of us practice, we have had to depart the usual, protocol driven practice of cardiac, thoracic, and vascular surgery/critical care to care for patients that are outside of our usual day to day life. In his book Resilience, Navy Seal Eric Greitens writes letters of support to a colleague who is suffering from post traumatic stress as a result of his deployments overseas. READ MORE
APACVS Board Discusses Racism and Justice APACVS From June 12: After robust discussion and debate, the leadership of APACVS endorses the American Academy of PAs’ statement, "AAPA Supports the Black Community and Pledges to Combat Racism." We believe creating real and lasting change in our world happens as a community. We pledge to engage with AAPA efforts to address inequality and racism in our community. Our unique perspective as PAs who practice in surgical subspecialties is vital to the success of the entire PA community. We will continue to highlight APACVS efforts as part of the community and will continue to invite all APACVS members to engage as leaders in our organization. READ MORE
The Role of the APP in the Surgical Treatment of AFIB — Earn 2.5 Hours of CME/CEUs APACVS From Sept. 11: APACVS is offering a free 2.5 hour session on the Role of the APP in the Surgical Treatment of AFIB. Visit our Learning center to watch this important program. The session has been accredited for 2.5 hours of CME/ CEUs. READ MORE
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
FDA Approves Ticagrelor DAPT for Patients Without CVD, Stroke History HCP Live From June 5: Thanks to a recent U.S. Food and Drug Administration (FDA) approval, patients now have an additional agent to help reduce the risk of first heart attack or stroke event in patients with coronary artery disease, with ticagrelor (Brilinta). An oral, reversibly binding, direct-acting P2Y12 receptor antagonist, the latest approval is the first regulatory approval for aspirin plus ticagrelor dual antiplatelet therapy in those with a high risk, but no history, of heart attack or stroke, AstraZeneca announced in a statement. READ MORE
Latest from Ischemia: Worse Outcomes in Patients with Intermediate Left Main Disease on CCTA Medscape From June 5: Patients in the landmark ISCHEMIA trial with intermediate left main disease had a greater extent of coronary artery disease on invasive angiography, indicating greater athero sclerotic burden. They also had worse prognosis with a higher risk of cardiovascular events. "Many times, we are looking at results as to whether patients have left main disease or not," Sripal Bangalore, M.D., said during the Society for Cardiovascular Angiography & Interventions virtual annual scientific sessions. READ MORE
APACVS Member Michael E. Champion, DHSc, PA-C, DFAAPA, Asks For Your Help With His Research APACVS From April 24: Michael Champion is working toward a Masters in Medical Science at the University of Oxford in Oxford, England. It is an amazing adventure and opportunity for PAs, which he will describe in his article, "A Texan in Oxford," in the upcoming issue of JAPACVS. In the meantime, you can contribute to the medical literature in our community by telling him your story for his dissertation. Here is his request. READ MORE
Vascular Surgeons Identify Health Concerns That Result from Quarantine Vascular News From June 12: Vascular surgeons from across the U.S. are reporting health impacts on some patients, particularly elderly ones, in quarantine. The Society for Vascular Surgery (SVS) queried vascular surgeons regarding their concerns for patients’ health during the pandemic, and shared the findings as well as suggested solutions for patients with vascular disease who are confined at home. READ MORE
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery
Cardiogenic Shock Spells Poor Outcomes Despite Successful TAVR TCTMD From June 5: TAVR is feasible and associated with high success rates in patients with severe aortic stenosis who present with acute cardiogenic shock, but mortality remains much higher in this group than in the broader high-risk TAVR population, registry data show. READ MORE
Mounting Use of 'Primary' TAVR in Shock from Aortic Stenosis Medscape From June 12: The buzz on transcatheter aortic valve replacement (TAVR) has long focused on its steady expansion to patients at progressively lower levels of surgical risk. But there are patients with aortic stenosis whose overall risk exceeds even the most severe that was addressed in the earliest major trials comparing TAVR with surgical aortic valve replacement. READ MORE
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Journal of the Association of PAs in Cardiothoracic and Vascular Surgery