CA Reports Stroke Rates in Bypass Surgery Data

http://www.healthleadersmedia.com/content/QUA-257919/CA-Reports-Stroke-Rates-in-Bypass-Surgey-Data

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CA Reports Stroke Rates in Bypass Surgery Data
Cheryl Clark, for HealthLeaders Media , October 20, 2010

California has recently become the first state to report hospital data on rate of stroke in patients after coronary artery bypass graft (CABG) surgery, and the results show a wide variation among 121 hospitals.


The new measure comes in the state's regular hospital data report for 2007 on CABG mortality, which has been issued eight times since 2001 when the first report covered hospital performance for 1998-99.

Joe Parker, director of healthcare outcomes for the California Office of Statewide Health Planning and Development, which issued the report, says that stroke was included this time in the CABG data because better hospital practices can reduce the number of patients who develop the complication, a known risk factor in these procedures.

"We want to be selecting something over which there is a possibility of control and improvement by a hospital," he says. "Stroke was selected because it is an important negative outcome of CABG surgery, and one that has a huge impact on families of those who care for stroke victims, as well as on the patients."

Of the 121 hospitals in the state that perform bypass graft surgery, one hospital had the lowest rate of stroke complications, Alta Bates Summit Medical Center, Summit Campus, a 337-bed hospital in Oakland.

Parker says that he visited with Russell Stanten, MD, cardiothoracic surgeon at Alta Bates, to learn what the hospital does to prevent stroke in these patients. He says Stanten replied that the hospital screens each patient for carotid disease, "and if they find it they deal with it prior to the CABG surgery." Additionally, Alta Bates surgeons also make sure the patients have transesophageal echocardiograms performed intraoperatively.

Additionally, Junaid Khan, MD director of cardiovascular services at Alta Bates, says a crucial reason for the hospital's success is in making sure that every anesthesiologist on a CABG case is board certified in echocardiography. The hospital, which does about 800 open heart procedures a year—many of them CABG—also limits the number of anesthesiologists and others who are allowed to work on these patients only "to those who do a lot of them."

"You may have people who are doing 10 cardiac surgeries a year. Ours are doing 100 cardiac cases a year," Khan says. "We also work with the perfusionists to make sure they maintain adequate pressure,"


The state's report says that risk adjusted post-operative stroke rates for five hospitals were worse than average:

1.Los Angeles County Harbor-UCLA Medical Center (4.17%)
2.Tri-City Medical Center in Oceanside (3.97)
3.Sharp Memorial Hospital in San Diego (3.15%)
4.Memorial Medical Center of Modesto (2.63%)
5.Sutter Memorial Hospital in Sacramento (2.43%)
In a letter to the state agency, Robert Adamson, MD, medical director of the cardiac transplant program at Sharp, says that in 2006, "we noted an unusual cluster of six strokes. Each case was individually reviewed and no trends or common causes could be identified," but "strongly influenced our results for the two-year period."

He says that in 2007, the incidence of stroke in this population was half that in 2006 and zero in 2008. "In view of this, we feel that the rating, while accurate in number, does not reflect our current performance in this area."

For Harbor-UCLA, Bassam Omari, MD, chief of the division of cardiothoracic Surgery, wrote the agency explaining that the hospital has discovered discrepancies in risk factors reported for its CABG patients, which "adversely affected our expected mortality and morbidity."

Other reasons for Harbor-UCLA's high rates, he wrote, dealt with the high number of Jehovah's Witnesses "whose beliefs preclude our ability to provide life-saving blood transfusions" and said the hospital failed to adequately count those patients who had a prior stroke, which put them at greater risk.

For bypass graft mortality without stroke, no hospital performed significantly better than the state average. But Enloe Medical Center in Sacramento, Los Angeles Co. Harbor—UCLA Medical Center, St. Joseph's Medical Center in Stockton and Valley Presbyterian Hospital in Van Nuys, performed significantly worse.

The California agency keeps the largest public outcomes database in the country and is an important source of comparative information for performance.


Other significant findings from the report include the following:

•Of the 30,379 patients who underwent isolated CABG surgery, 405 experienced a stroke in which symptoms lasted for 72 hours or longer, a rate of 1.33%, which is close to the national rate of 1.4% reported by the Society of Thoracic Surgeons.
• The operative mortality rate for CABG surgery in the state in 2007 was 2.35%, slightly higher than 2.2% for 2006, but much lower than in the prior three years 3.1%, 3.3% and 2.9%.
•There were 347 operative deaths among the 14,756 CABG surgeries during 2007.
This latest report also scored hospitals on their use of the internal mammary artery (IMA) during CABG procedures, a practice associated with better surgical outcomes but may take longer. Five hospitals had low rates of IMA usage, including Citrus Valley Medical Center in Covina, Dameron Hospital in Stockton, Lakewood Regional Medical Center in Lakewood, Suttter Medical Center in Santa Rosa and Tri-City Medical Center in Oceanside.

Parker says that use of the IMA in bypass graft surgery is longer lasting and is associated with lower mortality, but takes about 15 minutes longer to perform than traditional use of the radial artery or saphenous vein, and that may be why some surgeons fail to use it. In 2007, the state had a 93.7% IMA usage, a 4% increase since 2003.

With its next report the state hopes to add in comparative data on how many CABG patients go into renal failure and require post-operative dialysis, another complication. Renal failure occurs in between 1% and 2% of CABG cases, on average, he says.

Debby Rogers, vice president for Quality and Emergency Services for the California Hospital Association, says her organization is "pleased that they're issuing reports with more recent data." She noted that the reports indicate a distinct "through the years that care is improving" related to CABG mortality.


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Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached at cclark@healthleadersmedia.com.

American Heart Association honors new research grant recipients and leaders in cardiovascular innovation in the Bay Area

FOR IMMEDIATE RELEASE

CONTACTS: Linda Tsai, communications director,
(408) 367-9784; linda.tsai@heart.org


(SAN FRANCISCO) – More than 100 people, including prominent leaders and pioneers in the health and medical community, joined together this week evening to honor the American Heart Association’s newest local recipients of cardiovascular research funding at the Four Seasons San Francisco.

The evening reception, made possible with support from Gilead Sciences Inc., is the first ever gathering dedicated to the Association’s Northern California research grant recipients. It is also honored research recipients from the past decade.

Deepak Srivastava, M.D., President of the American Heart Association’s San Francisco Board of Directors, had this message for the awardees, “Young scientists in the room: Never give up. It does not matter if you are a post-doctoral scholar, a medical student or an undergraduate. There are opportunities for you to pursue your dream.” Dr. Srivastava first received American Heart Association funding early in his career; today he serves as Director of the Gladstone Institute of Cardiovascular Disease at the University of California, San Francisco.

Junaid Khan, M.D., President of the Association’s East Bay Board, also knows the value of an early research grant. “I received funding from the AHA as a medical student and it helped define the direction of my medical career.” Today, Dr. Khan is Managing Partner at East Bay Cardiac Surgery, with hospital affiliations at both Alta Bates Summit Medical Center in Oakland and Doctors Medical Center in San Pablo.

This year’s awardees are recipients of nearly $4 million in grants funded by the American Heart Association’s Western States Affiliate. Including funding from the American Heart Association’s National Center, $28 million in AHA research funds was awarded in the past year to Northern California institutions.

The 34 recipients of 2010 AHA Western States funding are:
Children’s Hospital Oakland Research Institute: Mistuni Ghosh, M.S.
Gladstone Institute of Cardiovascular Disease: Nathalie Gaborit, Ph.D.
Palo Alto Institute for Research and Education, Inc: Patricia Nguyen, M.D.
Stanford University and Stanford University School of Medicine: Marion Buckwalter, Ph.D., M.D.; Cindy Chung, Ph.D.; Shijun Hu, Ph.D.; Kiran Khush, M.D.; Josh Knowles, Ph.D., M.D.; Nick Leeper, M.D.; Merritt Maduke, Ph.D.; Foteini Mourkioti, Ph.D.; Mikyoung Park, M.S.; Valeria Vásquez, Ph.D.; Iqin Xiiong, M.D.; Masayuki Yazawa, Ph.D.; Yaozhong Zou, Ph.D.
University California, San Francisco: Gregory Marcus M.D.; Khanh Nguyen, M.D.; Jose Perez, Ph.D.; Sharon Poisson, M.D.; Sven Reischauer, Ph.D.; Carrie Shiau, B.A.; Jeoung-Sook Shin, Ph.D.; James Smyth, Ph.D.; Samantha Stehbens, Ph.D.; Hua Su, M.D.; Monika Suchanek, Ph.D.; Shantel Weinsheimer, Ph.D.; Yafeng Zhang, Ph.D.
UCSF and San Francisco Veterans Affairs Medical Center: Elaine Tseng, M.D.
University of California, Davis: Colleen Clancy, Ph.D.; Javier López, M.D.; Jon Sack, Ph.D.; Fan Yang, B.S.

Tuesday was also a celebration for the Bay Area’s productive cardiovascular research community and the American Heart Association’s commitment to support it.

In addition to Dr. Khan and Dr. Srivastava, other notable speakers Tuesday night included: José Cisneros, Treasurer for the City and County of San Francisco, and Luiz Belardinelli, M.D., Senior Vice President of Cardiovascular Therapeutics, Gilead Sciences Inc.

Dr. Belardinelli, an American Heart Association grant recipient early in his own career, mentioned the importance of giving back to the community.

Dr. Khan gave special recognition to the following attendees for their dedication to and support of the American Heart Association, including:
Rod Starke, Former Chief Science Officer for the American Heart Association
Fredric B. Kraemer, MD, Western States Affiliate Board Member
Hal Barron, Executive Vice President and Chief Medical Officer at Genentech
Shaun Coughlin, Director, Cardiovascular Research Institute at UCSF
R. Sanders "Sandy" Williams, President of The J. David Gladstone Institutes
Mark Hlatky, Professor of Health Research and Policy and of Medicine at Stanford University
Hans Reiser, Senior Vice President, Medical Affairs, at Gilead Science
Patricia Sprincin, Chair of the American Heart Association’s Heart and Stroke Society
John Woods, Executive Vice President and CFO of Union Bank and Chair of the Bay Area Heart Walk
Amanda Wallis-Blue, Chair of the Patron Committee for the Celebrate with Heart Gala.

These individuals are “true leaders in the world of research and leaders within the American Heart Association,” Dr. Khan said.

The American Heart Association is the second largest single funder of cardiovascular research after the National Institutes of Health. The Association has invested more than $3.2 billion nationally in cardiovascular research since 1949.

Tuesday’s event was the first of what will become an annual celebratory gathering to highlight the lifesaving work quietly being carried out every day by so many members of the Bay Area community.

About the American Heart Association
Founded in 1924, we’re the nation’s oldest and largest voluntary health organization dedicated to building healthier lives, free of heart disease and stroke. To help prevent, treat and defeat these diseases — America’s No. 1 and No. 3 killers — we fund cutting-edge research, conduct lifesaving public and professional educational programs, and advocate to protect public health. To learn more or join us in helping all Americans, call 1-800-AHA-USA1 or visit www.heart.org.

Aortic Valve Replacement (MIS)

Mouth-to-Mouth May Not Save More Lives During CPR, Two Studies Conclude

Mouth-to-Mouth May Not Save More Lives During CPR, Two Studies Conclude
By Arielle Fridson - Jul 28, 2010 2:06 PM PDT Wed Jul 28 21:06:34 UTC 2010

CPR is performed on a dummy. Source: American Heart Association

Hollywood heroics aside, mouth-to- mouth resuscitation does nothing to improve the outcome of CPR, two studies showed. It doesn’t provide any benefit over the chest-pumping procedure, U.S. and Swedish scientists said.

In the research, there was no significant difference in survival for patients who received just chest-compression CPR from bystanders after heart stoppages compared with those who got both that treatment and mouth-to-mouth breathing, according to two papers published today in the New England Journal of Medicine.

While cardiopulmonary resuscitation can double or even triple a patient’s rate of survival, two-thirds of people in cardiac arrest outside a hospital don’t receive CPR, according to the American Heart Association. Bystanders might refrain from acting because they can’t identify cardiac arrest, are afraid of hurting the person, or are averse to mouth-to mouth contact, said Thomas D. Rea, an associate professor of medicine at the University of Washington in Seattle.

“Eliminating mouth-to-mouth from CPR may make a layperson less reticent to act and if they act, they can save a life,” said Rea, the lead author of the U.S. study. “Chest compression alone is simpler and intuitively easier.”

The U.S. researchers considered 1,941 people in cardiac arrest who needed bystanders to perform CPR until an ambulance arrived. The scientists reported finding no significant difference between the 981 patients who received chest compression alone and the 960 who received both that procedure and mouth-to-mouth breathing.

Survival Rates

The first group survived to hospital discharge at a rate of 12.5 percent and the second had an 11 percent survival rate, the scientists wrote. The trials were carried out in two counties in Washington state and in London in 2009. The Laerdal Foundation for Acute Medicine, based in Stavanger, Norway, funded the research.

For the other study, Swedish researchers collected data on 1,276 patients from 2005 to 2009. Of the 620 patients who received chest pumping only, the rate of 30-day survival was 8.7 percent. Of the 656 patients who received both chest pumping and mouth-to-mouth breathing, 7 percent survived the 30-day period. The study was funded by the Swedish Heart-Lung Foundation, based in Stockholm.

Emergency medical services each year treat about 300,000 people in the U.S., according to the Dallas-based heart association. These patients have a less than 8 percent chance of survival. Sudden cardiac arrest is the loss of heart function, breathing and consciousness, according to the Mayo Clinic, based in Rochester, Minnesota. It can be caused by diverse conditions, including heart attack, drowning, choking, and electrocution, or it can happen without any known cause, according to the heart association.

CPR Guidelines

The group, in guidelines published jointly with the Antwerp, Belgium-based International Liaison Committee on Resuscitation, has recommended hands-only CPR since April 2008, said Junaid Khan, president of the association’s East Bay Division and a cardiothoracic surgeon at Alta Bates Summit Medical Center in Oakland.

“These two studies are the first randomized control trial in this area, which constitutes the highest level of evidence that physicians trust,” Khan said in a telephone interview. “This will enable the strongest level of recommendation.”

Association officials now are “probably going to modify their statements in a more forceful way based on this study and other similar ones,” most likely by the end of this year, said Myron L. Weisfeldt, director of the Department of Medicine at John Hopkins Hospital in Baltimore.

Weisfeldt wrote an editorial on CPR, urging more research, that was published in the medical journal along with the studies.

Rescue Training

While the studies may cause instructors to place less emphasis on mouth-to-mouth techniques, it would be a mistake to eliminate them from CPR courses, Weisfeldt wrote in the editorial. The technique is effective against respiratory failure, the most common cause of cardiac arrest in children, he wrote. Each year, about 5,800 children under 18 suffer cardiac arrest in the U.S., according to the heart association.

MIS Surgery w/ Edwards IMRand MC3 Rings Videos

Aortic Stenosis Still Goes Under-treated Despite Lower Risk Surgical Procedures

Aortic Stenosis Still Goes Under-treated Despite Lower Risk Surgical Procedures — Junaid Khan, M.D.

In the United States, up to four percent of the population over the age of 65 is affected by aortic stenosis. Yet, for every one patient treated for this condition, it is estimated that there is one patient who goes untreated. The consequences of not treating aortic stenosis are dire. The average survival of patients with the condition who are experiencing symptoms and do not receive treatment is only two years, and the five-year survival rate is less than 20 percent. Unfortunately many of these patients are not referred for surgical consultation because severity of the disease is underestimated or the operative risk is overestimated by nonsurgeons (Surgeons use the STS national database to calculate predicted risk of mortality). To better understand the prevalence of unoperated severe aortic stenosis within the Oakland community, two local cardiology groups participated with the Alta Bates Summit Research and Education Institute analyzing 101 patients with clinically severe aortic stenosis. The results were surprising: 73% of the patient cohort was not referred for surgical intervention, despite half of them reporting symptoms related to AS. Eleven of these patients died within 11 months following their last echocardiogram.

Outcomes
Aortic valve replacement surgery has advanced over the past decade. Cutting-edge procedural techniques and innovations have led to an average mortality below 5% nationwide and at the Summit Campus, even patients in their eighties with comorbidities have a lower than expected surgical risk and typically gain an additional 6 to 8 years of quality life. Age is not a contraindication for surgery and more of these patients should be considered for surgical intervention. In addition, minimally invasive techniques like port access can result in faster recovery for patients. As surgical techniques continue to improve and risk declines, efforts must continue to reduce the number of untreated patients with severe valve disease.

Routine EKG testing of young athletes' hearts could save lives, Stanford study says

Routine EKG testing of young athletes' hearts could save lives, Stanford study says

By Sandy Kleffman

Contra Costa Times

Posted: 03/01/2010 04:30:31 PM PST

Updated: 03/01/2010 05:32:57 PM PST

Using electrocardiograms to test the hearts of young athletes before they participate in sports could be a cost-effective way to reduce sudden deaths, a Stanford University study concludes.

Questions about what type of pre-screening to require have drawn heightened interest since two seemingly healthy East Bay high school students suddenly collapsed during basketball games earlier this year.

One student died. The other was hospitalized and later released with a diagnosis of an electrical abnormality in his heart.

The California Interscholastic Federation, which oversees high school sports, requires all students to have a physical exam, including providing a family health history, before participating. That is the extent of screening for most students.

EKGs can detect signs of hypertrophic cardiomyopathy, a genetic defect that causes thickening of the heart muscle and can lead to dangerous heart rhythms that can stop the organ. Nationally, it is estimated that one in 500 people have this condition, a common cause of sudden deaths in young athletes.

But many experts consider routine EKG screening too expensive, especially since sudden deaths remain rare, involving fewer than 100 young athletes each year in the United States. A panel of the American Heart Association estimated mandatory EKG screening for all middle school and high school athletes would cost $2 billion annually.

The Stanford study, published today in the Annals of Internal Medicine, challenges such opinions and encourages people to re-examine the issues.

Combining routine EKG screening with a family health history and physical exam "would save the most lives at a cost that is generally acceptable for the U.S. health care system," said Dr. Matthew Wheeler, a fellow in cardiovascular medicine at Stanford and a lead author of the study.

EKG screening would cost about $88 per athlete, including follow-up tests, the study estimates. The test takes about 10 minutes, with five minutes more for a physician to examine the results.

For every 1,000 athletes screened, it would save the equivalent of two years of life, the study concludes. The expense for saving one year of life would be $42,900. Anything under $50,000 is generally considered cost-effective in health care, the study notes.

In Italy, where routine EKG screening of young athletes has been mandatory since 1982, sudden deaths during competitions have plunged nearly 90 percent since testing began, Wheeler said.

Yet many experts continue to have reservations about routine EKG screening.

EKGs do not pick up all heart problems, notes Dr. Junaid Khan, director of cardiac services at Alta Bates Summit Medical Center in Oakland. He worries that after getting a clean bill of health, students may no longer be concerned if they start to feel faint, have shortness of breath or develop chest pain.

"They could ignore symptoms," said Khan, president of the East Bay division of the American Heart Association. "That's a real issue."

Khan added that there would be an emotional toll on students who have false positives. They might become unduly worried and might be denied participation in sports until additional tests rule out heart problems.

The best way to save lives, Khan argues, would be to have more defibrillators at schools and to ensure that adults know how to use the equipment and to do CPR.

Pat Middendorf, athletic director at Clayton Valley High School in Concord, which will soon receive defibrillators, said the $88 expense for an EKG could be a "huge burden" for many families and prevent some students from participating.

"I don't see the state or federal government picking up the cost of it," she said. "Would it be covered by insurance? Now that's a different story."

In an editorial accompanying the study in the Annals of Internal Medicine, Dr. Barry Maron of the Minneapolis Heart Institute Foundation calls mandatory EKG screening impractical at this time. He questioned whether there would be enough doctors to perform the tests, whether students would argue that their liberties had been infringed upon if they are denied the ability to play sports, and whether nonathletes could argue that they should also receive screening.

Wheeler counters that a massive, nationwide program is not necessary and that local school districts could consider requiring EKGs for their students.

Contact Sandy Kleffman at 925-943-8249.