Academic Appointments

Honors & Awards

  • Graduation with Distinction, Northwestern University Medical School (1985)
  • Alpha Omega Alpha, Alpha Omega Alpha (1985)
  • Donald B. Doty Award, Western Thoracic Surgical Association (2006,2012)
  • Teaching Award, Henry J. Kaiser Family Foundation Award for Excellence in Clinical Teaching, Stanford University Medical School (2014)
  • Simulation Award (Boot Camp), Thoracic Surgery Directors Association (2016)
  • Simulation Grant, Thoracic Surgery Foundation for Research and Education (2009)

Boards, Advisory Committees, Professional Organizations

  • Director, American Board of Thoracic Surgery (2015 - Present)
  • Chair, ABTS Cardiac Consultant Subcommittee (2017 - Present)
  • Examiner, ABTS Certifying Examination (2011 - Present)
  • President, Western Thoracic Surgical Association (2016 - 2017)
  • Vice-President, Western Thoracic Surgical Association (2015 - 2016)
  • Council Member, Western Thoracic Surgical Association (2011 - 2014)
  • Member, Program Committee, Western Thoracic Surgical Association (2002 - 2006)
  • Associate Editor, Education, Journal of Thoracic and Cardiovascular Surgery (2017 - Present)
  • Member, Editorial Board, Journal of Thoracic and Cardiovascular Surgery (2011 - 2017)
  • Member, Advisory Panel on CT Surgery, American College of Surgeons (2016 - Present)
  • Council on Quality, Research and Patient Safety, Society of Thoracic Surgeons (2015 - Present)
  • Council on Education and Member Services Operating Board, Society of Thoracic Surgeons (2011 - 2015)
  • Chair, Workforce on Patient Safety, Society of Thoracic Surgeons (2015 - Present)
  • Member, Workforce on Patient Safety, Society of Thoracic Surgeons (2008 - Present)
  • Member, Thoracic Surgery Working Group, ACGME Milestones (2012 - 2013)
  • Co-director, Boot Camp, Thoracic Surgery Directors Association (2009 - Present)
  • Member, Joint Council on Thoracic Surgery Education Advisory Board (2008 - 2016)
  • Chair, Simulation Committee, Joint Council on Thoracic Surgery Education (2008 - 2016)
  • Member, Editorial Board, Thoracic Surgery Curriculum, Joint Council on Thoracic Surgery Education (2012 - 2016)
  • Secretary, Bay Area Society of Thoracic Surgeons (2011 - Present)
  • Council Member, Bay Area Society of Thoracic Surgeons (2008 - Present)

Professional Education

  • B.S., Northwestern University, Medicine (1983)
  • M.D., Northwestern Univ. Med. School, Medicine (1985)

Research & Scholarship

Current Research and Scholarly Interests

Cardiac surgery education and simulation-based learning, coronary artery bypass surgery, cardiac valve disease


2017-18 Courses

Graduate and Fellowship Programs


All Publications

  • Decision Making, Evidence, and Practice ANNALS OF THORACIC SURGERY Lobdell, K. W., Rose, G. A., Mishra, A. K., Sanchez, J. A., Fann, J. I. 2018; 105 (4): 994–99
  • Leadership Oversight for Patient Safety Programs: An Essential Element. The Annals of thoracic surgery Moffatt-Bruce, S., Clark, S., DiMaio, M., Fann, J. 2018; 105 (2): 351–56


    Leadership in the realm of quality oversight and endorsing a culture of safety is paramount. The stakeholders, ranging from the surgeons to the Chair of the Board have to be engaged and really understand the importance of leadership support. Clarity of leadership support, innovation in process improvement as well as performance management and accountability are the foundational components of a strong culture of safety. Alignment of all stakeholders and continuous improvement that is supported by leadership will ensure the best outcomes for surgical patients.

    View details for DOI 10.1016/j.athoracsur.2017.11.021

    View details for PubMedID 29275825

  • The long and winding route. The Journal of thoracic and cardiovascular surgery Fann, J. I. 2018; 155 (4): 1578–79

    View details for DOI 10.1016/j.jtcvs.2017.12.059

    View details for PubMedID 29331182

  • Investigating the Causes of Adverse Events. Annals of thoracic surgery Sanchez, J. A., Lobdell, K. W., Moffatt-Bruce, S. D., Fann, J. I. 2017; 103 (6): 1693-1699

    View details for DOI 10.1016/j.athoracsur.2017.04.001

    View details for PubMedID 28528027

  • The more things change. journal of thoracic and cardiovascular surgery Fann, J. I. 2017

    View details for DOI 10.1016/j.jtcvs.2017.03.124

    View details for PubMedID 28442148

  • Simulation-Based Training in Cardiac Surgery. Annals of thoracic surgery Feins, R. H., Burkhart, H. M., Conte, J. V., Coore, D. N., Fann, J. I., Hicks, G. L., Nesbitt, J. C., Ramphal, P. S., Schiro, S. E., Shen, K. R., Sridhar, A., Stewart, P. W., Walker, J. D., Mokadam, N. A. 2017; 103 (1): 312-321


    Operating room surgical training has significant limitations. This study hypothesized that some skills could be learned efficiently and safely by using simulation with component task training, deliberate practice, progressive complexity, and experienced coaching to produce safer cardiac surgeons.Training modules included cardiopulmonary bypass, coronary artery bypass grafting, aortic valve replacement, massive air embolism, acute intraoperative aortic dissection, and sudden deterioration in cardiac function. Using deliberate practice, first-year cardiothoracic surgical residents at eight institutions were trained and evaluated on component tasks for each module and later on full cardiac operations. Evaluations were based on five-point Likert-scale tools indexed by module, session, task items, and repetitions. Statistical analyses relied on generalized linear model estimation and corresponding confidence intervals.The 27 residents who participated demonstrated improvement with practice repetitions resulting in excellent final scores per module (mean ± two SEs): cardiopulmonary bypass, 4.80 ± 0.12; coronary artery bypass grafting, 4.41 ± 0.19; aortic valve replacement, 4.51 ± 0.20; massive air embolism, 0.68 ± 0.14; acute intraoperative aortic dissection, 4.52 ± 0.17; and sudden deterioration in cardiac function, 4.76 ± 0.16. The transient detrimental effect of time away from training was also evident.Overall performance in component tasks and complete cardiac surgical procedures improved during simulation-based training. Simulation-based training imparts skill sets for management of adverse events and can help produce safer surgeons.

    View details for DOI 10.1016/j.athoracsur.2016.06.062

    View details for PubMedID 27570162

  • The seasons of a thoracic surgeon. The Journal of thoracic and cardiovascular surgery Fann, J. I. 2017; 154 (5): 1477–86

    View details for DOI 10.1016/j.jtcvs.2017.07.013

    View details for PubMedID 28822569

  • Physician Burnout: Are We Treating the Symptoms Instead of the Disease? The Annals of thoracic surgery Squiers, J. J., Lobdell, K. W., Fann, J. I., DiMaio, J. M. 2017; 104 (4): 1117–22


    Despite increasing recognition of physician burnout, its incidence has only increased in recent years, with nearly half of physicians suffering from symptoms of burnout in the most recent surveys. Unfortunately, most burnout research has focused on its profound prevalence rather than seeking to identify the root cause of the burnout epidemic. Health care organizations throughout the United States are implementing committees and support groups in an attempt to reduce burnout among their physicians, but these efforts are typically focused on increasing resilience and wellness among participants rather than combating problematic changes in how medicine is practiced by physicians in the current era. This report provides a brief review of the current literature on the syndrome of burnout, a summary of several institutional approaches to combating burnout, and a call for a shift in the focus of these efforts toward one proposed root cause of burnout.

    View details for DOI 10.1016/j.athoracsur.2017.08.009

    View details for PubMedID 28935298

  • Is "As Good" Good Enough? Seminars in thoracic and cardiovascular surgery Fann, J. I. 2017

    View details for DOI 10.1053/j.semtcvs.2017.11.006

    View details for PubMedID 29191618

  • Experience With the Cardiac Surgery Simulation Curriculum: Results of the Resident and Faculty Survey. Annals of thoracic surgery Mokadam, N. A., Fann, J. I., Hicks, G. L., Nesbitt, J. C., Burkhart, H. M., Conte, J. V., Coore, D. N., Ramphal, P. S., Shen, K. R., Walker, J. D., Feins, R. H. 2017; 103 (1): 322-328


    The Cardiac Surgery Simulation Curriculum was developed at 8 institutions from 2010 to 2013. A total of 27 residents were trained by 18 faculty members. A survey was conducted to gain insight into the initial experience.Residents and faculty were sent a 72- and 68-question survey, respectively. In addition to demographic information, participants reported their view of the overall impact of the curriculum. Focused investigation into each of the 6 modules was obtained. Participants evaluated the value of the specific simulators used. Institutional biases regarding implementation of the curriculum were evaluated.Twenty (74%) residents and 14 (78%) faculty responded. The majority (70%) of residents completed this training in their first and second year of traditional-track programs. The modules were well regarded with no respondents having an unfavorable view. Both residents and faculty found low, moderate, and high fidelity simulators to be extremely useful, with particular emphasis on utility of high fidelity components. The vast majority of residents (85%) and faculty (100%) felt more comfortable in the resident skill set and performance in the operating room. Simulation of rare adverse events allowed for development of multidisciplinary teams to address them. At most institutions, the conduct of this curriculum took precedence over clinical obligations (64%).The Cardiac Surgery Simulation Curriculum was implemented with robust adoption among the investigating centers. Both residents and faculty viewed the modules favorably. Using this curriculum, participants indicated an improvement in resident technical skills and were enthusiastic about training in adverse events and crisis management.

    View details for DOI 10.1016/j.athoracsur.2016.06.074

    View details for PubMedID 27570163

  • Historical perspectives of The American Association for Thoracic Surgery: Delos M. Cosgrove, MD (1940-) JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I., Moon, M. R. 2016; 152 (6): 1471-1474

    View details for DOI 10.1016/j.jtcvs.2016.08.006

    View details for Web of Science ID 000390046900009

    View details for PubMedID 27597749

  • Impact of Moodle-Based Online Curriculum on Thoracic Surgery In-Training Examination Scores. Annals of thoracic surgery Antonoff, M. B., Verrier, E. D., Allen, M. S., Aloia, L., Baker, C., Fann, J. I., Iannettoni, M. D., Yang, S. C., Vaporciyan, A. A. 2016; 102 (4): 1381-1386


    The feasibility and efficacy of a web-based curriculum in supplementing thoracic surgical training was previously shown. However, the impact of curricular participation on validated knowledge tests remains unknown. We compared in-service training examination (ITE) results among trainees, stratified by curricular use.The national online curriculum was implemented in August 2013. We retrospectively reviewed trainees who participated in thoracic surgical training programs in both 2012 to 2013 and 2013 to 2014. Scores from the 2013 and 2014 ITEs were obtained, and curricular usage data were collected from site analytics. Trainees were separated into three groups according to 2013 ITE scores; within each group, changes in score for high- versus low-volume users were compared.187 trainees took the ITE both years, with exposure to the online curriculum during only the second year. High-volume users' scores trended toward greater improvement than scores of low-volume users (+18.2% versus +13.0%, p = 0.199). When stratified by 2013 score, the lowest scoring quartile improved substantially, and the highest scoring quartile improved modestly, regardless of curricular use. However, for those individuals who achieved mid-range scores in 2013, there was a trend toward much greater improvement in score with heavier use of the curriculum (+17.0% versus +7.0%, p = 0.094).Among trainees who had access to the novel online curriculum during the second of 2 consecutive years, we evaluated the impact of curricular participation on ITE scores. The effect appears to be most pronounced in individuals with mid-range scores, in whom high curricular use led to the greatest improvement.

    View details for DOI 10.1016/j.athoracsur.2016.03.100

    View details for PubMedID 27262911

  • "What's the Risk?" Assessing and Mitigating Risk in Cardiothoracic Surgery. Annals of thoracic surgery Lobdell, K. W., Fann, J. I., Sanchez, J. A. 2016; 102 (4): 1052-1058

    View details for DOI 10.1016/j.athoracsur.2016.08.051

    View details for PubMedID 27596918

  • Patient Safety: Disclosure of Medical Errors and Risk Mitigation. Annals of thoracic surgery Moffatt-Bruce, S. D., Ferdinand, F. D., Fann, J. I. 2016; 102 (2): 358-362

    View details for DOI 10.1016/j.athoracsur.2016.06.033

    View details for PubMedID 27373188

  • Human Factors and Human Nature in Cardiothoracic Surgery ANNALS OF THORACIC SURGERY Fann, J. I., Moffatt-Bruce, S. D., DiMaio, J. M., Sanchez, J. A. 2016; 101 (6): 2059-2066
  • Our New Reality of Public Reporting: Shame Rather Than Blame? ANNALS OF THORACIC SURGERY Moffatt-Bruce, S. D., Nguyen, M. C., Fann, J. I., Westaby, S. 2016; 101 (4): 1255-1261
  • Creation and Global Deployment of a Mobile, Application-Based Cognitive Simulator for Cardiac Surgical Procedures. Seminars in thoracic and cardiovascular surgery Brewer, Z. E., Ogden, W. D., Fann, J. I., Burdon, T. A., Sheikh, A. Y. 2016; 28 (1): 1-9


    Several modern learning frameworks (eg, cognitive apprenticeship, anchored instruction, and situated cognition) posit the utility of nontraditional methods for effective experiential learning. Thus, development of novel educational tools emphasizing the cognitive framework of operative sequences may be of benefit to surgical trainees. We propose the development and global deployment of an effective, mobile cognitive cardiac surgical simulator. In methods, 16 preclinical medical students were assessed. Overall, 4 separate surgical modules (sternotomy, cannulation, decannulation, and sternal closure) were created utilizing the Touch Surgery (London, UK) platform. Modules were made available to download free of charge for use on mobile devices. Usage data were collected over a 6-month period. Educational efficacy of the modules was evaluated by randomizing a cohort of medical students to either module usage or traditional, reading-based self-study, followed by a multiple-choice learning assessment tool. In results, downloads of the simulator achieved global penetrance, with highest usage in the USA, Brazil, Italy, UK, and India. Overall, 5368 unique users conducted a total of 1971 hours of simulation. Evaluation of the medical student cohort revealed significantly higher assessment scores in those randomized to module use versus traditional reading (75% ± 9% vs 61% ± 7%, respectively; P < 0.05). In conclusion, this study represents the first effort to create a mobile, interactive cognitive simulator for cardiac surgery. Simulators of this type may be effective for the training and assessment of surgical students. We investigated whether an interactive, mobile-computing-based cognitive task simulator for cardiac surgery could be developed, deployed, and validated. Our findings suggest that such simulators may be a useful learning tool.

    View details for DOI 10.1053/j.semtcvs.2016.02.006

    View details for PubMedID 27568126

  • The Society of Thoracic Surgeons Expert Consensus Statement: A Tool Kit to Assist Thoracic Surgeons Seeking Privileging to Use New Technology and Perform Advanced Procedures in General Thoracic Surgery ANNALS OF THORACIC SURGERY Blackmon, S. H., Cooke, D. T., Whyte, R., Miller, D., Cerfolio, R., Farjah, F., Rocco, G., Blum, M., Hazelrigg, S., Howington, J., Low, D., Swanson, S., Fann, J. I., Ikonomidis, J. S., Wright, C., Grondin, S. C. 2016; 101 (3): 1230-1237
  • Patient Safety Science in Cardiothoracic Surgery: An Overview ANNALS OF THORACIC SURGERY Sanchez, J. A., Ferdinand, F. D., Fann, J. I. 2016; 101 (2): 426-433
  • Gamification in thoracic surgical education: Using competition to fuel performance JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Mokadam, N. A., Lee, R., Vaporciyan, A. A., Walker, J. D., Cerfolio, R. J., Hermsen, J. L., Baker, C. J., Mark, R., Aloia, L., Enter, D. H., Carpenter, A. J., Moon, M. R., Verrier, E. D., Fann, J. I. 2015; 150 (5): 1052-1058

    View details for DOI 10.1016/j.jtcvs.2015.07.064

    View details for Web of Science ID 000365038900021

    View details for PubMedID 26318012

  • "Top Gun" Competition: Motivation and Practice Narrows the Technical Skill Gap Among New Cardiothoracic Surgery Residents ANNALS OF THORACIC SURGERY Enter, D. H., Lee, R., Fann, J. I., Hicks, G. L., Verrier, E. D., Mark, R., Lou, X., Mokadam, N. A. 2015; 99 (3): 870-876


    Adoption of simulation skills training in cardiothoracic (CT) surgery remains a challenge. This study sought to determine whether a "Top Gun" competition would encourage simulator use and improve technical skills among first-year CT residents.A coronary anastomosis simulation module with instructional video was sent to 96 first-year CT residents in traditional programs who were then invited to participate in a Top Gun competition. Residents uploaded a video recording of their baseline anastomosis using the simulator. After 6 weeks of practice under faculty supervision, each trainee uploaded a final video. All submissions were rated in blinded fashion by three CT surgeons. Twelve components were scored on a 5-point Likert scale (1 = poor; 5 = excellent); also, an overall pass-fail grade was given. Five trainees with the highest final scores were invited to compete at a live Top Gun competition.Seventeen trainees submitted a baseline anastomosis video for evaluation; 15 submitted a final video. Overall average scores improved from 3.24 ± 0.61 to 4.01 ± 0.33 (p < 0.001). Performance of the bottom 50% increased (1.11 ± 0.57) relative to the top 50% (0.43 ± 0.31), resulting in no detectable score difference after training (p = 0.14). Overall average time (minutes:seconds) decreased from 11:10 (range, 5:56 to 18:58) to 9:04 (range, 5:52 to 16:23; p < 0.01). Residents achieving a pass from all three raters increased from 13% (2 of 15) to 73% (11 of 15; p < 0.002). Thirteen of 15 residents completed a survey. Residents performed an average of 23 anastomoses (range, 10 to 40). The majority (10 of 13) agreed or strongly agreed that practicing on simulators will improve a trainee's technical skill acquisition.Focused training results in improved technical skills in vessel anastomosis, especially for residents with lower baseline skills. Simulation, as with any educational endeavor, requires the motivation of the trainee, commitment of the faculty educator, and a defined training curriculum.

    View details for DOI 10.1016/j.athoracsur.2014.09.051

    View details for Web of Science ID 000350570800030

    View details for PubMedID 25595829

  • Training less-experienced faculty improves reliability of skills assessment in cardiac surgery JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Lou, X., Lee, R., Feins, R. H., Enter, D., Hicks, G. L., Verrier, E. D., Fann, J. I. 2014; 148 (6): 2491-U1107


    Previous work has demonstrated high inter-rater reliability in the objective assessment of simulated anastomoses among experienced educators. We evaluated the inter-rater reliability of less-experienced educators and the impact of focused training with a video-embedded coronary anastomosis assessment tool.Nine less-experienced cardiothoracic surgery faculty members from different institutions evaluated 2 videos of simulated coronary anastomoses (1 by a medical student and 1 by a resident) at the Thoracic Surgery Directors Association Boot Camp. They then underwent a 30-minute training session using an assessment tool with embedded videos to anchor rating scores for 10 components of coronary artery anastomosis. Afterward, they evaluated 2 videos of a different student and resident performing the task. Components were scored on a 1 to 5 Likert scale, yielding an average composite score. Inter-rater reliabilities of component and composite scores were assessed using intraclass correlation coefficients (ICCs) and overall pass/fail ratings with kappa.All components of the assessment tool exhibited improvement in reliability, with 4 (bite, needle holder use, needle angles, and hand mechanics) improving the most from poor (ICC range, 0.09-0.48) to strong (ICC range, 0.80-0.90) agreement. After training, inter-rater reliabilities for composite scores improved from moderate (ICC, 0.76) to strong (ICC, 0.90) agreement, and for overall pass/fail ratings, from poor (kappa = 0.20) to moderate (kappa = 0.78) agreement.Focused, video-based anchor training facilitates greater inter-rater reliability in the objective assessment of simulated coronary anastomoses. Among raters with less teaching experience, such training may be needed before objective evaluation of technical skills.

    View details for DOI 10.1016/j.jtcvs.2014.09.017

    View details for Web of Science ID 000345686100015

    View details for PubMedID 25308119

  • Individual differences in field independence influence the ability to determine accurate needle angles JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Sheikh, A. Y., Keehner, M., Walker, A., Chang, P. A., Burdon, T. A., Fann, J. I. 2014; 148 (5): 1804-1810
  • Individual differences in field independence influence the ability to determine accurate needle angles. journal of thoracic and cardiovascular surgery Sheikh, A. Y., Keehner, M., Walker, A., Chang, P. A., Burdon, T. A., Fann, J. I. 2014; 148 (5): 1804-1810


    "Field dependence" is used in cognitive psychology to describe an individual's tendency to be visually distracted by the surrounding environment. Notwithstanding the role of field dependence in contexts in which spatial judgment is important, such as piloting an aircraft, to date, studies linking field dependence to surgical skills have been limited. We evaluated whether field dependence correlates with an ability to anticipate appropriate needle angles in a simulated setting.Trainees underwent field dependence testing and then participated in a surgical skills exercise. Correlations between field dependence and surgical skill were computed. Specifically, cardiothoracic surgery residents (n = 11) took a battery of cognitive examinations to assess general reasoning and visuospatial judgment. Two written tests, the Rod and Frame test and the Judgment of Line Orientation test, measured the degree of field dependence. The subjects then underwent surgical skills testing. Using a standard needle driver, the participants placed curved needles into a cylindrical silicone mitral valve model with 10 premarked needle entry and exit sites. The components assessed included the ability to load a needle on driver at the appropriate angle.The test results showed a parametric distribution, with internal cognitive testing controls demonstrating valid testing techniques and methods. Performance on the cognitive tests measuring spatial judgment and field dependence correlated significantly with skill at determining the appropriate needle angle load in an inverse fashion (Judgment of Line Orientation test, r = 0.61, P < .05; Rod and Frame test, r = -0.52, P = .05), suggesting that residents who were not distracted by surrounding objects performed better. Performance on the cognitive examinations did not correlate with resident training level.Although our study was of a small cohort, the findings suggest that individuals described as field independent (not easily distracted by external visual cues) might possess improved ability to determine appropriate needle angle loads compared with field-dependent individuals. Additional studies examining the role field dependence might play in the acquisition and execution of surgical tasks are warranted.

    View details for DOI 10.1016/j.jtcvs.2014.05.008

    View details for PubMedID 24928261

  • Integrated surgical residency initiative: implications for cardiothoracic surgery. Seminars in thoracic and cardiovascular surgery Ikonomidis, J. S., Crawford, F. A., Fann, J. I. 2014; 26 (1): 14-23


    The history, conceptualization, and implementation of the integrated six year cardiothoracic residency paradigm is discussed. Emphasis is placed of critcal logistical points, as well as the challenges associated with obtaining operative case requirements. Strategies for providing and monitoring didactic and technical skills education are presented.

    View details for DOI 10.1053/j.semtcvs.2014.02.003

    View details for PubMedID 24952753

  • "Boot Camp" Simulator Training in Open Hilar Dissection in Early Cardiothoracic Surgical Residency ANNALS OF THORACIC SURGERY Macfie, R. C., Webel, A. D., Nesbitt, J. C., Fann, J. I., Hicks, G. L., Feins, R. H. 2014; 97 (1): 161-166


    We evaluated focused training in lung hilar dissection with a reanimated porcine lung model in the boot camp setting.A total of 64 first-year cardiothoracic surgical residents participated in four consecutive hours devoted to training in open hilar dissection as part of the Thoracic Surgical Directors Association boot camps. Each resident participated in two open hilar dissections. Component tasks were assessed on a 5-point rating scale for the first and second dissections.Immediate assessment performed after completion of the session showed improvements in all graded components. The mean total score on a 50-point scale improved significantly between the first and second repetition (36.03 ± 7.03 to 41.16 ± 6.95; p = 0.001).Focused massed (single-session) practice in the boot camp setting improved the ability of residents to perform hilar dissection on simulators using reanimated porcine lung models. Given these early successes in massed simulation-based surgical education, there is good reason to expect that deliberate and distributed practice on similar simulators would improve resident education in cardiothoracic surgery.

    View details for DOI 10.1016/j.athoracsur.2013.07.074

    View details for Web of Science ID 000329155900033

    View details for PubMedID 24090574

  • Cardiothoracic surgery residency training: Past, present, and future JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Vaporciyan, A. A., Yang, S. C., Baker, C. J., Fann, J. I., Verrier, E. D. 2013; 146 (4): 759-767


    A dramatic transformation of cardiothoracic surgical education has evolved over the past few decades.We begin by presenting recognized catalysts of this change, organized by whom they primarily affect: the trainees, the trainers, and the profession as a whole. Our trainees' prior training is different, and their current demographics and priorities have changed. There is less incentive to teach, with time-honored traditions of education inadequate to meet the needs of trainees. Concurrently, our profession has to adjust to new regulations, increasing financial constraints, and an expanding body of knowledge and technology. To address these issues requires developing new models of education and assessment that can thrive in today's environment. We discuss efforts in the United States and abroad, including new training paradigms ranging from restructuring existing models to novel approaches (eg, competency-based training). Training tools are being developed, such as online instruction, simulation-based learning, and regular student-centered assessments. Finally, models that recognize and reward teaching as a scholarly activity are being implemented.Like the radical advances we have witnessed in surgical therapy, surgical education requires creative and perhaps disruptive changes if we are to continue to produce well-trained additions to our professional ranks.

    View details for DOI 10.1016/j.jtcvs.2013.06.004

    View details for Web of Science ID 000324481400016

    View details for PubMedID 23870155

  • The Joint Council on Thoracic Surgery Education Coronary Artery Assessment Tool Has High Interrater Reliability 49th Annual Meeting of the Society-of-Thoracic-Surgeons Lee, R., Enter, D., Lou, X., Feins, R. H., Hicks, G. L., Gasparri, M., Takayama, H., Young, J. N., Calhoon, J. H., Crawford, F. A., Mokadam, N. A., Fann, J. I. ELSEVIER SCIENCE INC. 2013: 2064–70


    Barriers to incorporation of simulation in cardiothoracic surgery training include lack of standardized, validated objective assessment tools. Our aim was to measure interrater reliability and internal consistency reliability of a coronary anastomosis assessment tool created by the Joint Council on Thoracic Surgery Education.Ten attending surgeons from different cardiothoracic residency programs evaluated nine video recordings of 5 individuals (1 medical student, 1 resident, 1 fellow, 2 attendings) performing coronary anastomoses on two simulation models, including synthetic graft task station (low fidelity) and porcine explant (high fidelity), as well as in the operative setting. All raters, blinded to operator identity, scored 13 assessment items on a 1 to 5 (low to high) scale. Each performance also received an overall pass/fail determination. Interrater reliability and internal consistency were assessed as intraclass correlation coefficients and Cronbach's α, respectively.Both interrater reliability and internal consistency were high for all three models (intraclass correlation coefficients = 0.98, 0.99, and 0.94, and Cronbach's α = 0.99, 0.98, and 0.97 for low fidelity, high fidelity, and operative setting, respectively). Interrater reliability for overall pass/fail determination using κ were 0.54, 0.86, 0.15 for low fidelity, high fidelity, and operative setting, respectively.Even without instruction on the assessment tool, experienced surgeons achieved high interrater reliability. Future resident training and evaluation may benefit from utilization of this tool for formative feedback in the simulated and operative environments. However, summative assessment in the operative setting will require further standardization and anchoring.

    View details for DOI 10.1016/j.athoracsur.2012.10.090

    View details for Web of Science ID 000319335400042

    View details for PubMedID 23706430

  • Invited commentary. Annals of thoracic surgery Fann, J. I. 2013; 95 (2): 633-634

    View details for DOI 10.1016/j.athoracsur.2012.10.009

    View details for PubMedID 23336875

  • Teaching behaviors in the cardiac surgery simulation environment JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I., Sullivan, M. E., Skeff, K. M., Stratos, G. A., Walker, J. D., Grossi, E. A., Verrier, E. D., Hicks, G. L., Feins, R. H. 2013; 145 (1): 45-53


    To understand how teaching behaviors contribute to simulation-based learning, we used a 7-category educational framework to assess the teaching behaviors used in basic skills training.Twenty-four first-year cardiothoracic surgery residents and 20 faculty participated in the Boot Camp vessel anastomosis sessions. A portable chest model with synthetic graft and target vessels and a tissue-based porcine model simulated coronary artery anastomosis. After each 2-hour session on days 1 and 2, residents assessed teaching behaviors of faculty using a 20-item questionnaire based on the 5-point Likert scale. After session on day 1, faculty completed a self-assessment questionnaire. At 3 months, faculty completed self-assessment questionnaires regarding teaching behaviors in simulation and clinical settings. Each questionnaire item represents 1 or more teaching categories: "learning climate," "control of session," "communication of goals," "promoting understanding and retention," "evaluation," "feedback," and "self-directed learning."Generally, resident ratings indicated that faculty showed positive teaching behaviors. Faculty self-assessment ratings were all lower (P < .025) than those assigned to them by the residents except for 1 component representative of "feedback," which approached significance (P = .04); 2 items, representative of "promoting understanding and retention" and "evaluation", had mean scores of less than 3. At 3 months, compared with self-assessment at Boot Camp, faculty ratings suggested improved teaching behaviors in their simulation settings in the following: "learning climate," "control of session," "communication of goals," "promoting understanding and retention," and "evaluation." The simulation environment was perceived as more positive for technical skills training in certain aspects compared with clinical setting: instructor reviewed function and operation of equipment with learner before session (representative of "promoting understanding and retention") and instructor allowed the learner ample time to practice (representative of "control of session" and "promoting understanding and retention") (P < .025).Simulation-based skills training is perceived by residents to be associated with positive teaching behaviors. Faculty self-ratings indicate that they do not always use many of these teaching behaviors and that their performance can be improved. The simulation setting may provide greater opportunity for positive teaching behaviors compared with the clinical environment.

    View details for DOI 10.1016/j.jtcvs.2012.07.111

    View details for Web of Science ID 000312386300017

    View details for PubMedID 23098747

  • Historical perspectives of The American Association for Thoracic Surgery: David J. Dugan (1910-1998) JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I. 2012; 144 (2): 297-299

    View details for DOI 10.1016/j.jtcvs.2012.05.023

    View details for Web of Science ID 000306482400010

    View details for PubMedID 22704285

  • Historical perspectives of The American Association for Thoracic Surgery: Lyman A. Brewer III (1907-1988) JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I. 2012; 143 (6): 1244-1246

    View details for DOI 10.1016/j.jtcvs.2011.06.035

    View details for Web of Science ID 000304110700002

    View details for PubMedID 21820676

  • Invited commentary. Annals of thoracic surgery Fann, J. I. 2012; 93 (2): 455-456

    View details for DOI 10.1016/j.athoracsur.2011.11.039

    View details for PubMedID 22269712

  • Evaluation of simulation training in cardiothoracic surgery: The Senior Tour perspective JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I., Feins, R. H., Hicks, G. L., Nesbitt, J. C., Hammon, J. W., Crawford, F. A. 2012; 143 (2): 264-U52


    The study objective was to introduce senior surgeons, referred to as members of the "Senior Tour," to simulation-based learning and evaluate ongoing simulation efforts in cardiothoracic surgery.Thirteen senior cardiothoracic surgeons participated in a 2½-day Senior Tour Meeting. Of 12 simulators, each participant focused on 6 cardiac (small vessel anastomosis, aortic cannulation, cardiopulmonary bypass, aortic valve replacement, mitral valve repair, and aortic root replacement) or 6 thoracic surgical simulators (hilar dissection, esophageal anastomosis, rigid bronchoscopy, video-assisted thoracoscopic surgery lobectomy, tracheal resection, and sleeve resection). The participants provided critical feedback regarding the realism and utility of the simulators, which served as the basis for a composite assessment of the simulators.All participants acknowledged that simulation may not provide a wholly immersive experience. For small vessel anastomosis, the portable chest model is less realistic compared with the porcine model, but is valuable in teaching anastomosis mechanics. The aortic cannulation model allows multiple cannulations and can serve as a thoracic aortic surgery model. The cardiopulmonary bypass simulator provides crisis management experience. The porcine aortic valve replacement, mitral valve annuloplasty, and aortic root models are realistic and permit standardized training. The hilar dissection model is subject to variability of porcine anatomy and fragility of the vascular structures. The realistic esophageal anastomosis simulator presents various approaches to esophageal anastomosis. The exercise associated with the rigid bronchoscopy model is brief, and adding additional procedures should be considered. The tracheal resection, sleeve resection, and video-assisted thoracoscopic surgery lobectomy models are highly realistic and simulate advanced maneuvers.By providing the necessary tools, such as task trainers and assessment instruments, the Senior Tour may be one means to enhance simulation-based learning in cardiothoracic surgery. The Senior Tour members can provide regular programmatic evaluation and critical analyses to ensure that proposed simulators are of educational value.

    View details for DOI 10.1016/j.jtcvs.2011.10.013

    View details for Web of Science ID 000299318000009

    View details for PubMedID 22075060

  • Historical perspectives of The American Association for Thoracic Surgery: Norman E. Shumway, Jr (1923-2006) JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I., Baumgartner, W. A. 2011; 142 (6): 1299-1302

    View details for DOI 10.1016/j.jtcvs.2011.09.005

    View details for Web of Science ID 000297214200005

    View details for PubMedID 22014718

  • Historical perspectives of The American Association for Thoracic Surgery: Paul C. Samson (1905-1982) JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I., Connolly, J. E. 2011; 142 (5): 967-969

    View details for DOI 10.1016/j.jtcvs.2011.05.014

    View details for Web of Science ID 000296337500005

    View details for PubMedID 21820675

  • Historical perspectives of the American Association for Thoracic Surgery: Harold Brunn (1874-1951) JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I. 2011; 141 (4): 872-874

    View details for DOI 10.1016/j.jtcvs.2010.09.040

    View details for Web of Science ID 000288541300005

    View details for PubMedID 21419900

  • Simulation and skills training in mitral valve surgery 36th Annual Meeting of the Western-Thoracic-Surgical-Association Joyce, D. L., Dhillon, T. S., Caffarelli, A. D., Joyce, D. D., Tsirigotis, D. N., Burdon, T. A., Fann, J. I. MOSBY-ELSEVIER. 2011: 107–12


    Limited exposure and visualization and technical complexity have affected resident training in mitral valve surgery. We propose simulation-based learning to improve skill acquisition in mitral valve surgery.After reviewing instructional video recordings of mitral annuloplasty in porcine and plastic models, 11 residents (6 integrated and 5 traditional) performed porcine model mitral annuloplasty. Video-recorded performance was reviewed by attending surgeon providing audio formative feedback superimposed on video recordings; recordings were returned to residents for review. After 3-week practice with plastic model, residents repeated porcine model mitral annuloplasty. Performance assessments initially (prefeedback) and at 3 weeks (postfeedback) were based on review of video recordings on 5-point rating scale (5, good; 3, average; 1, poor) of 11 components. Ratings were averaged for composite score.Time to completion improved from mean 31 ± 9 minutes to 25 ± 6 minutes after 3-week practice (P = .03). At 3 weeks, improvement in technical components was achieved by all residents, with prefeedback scores varying from 2.4 ± 0.6 for needle angles to 3.0 ± 0.5 for depth of bites and postfeedback scores of 3.1 ± 0.8 for tissue handling to 3.6 ± 0.8 for suture management and tension (P ≤ .001). Interrater reliability was greater than 0.8. In this sample, composite scores of first-year integrated and traditional residents were lower than those of senior level residents; comparatively, third-year integrated residents demonstrated good technical proficiency.Simulation-based learning with formative feedback results in overall improved performance of simulated mitral annuloplasty. In complex surgical procedures, simulation may provide necessary early graduated training and practice. Importantly, a "passing" grade can be established for proficiency-based advancement.

    View details for DOI 10.1016/j.jtcvs.2010.08.059

    View details for Web of Science ID 000285407500021

    View details for PubMedID 21074189

  • Simulation in coronary artery anastomosis early in cardiothoracic surgical residency training: The Boot Camp experience JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I., Calhoon, J. H., Carpenter, A. J., Merrill, W. H., Brown, J. W., Poston, R. S., Kalani, M., Murray, G. F., Hicks, G. L., Feins, R. H. 2010; 139 (5): 1275-1281


    We evaluated focused training in coronary artery anastomosis with a porcine heart model and portable task station.At "Boot Camp," 33 first-year cardiothoracic surgical residents participated in 4-hour coronary anastomosis sessions (6-7 attending surgeons per group of 8-9 residents). At beginning, midpoint, and session end, anastomosis components were assessed on a 3-point rating scale (1 good, 2 average, 3 below average). Performances were video recorded and reviewed by 3 surgeons in a blinded fashion. Participants completed questionnaires at session end, with follow-up surveys at 6 months.Ten to 18 end-to-side anastomoses with porcine model and task station were performed. Initial assessments ranged from 2.11 +/- 0.58 (forceps use) to 2.44 +/- 0.48 (needle angles). Midpoint scores ranged from 1.76 +/- 0.63 (forceps use) to 1.91 +/- 0.49 (needle angles). Session end scores ranged from 1.29 +/- 0.45 (needle holder use) to 1.58 +/- 0.50 (needle transfer and suture management and tension; P < .001). Video recordings confirmed improved performance (interrater reliability >0.5). All respondents agreed that task station and porcine model were good methods of training. At 6 months, respondents noted that the anastomosis session provided a basis for training; however, only slightly more than half continued to practice outside the operating room.Four-hour focused training with porcine model and task station resulted in improved ability to perform anastomoses. Boot Camp may be useful in preparing residents for coronary anastomosis in the clinical setting, but emphasis on simulation development and deliberate practice is necessary.

    View details for DOI 10.1016/j.jtcvs.2009.08.045

    View details for Web of Science ID 000276944300026

    View details for PubMedID 19846125

  • Heparin-induced thrombosis without thrombocytopenia JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Tibayan, F. A., Leung, L. L., Burdon, T. A., Fann, J. I. 2010; 139 (2): E6-E7

    View details for DOI 10.1016/j.jtcvs.2008.07.006

    View details for Web of Science ID 000274014300050

    View details for PubMedID 19660256

  • Mitral repair with the Evalve MitraClip device: histopathologic findings in the porcine model CARDIOVASCULAR PATHOLOGY Luk, A., Butany, J., Ahn, E., Fann, J. I., Goar, F. S., Thornton, T., McDermott, L., Madayag, C., Komtebedde, J. 2009; 18 (5): 279-285


    Percutaneous mitral repair with the MitraClip device ("clip") is currently being evaluated in a Phase II clinical trial (EVEREST II). This device was evaluated in an animal model prior to use in humans.Twenty-one excised clips with accompanying leaflet tissue from pigs were examined at 4, 12, 17, 24, and 52 weeks. Sixteen specimens were available for hematoxylin and eosin and Movat pentachrome staining, and five were sent for scanning electron microscopy. The devices were examined grossly for tissue growth on flow and nonflow surfaces, thrombus, and vegetations. Microscopic evaluation focused on the presence of tissue growth around the device, the inflammatory response, and the presence of thrombus, infective endocarditis, and hematoma.Tissue growth on both flow and nonflow surfaces was seen in all specimens with variation of tissue thickness proportional to the duration of device implantation. Evidence of endothelialization, fibrous encapsulation, and organization of tissue between the aortic and mitral leaflets was observed. Adjacent chordae tendinae were incorporated into the healing tissue growth around the device as early as 4 weeks, in 33% of clips implanted for that time period, increasing to 67% of clips at 12 weeks, and 100% of clips at 17, 24, and 52 weeks. Two animals were diagnosed with infective endocarditis during life.Mechanical coaptation of the mitral leaflets in an animal model demonstrates adequate tissue response and healing with complete encapsulation of the device by 12 weeks and ongoing healing response proportional to duration of implantation. Infective endocarditis remains a potential complication in the animal model and for all implanted prosthetic devices.

    View details for DOI 10.1016/j.carpath.2008.07.001

    View details for Web of Science ID 000270060200004

    View details for PubMedID 18703359

  • Simulations of Virtual PET/CT 3-D Bronchoscopy Imaging Using a Physical Porcine Lung-Heart Phantom MOLECULAR IMAGING AND BIOLOGY Yerushalmi, D., Mullick, R., Quon, A., Fahrig, R., Pelc, N. J., Fann, J. I., Gambhir, S. S. 2009; 11 (4): 275-282


    We present a systematic approach for studying positron emission tomography-computed tomography (PET/CT) 3-D virtual fly-through endoscopy and for assessing the accuracy of this technology for visualizing and detecting endobronchial lesions as a function of focal lesion morphology and activity.Capsules designed to simulate endobronchial lesions were filled with activity and introduced into a porcine lung-heart phantom. PET/CT images were acquired, reconstructed, and volume rendered as 3-D fly-through and fly-around visualizations. Anatomical positioning of lesions seen on the 3-D-volume-rendered PET/CT images was compared to the actual position of the capsules.Lesion size was observed to be highly sensitive to PET threshold parameter settings and careful opacity and color transfer function parameter assignment.We have demonstrated a phantom model for studies of PET/CT 3-D virtual fly-through bronchoscopy and have applied this model for understanding the effect of PET thresholding on the visualization and detection of lesions.

    View details for DOI 10.1007/s11307-009-0201-8

    View details for Web of Science ID 000266830700010

    View details for PubMedID 19434462

  • Improvement in coronary anastomosis with cardiac surgery simulation JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Fann, J. I., Caffarelli, A. D., Georgette, G., Howard, S. K., Gaba, D. M., Youngblood, P., Mitchell, S., Burdon, T. A. 2008; 136 (6): 1486-1491


    Cardiac surgery trainees might benefit from simulation training in coronary anastomosis and more advanced procedures. We evaluated distributed practice using a portable task station and experience on a beating-heart model in training coronary anastomosis.Eight cardiothoracic surgery residents performed 2 end-to-side anastomoses with the task station, followed by 2 end-to-side anastomoses to the left anterior descending artery by using the beating-heart model at 70 beats/min. Residents took home the task station, recording practice times. At 1 week, residents performed 2 anastomoses on the task station and 2 anastomoses on the beating-heart model. Performances of the anastomosis were timed and reviewed.Times to completion for anastomosis on the task station decreased 20% after 1 week of practice (351 +/- 111 to 281 +/- 53 seconds, P = .07), with 2 residents showing no improvement. Times to completion for beating-heart anastomosis decreased 15% at 1 week (426 +/- 115 to 362 +/- 94 seconds, P = .03), with 2 residents demonstrating no improvement. Home practice time (90-540 minutes) did not correlate with the degree of improvement. Performance rating scores showed an improvement in all components. Eighty-eight percent of residents agreed that the task station is a good method of training, and 100% agreed that the beating-heart model is a good method of training.In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation.

    View details for DOI 10.1016/j.jtcvs.2008.08.016

    View details for Web of Science ID 000261970100016

    View details for PubMedID 19114195

  • Invited commentary. Annals of thoracic surgery Fann, J. I. 2008; 86 (5): 1478-1479

    View details for DOI 10.1016/j.athoracsur.2008.08.022

    View details for PubMedID 19049734

  • Congenital Coronary Artery Anomalies Presenting in Late Adulthood with Concurrent Acquired Heart Disease: Report of Two Cases JOURNAL OF CARDIAC SURGERY Timek, T. A., Kimm, S., Burdon, T. A., Fann, J. I. 2008; 23 (6): 773-776


    Congenital coronary anomalies can be found in up to 1% of patients undergoing angiography. The most severe of these lesions become symptomatic in early childhood, while others can remain without consequence. However, while being silent in the early decades of life, these asymptomatic anomalies can contribute to the presentation of acquired heart disease and can themselves become clinically significant. We describe the clinical course of two patients with congenital coronary artery anomalies presenting beyond the fifth decade of life with concurrent acquired heart disease.

    View details for DOI 10.1111/j.1540-8191.2008.00645.x

    View details for Web of Science ID 000260499400043

    View details for PubMedID 19017010

  • Successful lysis of an aortic prosthetic valve thrombosis with a dosing regimen for peripheral artery and bypass graft occlusions JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY Nguyen, P. K., Wasserman, S. M., Fann, J. I., Giacomini, J. 2008; 135 (3): 691-693

    View details for DOI 10.1016/j.jtcvs.2007.11.012

    View details for Web of Science ID 000253860300043

    View details for PubMedID 18329497

  • Evolving strategies for the treatment of valvular heart disease: Preclinical and clinical pathways for percutaneous aortic valve replacement CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS Fann, J. I., Chronos, N., Rowe, S. J., Michiels, R., Lyons, B. E., Leon, M. B., Kaplan, A. V. 2008; 71 (3): 434-440


    To decrease the morbidity associated with conventional surgery for calcific aortic stenosis, there has been increasing interest in catheter-based treatment using a stent or frame mounted bioprosthetic valve. Critical to its success is knowledge of pathoanatomy, risk of embolization of calcific debris, and issues associated with device anchoring and paravalvular leaks. In the absence of a chronic animal model of aortic stenosis, development of a catheter-based device has been an iterative process based on experimental and early clinical data gathered abroad, where marketing may be permitted with less clinical data than required in the United States. This process has persuaded many companies to circumvent the time delays occasioned by the FDA regulatory validation of iterative design changes by performing initial studies outside the United States. Because percutaneous aortic valve replacement is considered a Class III device, premarket approval, including defining the patient population, inclusion and exclusion criteria, control population, and interpretable clinical endpoints, is required. In the early clinical experience, percutaneous aortic valve replacement has been directed at high-risk patients who were considered "very poor" or "non-surgical" candidates. Defining and identifying patients for the clinical trial may be challenging, in part because of the difficult selection of an appropriate control group, e.g., conventional aortic valve replacement, best medical management, and/or balloon valvuloplasty.

    View details for DOI 10.1002/ccd.21381

    View details for Web of Science ID 000253570000033

    View details for PubMedID 18288759

  • Invited commentary. Annals of thoracic surgery Fann, J. I. 2007; 84 (3): 1006-?

    View details for PubMedID 17720419

  • The use of endobronchial valve device to eliminate air leak RESPIRATORY MEDICINE Fann, J. I., Berry, G. J., Burdon, T. A. 2006; 100 (8): 1402-1406


    We evaluated an endobronchial valve device in the treatment of surgically created air leak or pneumothorax by eliminating antegrade flow.Six sheep underwent general anesthesia with positive pressure ventilation and left thoracotomy. After division of the mediastinal pleura, the contralateral cranial lobe was identified and a 2.5 cmx1.5 cm laceration created with resultant air leak. Using bronchoscopy, we deployed a valve device in the bronchus of the injured segment. Chest drainage tube was placed and the thoracotomy closed. At 1 week (n=3) and 4 weeks (n=3), the animals underwent general anesthesia, bronchoscopy and right thoracotomy.All animals survived the procedure. Bronchoscopic valve device placement in the segmental bronchus resolved the air leak immediately. After closure of thoracotomy, the chest tube demonstrated minimal drainage with no air leak. At 1 and 4 weeks, bronchoscopy showed no change in device location, and the treated segments were atelectatic with fibrous scar at the injured site.Collapse of a selected lung segment with resolution of air leak can be achieved using bronchoscopically implanted valve device. The valve device may facilitate treatment of patients with post-surgical or post-traumatic persistent air leak.

    View details for DOI 10.1016/j.rmed.2005.11.011.

    View details for Web of Science ID 000239219000014

    View details for PubMedID 16376535

  • Chronic mitral valve rejection requiring replacement in a nine-year-old allograft ANNALS OF THORACIC SURGERY Ihnken, K., Fann, J. I., Burdon, T. A., Johnson, F. L., Kosek, J. C., Shumway, N. E. 2005; 80 (5): 1909-1911


    A 43-year-old woman underwent mitral valve replacement for severe mitral regurgitation nine years after orthotopic heart transplant. Histopathology showed chronic rejection of the mitral valve with lymphocytic infiltrates. The patient is well at one year follow-up. This report describes an identified case of chronic mitral valve rejection requiring valve replacement.

    View details for DOI 10.1016/j.athoracsur.2004.06.036

    View details for Web of Science ID 000232970500054

    View details for PubMedID 16242482

  • Cardiac allograft aortic dissection: Successful repair using a composite valve graft and modified-cabrol coronary reconstruction JOURNAL OF CARDIAC SURGERY Caffarelli, A. D., Fann, J. I., Salerno, C. T., Johnson, F., Jenkins, D. D., O'Bannon, L., Burdon, T. A. 2005; 20 (5): 450-452


    We report a 55-year-old man, the recipient of a cardiac allograft for ischemic cardiomyopathy 9 years earlier, who presented with progressive aortic root dilation, worsening aortic insufficiency, and an incidentally discovered chronic type A aortic dissection limited to the donor aorta. The patient was taken to the operating room, and the aortic dissection successfully repaired using standard reoperative techniques. This is the sixth case reported in the literature, and only the fourth survivor. To our knowledge, this case represents the first successful repair, of a limited aortic dissection of the donor aorta postcardiac transplantation, using a composite valve graft and modified-Cabrol coronary reconstruction.

    View details for DOI 10.1111/j.1540-8191.2005.200467.x

    View details for Web of Science ID 000232380400010

    View details for PubMedID 16153277

  • Percutaneous aortic valve replacement and mitral valve repair. Future cardiology Fann, J. I., St Goar, F. G. 2005; 1 (3): 393-403


    For mitral regurgitation and aortic valve disease warranting replacement, the surgical approach has been the mainstay therapy since the 1960s. Technological advances have provided potentially less invasive alternatives to surgery. Novel catheter-based techniques include aortic valve replacement with a valved stent, and devices aimed at reconfiguring the annulus or approximating a portion of the leaflets for mitral regurgitation. The main considerations regarding aortic valved stents include device anchoring and orientation, potential restriction of coronary flow, optimal method of delivery, ideal leaflet material, stent characteristics, and valve durability. The catheter-based approaches to mitral regurgitation are undergoing further experimental and clinical evaluations, and its success will be partially dependent on a thorough understanding of the underlying valvular pathology. Patient selection will be a critical component in the long-term efficacy of these new therapies. Close collaboration among the cardiovascular specialists and biomedical engineers will enable the development of safe and effective devices.

    View details for DOI 10.1517/14796678.1.3.393

    View details for PubMedID 19804122

  • Beating heart catheter-based edge-to-edge mitral valve procedure in a porcine model - Efficacy and healing response CIRCULATION Fann, J. I., St Goar, F. G., Komtebedde, J., Oz, M. C., Block, P. C., Foster, E., Butany, J., Feldman, T., Burdon, T. A. 2004; 110 (8): 988-993


    Surgical edge-to-edge repair has been used in the treatment of mitral regurgitation. We evaluated the ability of a catheter-delivered clip (Evalve, Inc) to achieve edge-to-edge mitral valve approximation without cardiopulmonary bypass and the healing response of this technique.Twenty-one pigs underwent general anesthesia and left thoracotomy. A 10F flexible delivery catheter with a clip was placed into the left atrium. With echocardiographic and fluoroscopic guidance, the clip grasped and approximated the mid portion of the anterior and posterior leaflets. After a double orifice had been confirmed, the clip was detached and the catheter withdrawn. All animals survived and had successful clip placement. Three animals were euthanized at 4 weeks, 9 at 12 weeks, 1 at 17 weeks, 7 at 24 weeks, and 1 at 52 weeks. The clip was well positioned, with leaflet approximation in all animals except 1, in which the clip separated from the posterior leaflet at 4 weeks without affecting valve function. The clip was modified and implanted in 4 pigs; all were intact at 12 to 24 weeks. Scanning electron microscopy showed clip encapsulation with complete endothelialization. Mitral stenosis and thromboembolism did not develop. Two animals developed endocarditis (1 at 12 weeks and 1 at 17 weeks). Progressive healing occurred in all other animals.Edge-to-edge mitral valve approximation can be successfully and reliably achieved with a catheter-delivered clip without cardiopulmonary bypass, resulting in durable healing. The success of this device supports the development of a percutaneous catheter-based system for mitral valve repair.

    View details for DOI 10.1161/01.CIR.0000139855.12616.15

    View details for Web of Science ID 000223492700016

    View details for PubMedID 15302782

  • Repair of superior vena caval perforation during pacemaker placement with video-assisted limited thoracotomy HEART SURGERY FORUM Fann, J. I., Atwood, J. E., Burdon, T. A. 2004; 7 (1): E1-E3
  • Endovascular edge-to-edge mitral valve repair - Short-term results in a porcine model CIRCULATION St Goar, F. G., Fann, J. I., Komtebedde, J., Foster, E., Oz, M. C., Fogarty, T. J., Feldman, T., Block, P. C. 2003; 108 (16): 1990-1993


    The edge-to-edge technique is an accepted method for the surgical repair of a regurgitant mitral valve. This study reports the initial use of an endovascular technology that enables a double-orifice edge-to-edge mitral valve repair without cardiopulmonary bypass in an animal model.Adult pigs (n=14) were anesthetized, and left thoracotomy was performed for epicardial echo imaging. Using femoral vein access, a steerable guide catheter was placed transseptally into the left atrium. An implantable clip designed to grasp and approximate the middle scallops of the anterior and posterior mitral leaflets was introduced through the guide catheter. The clip was opened in the left atrium, advanced through the mitral orifice, and retracted to grasp the leaflet edges. When a functional double-orifice valve was confirmed by echo, the clip was closed to coapt the leaflets and detached from the delivery catheter. Before final clip detachment, echo demonstrated a double orifice in all 14 animals. In 2 studies, the clip released from the anterior mitral leaflet. Retrospective analysis of echo images indicated an incomplete grasp of the anterior leaflet. Immediate postmortem examination revealed that the clip successfully approximated the middle scallops of the anterior and posterior leaflets in all 12 double-orifice studies.This study demonstrates for the first time that an endovascular system can be successfully used to perform the edge-to-edge repair technique in a nondiseased porcine model. This technique is potentially applicable as a percutaneous catheterization laboratory procedure for the treatment of mitral regurgitation in humans.

    View details for DOI 10.1161/01.CIR.0000096052.78331.CA

    View details for Web of Science ID 000186055600014

    View details for PubMedID 14530193

  • Bronchoscopic approach to lung volume reduction using a valve device J Bronchol Fann JI, Berry GJ, Burdon TA 2003; 10 (4): 253-259
  • Endovascular edge-to-edge mitral valve repair: Short-term results in a porcine model. Circulation St Goar FG, Fann JI, Komtebedde J, Foster E, Oz MC, Fogarty TJ, Feldman T, Block PC 2003; 108: 1990-1993
  • Treatment of abdominal aortic anastomotic pseudoaneurysm with percutaneous coil embolization JOURNAL OF VASCULAR SURGERY Fann, J. I., Samuels, S., Slonim, S., Burdon, T. A., Dalman, R. L. 2002; 35 (4): 811-814


    Intraabdominal anastomotic pseudoaneurysms continue to be a late complication of aortic reconstructive procedures. Early surgical repair is critical but is associated with high operative mortality rates. We present a patient who was diagnosed with a distal anastomotic pseudoaneurysm 13 months after transabdominal repair of a symptomatic abdominal aortic aneurysm. Because of the poor operative risk, the patient was considered for a less invasive approach and underwent coil embolization of the abdominal aortic anastomotic pseudoaneurysm. The patient remains without recurrence of pseudoaneurysm 3.5 years later.

    View details for DOI 10.1067/mva.2002.121744

    View details for Web of Science ID 000175366300033

    View details for PubMedID 11932686

  • Descending thoracic and thoracoabdominal aortic aneurysms CORONARY ARTERY DISEASE Fann, J. I. 2002; 13 (2): 93-102

    View details for Web of Science ID 000175470200004

    View details for PubMedID 12004261

  • Torsion dynamics in the evolution from acute to chronic mitral regurgitation 1st Biennial Meeting of the Society-for-Heart-Valve-Disease Tibayan, F. A., Yun, K. L., Lai, D. T., Timek, T. A., Daughters, G. T., Ingels, N. B., Miller, D. C. I C R PUBLISHERS. 2002: 39–46


    Left ventricular (LV) torsion reduces transmural fiber strain gradients during systole, and torsional recoil in early diastole is thought to assist LV filling. To test the hypothesis that deterioration of torsional dynamics accompanied LV dysfunction during the evolution of mitral regurgitation (MR), torsion was measured during the progression from acute to chronic MR in a canine model.Seven dogs underwent cardiopulmonary bypass for LV marker placement and creation of MR by disrupting the posterior leaflet. After 7-10 days, three-dimensional marker coordinates were measured with biplane videofluoroscopy to study LV geometry, size and function, plus maximal torsional deformation, time of maximal torsion relative to end-ejection, and early diastolic torsional recoil during the first 5% of filling. After three months, the animals were re-studied.Progression from acute to chronic MR was associated with a significant decrease in maximum LV dP/dt (1,574+/-213 to 1,300+/-252 mmHg/s, p <0.01) and an increase in LVEDP from 11+/-5 to 15+/-5 mmHg (p <0.01). After three months of MR, maximum torsional deformation decreased from 6.3+/-1.9 to 4.7+/-2.0 degrees (p = 0.04), as did early diastolic recoil (-3.8+/-1.0 to -1.5+/-1.7 degrees, p = 0.03).Progression from acute to chronic MR is accompanied by decreased and delayed systolic LV torsional deformation and a decline in early diastolic recoil, which may contribute to LV dysfunction by increasing transmural strain gradients during systole and impairing diastolic filling. As torsional deformation and recoil can be measured non-invasively with MRI in humans, such measurements might prove useful in patients with progressive MR as an adjunct to determine the timing of surgical repair.

    View details for Web of Science ID 000173359900010

    View details for PubMedID 11858164

  • Acquired left ventricular-right atrial communication - Gerbode-type defect ECHOCARDIOGRAPHY-A JOURNAL OF CARDIOVASCULAR ULTRASOUND AND ALLIED TECHNIQUES Wasserman, S. M., Fann, J. I., Atwood, J. E., Burdon, T. A., Fadel, B. M. 2002; 19 (1): 67-72


    Left ventricular-right atrial (LV-RA) communications are rare intracardiac defects, often congenital in nature and clinically apparent during childhood. Acquired LV-RA shunts are encountered occasionally in the adult population as a result of a defect in the upper portion of the membranous ventricular septum. We describe the clinical and echocardiographic features of an elderly patient with an acquired LV-RA communication in the setting of an aortic composite valve graft and endocarditis. We also review the anatomical features and hemodynamic consequences of such defects.

    View details for Web of Science ID 000174467600010

    View details for PubMedID 11884258

  • Influence of three-dimensional vision on surgical telemanipulator performance SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES Falk, V., Mintz, D., Grunenfelder, J., Farm, J. I., Burdon, T. A. 2001; 15 (11): 1282-1288


    Different viewing conditions (two- and three-dimensional National Television Standard Committee [2D-NTSC and 3D-NTSC] and two-dimensional high-definition television [2D-HDTV]) on telemanipulator performance were evaluated.Six taskes were performed by 15 endoscopic surgeons using the daVinci telemanipulation system. Performance time and errors were measured. Encoder data from the system were used for kinematic analysis of motion. A self-evaluation questionnaire regarding performance under various viewing conditions was obtained.Resolution was better with 2D-HDTV. The estimate of relative distance was not influenced by the different visualization systems. Motor skill tasks were performed faster with binocular vision (3D-NTSC) than with monocular vision (2D-NTSC, 2D-HDTV). For both 2D settings, the deceleration phase of motion was prolonged (p < 0.05 vs 3D). Peak velocity was reduced with 2D-HDTV as compared with 3D-NTSC (p = 0.01). The surgeons tended to favor the 3D system despite their use of 2D systems in their own practice.Three-dimensional vision enhances telemanipulator performance as compared with a 2D system at the same or higher level of resolution. Because it allows faster and more precise movement, future surgical systems should focus on 3D visualization.

    View details for Web of Science ID 000171950700005

    View details for PubMedID 11727134

  • Are the indications for tissue valves different in 2001 and how do we communicate these changes to our cardiology colleagues? CURRENT OPINION IN CARDIOLOGY Fann, J. I., Burdon, T. A. 2001; 16 (2): 126-135


    The indications for tissue valves in the aortic and mitral positions are becoming better defined with advances in valve design, valve preservation, and management of reoperations. Although some patients who require cardiac valve replacement clearly benefit more from one type of valve than from another, not infrequently one encounters a patient who is in the "gray zone," where the optimal choice is difficult. At present, bioprostheses for the diseased aortic valve include stented porcine and pericardial valves, stentless porcine valves, aortic homograft, and pulmonary autograft. For patients with mitral valve disease, options for tissue valve replacement are a stented porcine or pericardial prosthesis. Generally, factors to consider in choosing the appropriate valve substitute include the patient's age, expected life expectancy, coexisting medical problems, lifestyle, and socioeconomics; the etiology of the valve disease, annular size, and physician and patient preference are also relevant. Despite the known finite durability of tissue valves, which is the main limitation in their use, the long-term results have been satisfactory, particularly in older patients, patients with a limited life expectancy, and those undergoing valve replacement in the aortic position. Distillation of available information and ongoing communication between the surgeon and the cardiologist will enable us to assist the patient in choosing the best valve substitute.

    View details for Web of Science ID 000167419100009

    View details for PubMedID 11224645

  • Endoscopic computer-enhanced beating heart coronary artery bypass grafting ANNALS OF THORACIC SURGERY Falk, V., Fann, J. I., Grunenfelder, J., Daunt, D., Burdon, T. A. 2000; 70 (6): 2029-2033


    Telemanipulation systems have enabled coronary revascularization on the arrested heart. The purpose of this study was to develop a technique for computer-enhanced endoscopic coronary artery bypass grafting on the beating heart.The operation was performed using the daVinci telemanipulation system. Through three ports, the left internal thoracic artery was harvested in 10 mongrel dogs (30 to 35 kg) using single right-lung ventilation and CO2 insufflation. Through a fourth port an articulating stabilizer, manipulated from a second surgical console, was inserted to stabilize the heart. The left anterior descending artery was snared using silicone elastomer slings anchored in the stabilizer cleats and the graft to coronary artery anastomosis was performed.In 7 of 10 dogs, total endoscopic beating heart bypass grafting, cardiac stabilization, arteriotomy, and arterial anastomosis were performed using computer-enhanced technology. Endoscopic stabilization and temporary left anterior descending artery occlusion were well tolerated. All grafts were patent although minor strictures were found in 2. In 3 dogs, the procedure could not be completed (1 ventricular arrhythmia, 1 left atrial laceration, and 1 right ventricular outflow tract compression).Endoscopic beating heart coronary artery bypass grafting is possible in a canine model using a computer-enhanced instrumentation system and articulating stabilization.

    View details for Web of Science ID 000166022900059

    View details for PubMedID 11156115

  • Endoscopic Doppler for detecting vessels in closed chest bypass grafting HEART SURGERY FORUM Falk, V., Fann, J. I., Grunenfelder, J., Burdon, T. A. 2000; 3 (4): 331-333


    A new method of endoscopic ultrasonography during endoscopic bypass grafting is described. Using a 7.5 MHz ultrasonic catheter (AcuNav, Acuson, Mountain View, CA) that was introduced through a 5mm port and manipulated by robotically enhanced endoscopic instruments, detection of the internal thoracic artery (ITA) and the left anterior descending (LAD) artery was possible through layers of fat and muscle in a canine model.

    View details for Web of Science ID 000166577900014

    View details for PubMedID 11178297

  • Endovascular treatment of descending thoracic aortic aneurysms and dissections SURGICAL CLINICS OF NORTH AMERICA Fann, J. I., Miller, D. C. 1999; 79 (3): 551-?


    Various endovascular techniques have become viable therapeutic alternatives in the treatment of patients with many types of descending thoracic aortic pathology and aortic dissections. Descending thoracic aortic aneurysms can be successfully treated using stent grafts. This technique is less invasive and is associated with acceptable morbidity and mortality rates. Patients who are particularly likely to benefit include the very elderly population; those with markedly compromised cardiac, pulmonary, or renal status; and individuals who have previously undergone complex operations on the thoracic aorta. Other endovascular methods, such as aortic flap fenestration, stent, or covering of the primary intimal tear in the descending thoracic aorta with a stent graft, have also been effectively employed in the treatment of peripheral arterial complications of aortic dissection. Despite the reported early success of these endovascular percutaneous methods, true assessment of the effectiveness of these various techniques awaits long-term follow-up evaluation in large patient populations.

    View details for Web of Science ID 000081204200008

    View details for PubMedID 10410687

  • Minimally invasive cardiac surgery using the Heartport technique Asian Pacific Heart J Fann JI, Burdon TA, Pompili MF 1999; 8: 19-26
  • Tophaceous pseudogout of the mitral valve ANNALS OF THORACIC SURGERY Moon, M. R., Fann, J. I., Deedwania, P. C., Ferguson, R., Kosek, J. C., Burdon, T. A. 1998; 66 (3): 952-954


    This report describes a 61-year-old patient on chronic hemodialysis with multiple, left-sided, intracardiac masses causing intermittent coronary obstruction. Mitral valve replacement was performed. Massive deposition of calcium pyrophosphate crystals in and around the valve cusps led to the diagnosis of tophaceous pseudogout (tumoral calcinosis) of the mitral valve.

    View details for Web of Science ID 000076166100077

    View details for PubMedID 9768968

  • Port-access cardiac surgery: a system analysis PERFUSION-UK Peters, W. S., Fann, J. I., Burdon, T. A., Pompili, M. F. 1998; 13 (4): 253-258
  • Combined heart and single-lung transplantation in complex congenital heart disease ANNALS OF THORACIC SURGERY Fann, J. I., Wilson, M. K., Theodore, J., Reitz, B. A. 1998; 65 (3): 823-825


    We present a patient with a history of tricuspid and pulmonary atresia who underwent a classic Glenn shunt and a Potts shunt during childhood, resulting in different right and left pulmonary physiology. Because of progression of cardiopulmonary disease and the fact that the right lung was "protected," the patient underwent combined heart-left single-lung transplantation. The postoperative course was uneventful. Potential early and late advantages of this approach include simplifying of the operative procedure and mitigating the potential effects of obliterative bronchiolitis.

    View details for Web of Science ID 000072586100048

    View details for PubMedID 9527222

  • Port-access cardiac surgery: A system analysis Perfusion Peters WS, Fann JI, Burdon TA, Pompili MF 1998; 13: 253-258
  • Composite valve graft versus separate aortic valve and ascending aortic replacement: is there still a role for the separate procedure? Circulation Yun, K. L., Miller, D. C., Fann, J. I., Mitchell, R. S., Robbins, R. C., Moore, K. A., Oyer, P. E., Stinson, E. B., Shumway, N. E., Reitz, B. A. 1997; 96 (9): II-368 75


    To ascertain if operative technique has any bearing on outcome, the surgical results after aortic root replacement using either a composite valve graft (CVG) or a separate graft and valve (GV) were analyzed.Three hundred and ninety consecutive, nonrandomized patients treated for aortic valve disease and ascending aortic aneurysm (n=278) or type A dissection (n=112 [45 acute]) between 1965 and 1995 were analyzed retrospectively. One hundred and thirty-five patients received a CVG, and 255 had separate GV replacement. Mean age was 52+/-16 years (+/-1 SD). Eighty-two patients (44% of the CVG group) had the Marfan syndrome (MFS). Follow-up (96% complete) totaled 2247 patient-years and extended to 27 years. The operative mortality rate was 10+/-3% (+/-70% confidence limits) for patients receiving a CVG and 15+/-2% for GV replacement (P=NS). The 15-year actuarial survival estimate was higher for the CVG group (53+/-14% [+/-SEM] versus 36+/-4%, P=.037). Seven patients in the CVG group required reoperation on the aortic valve or ascending aorta, as did 49 in the GV group. The probabilities of freedom from reoperation on the aortic rootwere 82+/-9% and 75+/-4% at 10 years for the CVG and GV group (P=NS). Thirty variables were analyzed in a multivariate model: pulmonary disease, higher New York Heart Association functional class, and longer cardiopulmonary bypass time were linked with higher operative mortality risk; older age, emergency operation, coronary artery disease, and liver dysfunction were independent determinants of late death. Younger age and use of a bioprosthesis were predictors of late reoperation. Type of procedure (GV versus CVG) was not a significant predictor of any outcome variable.The long-term results after CVG or GV were similar, which reflects proper patient selection. Use of a composite valve graft theoretically confers more protection against recurrent aortic root aneurysm, and, unless one opts for a valve-sparing aortic root replacement procedure, is most appropriate for younger patients, those with the MFS (including acute dissections), and others with marked pathological involvement of the sinuses. On the other hand, use of a separate GV should not be abandoned; in carefully selected patients (and if properly performed, eg, excision of the sinuses), GV also provides satisfactory results.

    View details for PubMedID 9386126

  • Composite valve graft versus separate aortic valve and ascending aortic replacement - Is there still a role for the separate procedure? 69th Annual Scientific Session of the American-Heart-Association Yun, K. L., Miller, D. C., Fann, J. I., Mitchell, S., Robbins, R. C., Moore, K. A., Oyer, P. E., Stinson, E. B., Shumway, N. E., Reitz, B. A. LIPPINCOTT WILLIAMS & WILKINS. 1997: 368–75
  • Minimally invasive mitral valve surgery. Seminars in thoracic and cardiovascular surgery Fann, J. I., Pompili, M. F., Burdon, T. A., Stevens, J. H., St Goar, F. G., Reitz, B. A. 1997; 9 (4): 320-330


    Because of advances in video-assisted general and thoracic surgery, minimally invasive cardiac surgery has been successfully performed experimentally and clinically. Recently described techniques of less invasive mitral valve surgery include limited right thoracotomy, parasternal incision, and partial sternotomy. These methods have been coupled to video-assisted thoracoscopy to further decrease the incision size. Cardiopulmonary bypass (central or peripheral) and either hypothermic fibrillatory arrest or cardioplegic arrest are used. The Port-Access approach is a catheter-based system that provides effective cardiopulmonary bypass, cardioplegic arrest, and ventricular decompression. At Stanford University, 10 Port-Access mitral valve procedures were performed between May 1996 and January 1997. The mean age of the patients (eight men and two women) was 54 +/- 7 (SD) years. Nine patients had severe mitral regurgitation from myxomatous degeneration, and one suffered from severe mitral regurgitation and moderate mitral stenosis from a rheumatic etiology. Five patients underwent mitral valve replacement, and five underwent mitral valve repair. There was no operative mortality. The mean incision length was 8.1 +/- 2.5 cm. The aortic "cross-clamp" time was 99 +/- 22 minutes, and the cardiopulmonary bypass time was 151 +/- 52 minutes. The total hospitalization averaged 4.3 +/- 1.4 days. One patient developed third-degree atrioventricular block, requiring a prolonged stay in the intensive care unit and pacemaker placement; the same patient was found to have a perivalvular leak on follow-up, requiring reoperation at 3 months. Port-Access mitral valve procedures can be performed safely with satisfactory outcome. Greater clinical experience and long-term follow-up are necessary to fully assess these less invasive techniques of mitral valve surgery.

    View details for PubMedID 9352947

  • Minimally invasive coronary artery bypass grafting CURRENT OPINION IN CARDIOLOGY Fann, J. I., Stevens, J. H., Pompili, M. F., Burdon, T. A., Reitz, B. A. 1997; 12 (5): 482-487


    Minimally invasive cardiac surgery has generated a tremendous amount of enthusiasm in the cardiology and cardiac surgical communities. Coronary revascularization without cardiopulmonary bypass through a small anterior thoracotomy or mediastinotomy has been introduced as an alternative to the conventional approach. An endovascular or port-access technique for cardiopulmonary bypass and cardioplegic arrest has been developed for use in cardiac surgery. This peripherally based system achieves aortic occlusion, cardioplegia delivery, and left ventricular decompression; thus, coronary revascularization and various cardiac procedures can be effectively performed in a less invasive fashion than conventional median sternotomy. Continued technical advances in minimally invasive cardiac surgery will facilitate these procedures, increase patient safety, and contribute to acceptable long-term results.

    View details for Web of Science ID A1997YA09600008

    View details for PubMedID 9352176

  • Port-access cardiac operations with cardioplegic arrest 2nd Utrecht Minimally Invasive Coronary Artery Bypass Grafting Workshop Fann, J. I., Pompili, M. F., Stevens, J. H., Siegel, L. C., Goar, F. G., Burdon, T. A., Reitz, B. A. ELSEVIER SCIENCE INC. 1997: S35–S39


    A less invasive approach to cardiac surgery has been propelled by recent advances in video-assisted surgery. Previous obstacles to minimally invasive cardiac operations with cardioplegic arrest included limitations in operative exposure, inadequate perfusion technology, and inability to provide myocardial protection.Port-access technology allows endovascular aortic occlusion, cardioplegia delivery, and left ventricular decompression. The endoaortic clamp is a triple-lumen catheter with an inflatable balloon at its distal end. Antegrade cardioplegia is delivered through a central lumen, which also acts as an aortic root vent, a second lumen is used as an aortic root pressure monitor, and a third lumen is used for balloon inflation to provide aortic occlusion.Experimental and clinical studies have demonstrated the feasibility of port-access coronary artery bypass grafting and port-access mitral valve procedures. Endovascular cardiopulmonary bypass using the endoaortic clamp was effective in achieving cardiac arrest and myocardial protection to allow internal mammary artery to coronary artery anastomosis in a still and bloodless field. Intracardiac procedures, such as mitral valve replacement or repair, have been successfully performed clinically.The port-access system effectively achieves cardiopulmonary bypass and cardioplegic arrest, thereby enabling the surgeon to perform cardiac procedures in a minimally invasive fashion. This system provides for endovascular aortic occlusion, cardioplegia delivery, and left ventricular decompression.

    View details for Web of Science ID A1997XH60000008

    View details for PubMedID 9203594

  • Simultaneous abdominal aortic replacement and thoracic stent-graft placement for multilevel aortic disease Joint Annual Meeting of the Society-for-Vascular-Surgery and the North-American-Chapter of the International-Society-for-Cardiovascular-Surgery Moon, M. R., Mitchell, R. S., Dake, M. D., Zarins, C. K., Fann, J. I., Miller, D. C. MOSBY-YEAR BOOK INC. 1997: 332–40


    Patients with aneurysmal disease involving both the descending thoracic and abdominal aorta have historically required simultaneous or sequential conventional operations, but the morbidity rate is high with either approach in these patients, who often exhibit coexisting cardiopulmonary disease. Transluminally placed endovascular grafts have recently been developed for repair of aortic aneurysms, and we have implemented these techniques to eliminate the need for a thoracotomy in patients with multilevel aortic disease.Since January 1994, 18 patients have undergone conventional abdominal aortic replacement with endovascular stent-graft placement into the descending thoracic aorta under fluoroscopic guidance through a 10 mm Dacron side limb off the abdominal graft. Abdominal aortic replacement required a tube graft in eight patients and bifurcated grafts in 10 patients. Thoracic stent-grafts (custom fabricated, woven Dacron covered, self-expandable stents) averaged 12.2 +/- 4.2 cm (mean +/- SD) in length.One patient died, resulting in a hospital mortality rate of 6%. No patients required further surgical intervention to treat their aortic disease. Seventeen patients (94%) are currently well 14 +/- 8 months after surgery (range, 3 to 29 months) with completely excluded thoracic aortic disease, no stent migration, and no change in stent configuration documented by serial radiologic examinations.Simultaneous abdominal aortic replacement and deployment of a thoracic stent-graft can safely exclude multilevel aortic aneurysmal disease and may be a valuable treatment option for these otherwise high-risk patients.

    View details for Web of Science ID A1997WL46300024

    View details for PubMedID 9052568

  • Port-access cardiac surgery with cardiopulmonary bypass and cardioplegic arrest. Surgical technology international Fann, J. I., Pompili, M. F., Stevens, J. H., Siegel, L. C., St Goar, F. G., Burdon, T. A. 1997; 6: 279-284


    In the past decade, laparoscopic and thoracoscopiC technology have significantly and irreversibly altered the approach to many general and thoracic surgical diseases. With advances in laparoscopy and thoracoscopy, the concept of a minimally invasive approach to cardiac surgery has been realized.

    View details for PubMedID 16160987

  • Twenty-year clinical experience with porcine bioprostheses 32nd Annual Meeting of the Society-of-Thoracic-Surgeons Fann, J. I., Miller, D. C., Moore, K. A., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Robbins, R. C., Reitz, B. A., Shumway, N. E. ELSEVIER SCIENCE INC. 1996: 1301–11


    For the past 25 years, porcine valves have been the most widely implanted bioprosthesis, thereby becoming the standard for comparison with newer bioprosthetic valves.We retrospectively analyzed 2,879 patients who underwent aortic (AVR; n = 1,594) or mitral (MVR; n = 1,285) valve replacement between 1971 and 1990. Follow-up was 97% complete and extended to 20 years (total, 17,976 patient-years). Patient age ranged from 16 to 94 years; mean age in patients who underwent AVR was 60 +/- 15 (+/- standard deviation) years; that for patients who underwent MVR was 58 +/- 13 years.The operative mortality rates were 7% +/- 1% (70% confidence limits) for AVR and 10% +/- 1% for MVR. Actuarial estimates of freedom from structural valve deterioration at 10 and 15 years were 78% +/- 2% (SE) and 49% +/- 4%, respectively, for the AVR subgroup; and 69% +/- 2% and 32% +/- 4%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from reoperation at 10 and 15 years were 76% +/- 2% and 53% +/- 4%, respectively, for the AVR subgroup and 70% +/- 2% and 33% +/- 4%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from thromboembolism at 10 and 15 years were 92% +/- 1% and 87% +/- 2%, respectively, for the AVR subgroup and 86% +/- 1% and 77% +/- 3%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from anticoagulant-related hemorrhage at 10 and 15 years were both 96% +/- 1% for the AVR subgroup and 93% +/- 1% and 90% +/- 2%, respectively, for the MVR subgroup (AVR > MVR; p < 0.05). Estimates of freedom from valve-related mortality at 10 and 15 years were 86% +/- 1% and 78% +/- 3%, respectively, for the AVR subgroup and 84% +/- 2% and 70% +/- 4%, respectively, for the MVR subgroup (p = not significant). Multivariate analysis (Cox model) showed younger age, later year of operation, and valve site (MVR > AVR) to be significant risk factors for structural valve deterioration. Younger age, later year of operation, valve site (MVR > AVR), and renal insufficiency were the significant, independent risk factors for reoperation. Multivariate analysis revealed that higher New York Heart Association functional class, longer cardiopulmonary bypass time, congestive heart failure, renal insufficiency, and longer cross-clamp time were significant risk factors for valve-related mortality. Valve manufacturer did not emerge as a factor in any analysis.These long-term results with porcine bioprostheses were satisfactory, particularly in older patients and those undergoing AVR. As expected, younger age was a significant risk factor for structural valve deterioration and reoperation in both groups. Surprisingly, the durability of porcine bioprosthetic valves has not improved over time, which possibly can be attributed to more enhanced postoperative surveillance and earlier reintervention. These first-generation Hancock and Carpentier-Edwards porcine bioprostheses achieved similar long-term performance.

    View details for Web of Science ID A1996VQ16700014

    View details for PubMedID 8893561

  • Composite versus separate aortic valve and ascending aortic replacement - 30 year experience Yun, K. L., Fann, J. I., Miller, D. C., Mitchell, R. S., Robbins, R. C., Oyer, P. E., Stinson, E. B., Reitz, B. A., Shumway, N. E. LIPPINCOTT WILLIAMS & WILKINS. 1996: 1017–17
  • Porcine valves: Hancock and Carpentier-Edwards aortic prostheses. Seminars in thoracic and cardiovascular surgery Fann, J. I., Miller, D. C. 1996; 8 (3): 259-268


    Hancock and Carpentier-Edwards porcine bioprostheses are the two most widely implanted biological valves and have become the standard by which the performance of newer tissue valves are measured. New guidelines for reporting valve-related complications have provided more comprehensive evaluations and meaningful comparison of the long-term results of valve substitutes. Clinical investigations directly comparing the Hancock and Carpentier-Edwards bioprostheses have shown no significant differences in the long-term performance of these two valves. The incidence of structural valve deterioration for porcine bioprostheses begins to increase 5 to 6 years after implantation. For patients undergoing aortic valve replacement, estimates of freedom from structural valve deterioration at 10 and 15 years range from 76% to 91% and 37% to 63%, respectively. The incidence of structural valve deterioration may be offset by the limited survival of older patients; thus, the durability of a bioprosthesis may be sufficient for the majority of these patients. The long-term results of the porcine bioprosthesis have been satisfactory, particularly in older patients and those undergoing aortic valve replacement. The performance of the Hancock modified orifice (MO) bioprosthesis is comparable with that of other bioprostheses despite its more complex fabrication process. Although it does not offer any distinct advantages in terms of durability, the Hancock MO valve is associated with lower pressure gradients and larger calculated valve areas compared with other porcine valves in the smaller sizes. Based on currently available data, there are no distinct differences in the performance of the second-generation porcine bioprostheses compared with the first-generation valves, and any purported advantages need to be confirmed with long-term evaluations.

    View details for PubMedID 8843517

  • SURGICAL-MANAGEMENT OF AORTIC DISSECTION DURING A 30-YEAR PERIOD CIRCULATION Fann, J. I., Smith, J. A., Miller, D. C., Mitchell, R. S., Moore, K. A., Grunkemeier, G., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1995; 92 (9): 113-121
  • ENDOVASCULAR STENT-GRAFTING AFTER ARCH ANEURYSM REPAIR USING THE ELEPHANT TRUNK ANNALS OF THORACIC SURGERY Fann, J. I., Dake, M. D., Semba, C. P., Liddell, R. P., Pfeffer, T. A., Miller, D. C. 1995; 60 (4): 1102-1105


    A 68-year-old woman with severe chronic obstructive pulmonary disease, aortic valvular insufficiency, and diffuse thoracic aortic aneurysm underwent aortic valve replacement and separate Dacron graft replacement of the ascending aortic and arch aneurysms using the elephant trunk technique. She was discharged on the tenth postoperative day. Five months later, she underwent endovascular stent-graft repair of the descending thoracic aortic aneurysm. She recovered uneventfully, and was discharged on the third postoperative day. Follow-up computed tomography at 6 months demonstrated exclusion of all flow into the descending thoracic aortic aneurysm. The elephant trunk technique followed by endovascular stent-grafting of the descending thoracic component is a potential therapeutic option in selected high-risk patients with diffuse aortic aneurysmal disease.

    View details for Web of Science ID A1995RZ17900045

    View details for PubMedID 7574959



    Knowledge of the instantaneous geometry of the left ventricular (LV) chamber is necessary to calculate LV function and wall stresses. We describe a method utilizing myocardial markers that does not rely on any a priori assumptions of global LV geometry. Five dogs underwent placement of 25 endocardial and 3 epicardial miniature LV markers. Six weeks later, the animals were studied during conscious closed-chest conditions. The three-dimensional coordinates of the LV markers were used to compute longitudinal fitted curves for LV walls and septum during steady-state conditions; endocardial radii of curvature (rcurv) were then computed for each region at the midequatorial (rcurv-eq) and apical levels. There was a uniform decrease in rcurv in each LV wall during systole (compared with diastole, P < 0.01); at end systole, rcurv was regionally heterogeneous between opposing walls, e.g., anterior and posterior rcurv-eq values were 17.2 +/- 2.0 and 17.7 +/- 1.8 (SD) cm, respectively (P < 0.05). At end diastole, only septal-lateral rcurv-eq was different (16.9 +/- 2.1 vs. 18.7 +/- 1.3 cm: P < 0.05). Normalization of rcurv (to instantaneous LV volume) removed the systolic-diastolic differences, but a similar pattern of regional heterogeneity persisted. The data presented pertain to the LV endocardial surface, but the method described can be applied to the epicardial surface as well; this new method offers promise in assessing dynamic changes in longitudinal LV endocardial curvature.

    View details for Web of Science ID A1995RE37300045

    View details for PubMedID 7611505

  • AORTIC DISSECTION ANNALS OF VASCULAR SURGERY Fann, J. I., Miller, D. C. 1995; 9 (3): 311-323

    View details for Web of Science ID A1995QZ74600014

    View details for PubMedID 7632561

  • Management of ascending aortic dissections ACC Current Journal Rev Fann JI, Miller DC 1995; May/June: 39-41
  • SYMPTOMATIC BRACHIAL-ARTERY ANEURYSM IN A CHILD JOURNAL OF PEDIATRIC SURGERY Fann, J. I., Wyatt, J., Frazier, R. L., Cahill, J. L. 1994; 29 (12): 1521-1523


    The authors present the case of a 3-year-old boy who had transient ischemic symptoms secondary to thromboembolism from a left brachial artery aneurysm not associated with trauma or an autoimmune or connective tissue disorder. He underwent emergency resection of a brachial artery aneurysm and interposition grafting. Two months later he was found to have a right brachial artery aneurysm and underwent elective aneurysm resection and interposition grafting. He was well at the 3-year follow-up and had no other arterial aneurysms. The risk of limb threat or loss can be avoided by prompt diagnosis and early surgery. The authors advocate brachial artery aneurysm resection when it becomes technically feasible and/or when thrombus is present. Patients with upper extremity aneurysms should have continuous follow-up with serial examinations to detect concomitant or subsequent aneurysm formation.

    View details for Web of Science ID A1994PW61200004

    View details for PubMedID 7877014

  • Surgical management of aortic dissection in patients with the Marfan syndrome. Circulation Smith, J. A., Fann, J. I., Miller, D. C., Moore, K. A., DeAnda, A., Mitchell, R. S., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. 1994; 90 (5): II235-42


    Aortic dissection is one of the most lethal potential complications in patients with the Marfan syndrome.Among 360 patients undergoing operative treatment of aortic dissection between 1963 and 1992, 40 had the Marfan syndrome. There were 24 men and 16 women with a mean age of 35 +/- 9 years (+/- 1 SD; range, 15 to 54 years). These patients included 16 with acute type A, 2 with acute type B, 18 with chronic type A, and 4 with chronic type B aortic dissections. The aortic arch was involved in 29 cases. Preoperative complications included acute aortic valvular insufficiency in 13 patients, rupture into the pericardial space in 3, and loss of peripheral pulses in 9. The site of primary intimal tear was the ascending aorta in 25 patients, the aortic arch in 2, the descending aorta in 7, and not identified in 6. Operations included ascending aortic and aortic valvular replacement (with or without coronary artery reimplantation) in 22 patients, ascending aortic replacement alone in 5, and descending thoracic aortic replacement in 9. Four operative deaths (10 +/- 5% [+/- 70% confidence limits]) occurred in 3 acute patient-years and 1 chronic type A patient-years. Long-term follow-up (216 patient-years; range, 1 month to 22 years; mean, 5.4 years) revealed 15 late deaths, 7 from late aortic sequelae. The overall actuarial survival estimates were 71 +/- 8%, 54 +/- 10%, and 22 +/- 11% at 5, 10, and 15 years, respectively. Twenty late aortic operations were required in 14 patients.Despite satisfactory early results, the long-term survival of patients with the Marfan syndrome was suboptimal (albeit similar to those without the Marfan syndrome). Future progress will pivot on reducing the incidence of aortic dissection in these patients with medical therapy and/or earlier surgical intervention and enhanced postoperative serial imaging surveillance of the entire aorta.

    View details for PubMedID 7955259

  • SURGICAL-MANAGEMENT OF AORTIC DISSECTION IN PATIENTS WITH THE MARFAN-SYNDROME 66th Scientific Sessions of the American-Heart-Association:Cardiovascular Surgery 1993 Smith, J. A., Fann, J. I., Miller, D. C., Moore, K. A., DeAnda, A., Mitchell, R. S., Stinson, E. B., Oyer, P. E., Reitz, B. A., Shumway, N. E. AMER HEART ASSOC. 1994: 235–42
  • SURGICAL-MANAGEMENT OF AORTIC DISSECTION OVER 30 YEARS Fann, J. I., Smith, J. A., Miller, D. C., Mitchell, R. S., Moore, K., Oyer, P. E., STINSOUN, E. B., Reitz, B. A., Shumway, N. E. LIPPINCOTT WILLIAMS & WILKINS. 1994: 96–96
  • Genetic and metabolic causes of arterial disease. Annals of vascular surgery Fann, J. I., Dalman, R. L., Harris, E. J. 1993; 7 (6): 594-604

    View details for PubMedID 8123465

  • PSEUDOMYXOMA PERITONEI SURGERY GYNECOLOGY & OBSTETRICS Fann, J. I., Vierra, M., Fisher, D., Oberhelman, H. A., Cobb, L. 1993; 177 (5): 441-447


    Pseudomyxoma peritonei results from implantation of malignant tumors or irritation from ruptured benign cysts. This disease is traditionally characterized by accumulation of mucinous ascites, relatively long survival period and absence of extraperitoneal metastases. Disease progression is difficult to predict because of the spectrum of underlying pathologic entities. Four unusual instances of pseudomyxoma peritonei are presented. An instance of the neoplasm confined to the splenic parenchyma suggests potential for hematogenous dissemination. The tumor can be limited to and extend along the retroperitoneum. Retained rectal tissue after proctocolectomy may be a possible origin of disease. Enterobronchial fistula formation is a serious long term complication. Aggressive surgical approach with resection of the bulk of disease offers the optimal palliation and prognosis.

    View details for Web of Science ID A1993MF15300001

    View details for PubMedID 8211593

  • Extra-anatomic bypass. Annals of vascular surgery Fann, J. I., Harris, E. J., Dalman, R. L. 1993; 7 (4): 378-383

    View details for PubMedID 8268081

  • Heritable arteriopathy. Seminars in vascular surgery Fann, J. I., Dalman, R. L. 1993; 6 (1): 46-55

    View details for PubMedID 8252228



    The effects of volume overload associated with mitral regurgitation on left ventricular systolic mechanics, energetics, mechanical to external stroke work efficiency, and ventriculoarterial coupling were examined in 11 conscious, closed-chest dogs. Miniature radiopaque tantalum markers were implanted into the myocardium to measure left ventricular volume, and biplane cinefluoroscopic images were obtained 1 week and 3 months after creation of mitral regurgitation. Echocardiographically determined left ventricular mass increased from 116 +/- 28 to 152 +/- 29 gm (p less than 0.001). Left ventricular end-diastolic and end-ejection volumes increased by 24% and 27%, respectively. Global left ventricular systolic performance was assessed by the slopes (linear regression) of the end-systolic pressure-volume and end-systolic stress-volume relationships corrected for change in end-diastolic volume; normalized end-systolic pressure-volume relationships fell by 36% (p less than 0.001), and normalized end-systolic stress-volume relationships declined by 21% (p less than 0.005). The normalized end-systolic volume at 100 mm Hg end-systolic left ventricular pressure increased from 0.63 to 0.75 (p less than 0.05). Similar results were observed based on a nonlinear (quadratic) fit of the end-systolic pressure-volume data. In terms of energetics, the slopes of the stroke volume-end-diastolic volume and pressure-volume area-end-diastolic volume relationships fell significantly, indicating reduced external stroke work and mechanical energy at any given level of preload. Additionally, the efficiency of energy transfer from pressure-volume area to external pressure-volume work at matched end-diastolic volume was 25% lower (p = 0.006) at 3 months compared with the 1-week measurements. While overall effective arterial (or total vascular) elastance tended to decrease after a period of time, the effective ventriculovascular coupling ratio increased from 1.6 +/- 0.6 to 2.7 +/- 1.1 (p less than 0.005), indicating a greater degree of mismatch between the left ventricle and the total (forward and regurgitant) vascular load. Therefore the low pressure-volume overload of mitral regurgitation not only resulted in depressed left ventricular systolic mechanics but also was associated with deterioration of global left ventricular energetics and efficiency and exacerbated mismatch in coupling between the left ventricle and the systemic arterial bed and left atrium.

    View details for Web of Science ID A1992JD13800006

    View details for PubMedID 1614212



    The effect of fish oil on accelerated graft coronary arteriosclerosis was assessed in Lewis to Brown-Norway rat heterotopic cardiac allografts. Twelve Brown-Norway rats were supplemented with 2 ml/kg/day of fish oil (68.3 mg eicosopentaenoic acid and 47.5 mg decosahexaenoic acid per milliliter). Eleven additional animals, receiving an isocaloric amount of safflower oil, served as control. All diets began 1 week before operation. Immunosuppression was obtained with low-dose cyclosporine (2 mg/kg/d). When killed (100 days), there were no significant differences in percentage weight gain, graft function, or histologic rejection score. Although lipid profiles were comparable, total cholesterol:high-density lipoprotein ratio was marginally higher in animals treated with fish oil (p = 0.069). Mean percentage luminal occlusion (before and after correcting for differences in size between coronary vessels analyzed) and average intimal thickness were similar between animals treated with fish oil and safflower oil as assessed by computer-assisted digitized, morphometric planimetry. In all allografts, donor interstitial dendritic cells were repopulated with recipient dendritic cells. The major histocompatibility complex class II cell density in the fish oil group did not differ significantly from rats supplemented with safflower oil (1.48 +/- 0.68 vs 1.48 +/- 0.65 cells per mm2, p = 0.995). In conclusion, fish oil did not exert any beneficial effect over safflower oil in terms of graft coronary arteriosclerosis, histologic rejection, or plasma lipids.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1991GT80200018

    View details for PubMedID 1756147

  • REGIONAL EPICARDIAL AND ENDOCARDIAL 2-DIMENSIONAL FINITE DEFORMATIONS IN CANINE LEFT-VENTRICLE AMERICAN JOURNAL OF PHYSIOLOGY Fann, J. I., Sarris, G. E., Ingels, N. B., Niczyporuk, M. A., Yun, K. L., Daughters, G. T., Derby, G. C., Miller, D. C. 1991; 261 (5): H1402-H1410


    We evaluated subepicardial and subendocardial two-dimensional finite deformations in the left ventricular (LV) anterior, lateral, and posterior regions in the closed-chest, conscious dog heart. Eight dogs underwent placement of 22 radiopaque markers in the LV myocardium. Sets of three markers were implanted in the anterior, lateral, and posterior subepicardium and subendocardium at the mid-ventricular level; reference markers were placed at apical and basal sites. Eight hours later, biplane videofluoroscopy was performed. Finite deformations for each subepicardial and subendocardial region were analyzed during three consecutive beats at end expiration. Circumferential shortening occurred in all layers and regions; similarly, longitudinal shortening occurred in all layers except that of the posterior endocardium. Values of principal strain were -0.19 +/- 0.08 (SD) and -0.10 +/- 0.03 for the anterior subendocardium and subepicardium, -0.20 +/- 0.07 and -0.10 +/- 0.02 for the lateral subendocardium and subepicardium, and -0.13 +/- 0.02 and -0.10 +/- 0.03 for the posterior subendocardium and subepicardium respectively (P less than 0.05 subendocardium vs. subepicardium). Second principal strain tended to be near zero or positive (from -0.01 +/- 0.05 to 0.04 +/- 0.05) in all regions. The end-systolic direction of principal strain was -29 +/- 32 degrees and -34 +/- 29 degrees in the anterior subepicardium and subendocardium, -47 +/- 10 degrees and -30 +/- 37 degrees in the lateral subepicardium and subendocardium, and -4 +/- 29 degrees and +7 +/- 23 degrees in the posterior subepicardium and subendocardium. Anterior and lateral directions of principal strain were similar in the subepicardial and subendocardial layers and oriented along the epicardial fiber axis, but the posterior direction tended to be circumferentially oriented.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1991GQ78100009

    View details for PubMedID 1951727



    Forty-seven patients with aortic dissection resulting from a primary tear located in the transverse aortic arch underwent surgical treatment. Twenty-six patients had acute type A, 7 had acute type B, 7 had chronic type A, and 7 had chronic type B aortic dissections. Of the 33 patients with acute dissections, 11 (7 acute type A and 4 acute type B) underwent concomitant arch repair with an operative (less than or equal to 30 days) mortality rate of 55% (35% to 73%, +/- 1 asymmetric 70% confidence limit) (2 of 7 acute type A and 4 of 4 acute type B). Concomitant arch repair was omitted in 22 patients with acute dissections (19 acute type A and 3 acute type B); the operative mortality rate was 41% (29% to 54%) (7 of 19 acute type A and 2 of 3 acute type B) (p = not significant versus arch repair). The overall survival rate for those with arch repair was 45% +/- 15% (+/- 1 standard error of the estimate) at 4 years, compared with 43% +/- 11% for patients without arch repair (p = not significant). Considering the type of dissection, the 4-year survival estimate for patients with acute type A dissections who underwent arch repair (5 hemiarch and 2 total arch) was 71% +/- 17% (versus 44% +/- 12% for acute type A patients without arch repair). There were no survivors among the 4 patients with acute type B dissections who had an arch repair (1 hemiarch and 3 total arch), whereas patients with acute type B dissections who did not undergo concomitant arch repair had a 4-year survival estimate of 33% +/- 27% (p = not significant versus arch repair). Four other patients with acute type B dissections resulting from an arch tear were managed medically and tended to have a slightly better prognosis (2-year survival estimate of 75% +/- 22% versus 14% +/- 13% for all surgically treated acute type B patients), but again this difference was not statistically significant. Multivariate analysis of the 47 surgical patients revealed that advanced age (p = 0.0008), preoperative dissection complications (p = 0.02), and other coexistent medical problems (p = 0.03) were the only significant, independent determinants of overall mortality. Initial arch repair was not a significant predictor. Nine percent (2/22) of patients with acute type A dissections who initially underwent isolated ascending aortic replacement required subsequent arch replacement; 1 died after reoperation.(ABSTRACT TRUNCATED AT 400 WORDS)

    View details for Web of Science ID A1991GE66000004

    View details for PubMedID 1881176



    With the advent of cyclosporin A, accelerated coronary arteriosclerosis has become the major impediment to the long-term survival of heart transplant recipients. Due to epidemiologic reports suggesting a salutary effect of fish oil, the dose response of fish oil on graft coronary arteriosclerosis in a rabbit heterotopic cardiac allograft model was assessed using safflower oil as a caloric control. Seven groups of New Zealand White rabbits (n = 10/group) received heterotropic heart transplants from Dutch-Belted donors and were immunosuppressed with low-dose cyclosporin A (7.5 mg/kg/day). Group 1 animals were fed a normal diet and served as control. Group 2, 3, and 4 animals received a daily supplement of low- (0.25 mL/kg/day), medium- (0.75 mL/kg/day), and high- (1.5 mL/kg/day) dose fish oil (116 mg n-3 polyunsaturated fatty acid/mL), respectively. Group 5, 6, and 7 animals were supplemented with equivalent dose of safflower oil (i.e., 0.25, 0.75, and 1.5 mL/kg/day). Oil-supplemented rabbits were pretreated for 3 weeks before transplantation and maintained on the same diet for 6 weeks after operation. The extent of graft coronary arteriosclerosis was quantified using computer-assisted, morphometric planimetry. When the animals were killed, cyclosporin A was associated with elevated plasma total cholesterol and triglyceride levels in the control group. While safflower oil prevented the increase in plasma lipids at all dosages, fish oil ameliorated the cyclosporin-induced increase in total cholesterol only with high doses. Compared to control animals, there was a trend for more graft vessel disease with increasing fish oil dose, as assessed by mean luminal occlusion and intimal thickness. A steeper trend was observed for increasing doses of safflower oil; compared to the high-dose safflower oil group, animals supplemented with low-dose safflower oil had less mean luminal occlusion (16.3% +/- 5.9% versus 41.4% +/- 7.6%, p less than 0.017) and intimal thickness (7.9 +/- 1.9 microns versus 34.0 +/- 13.0 microns, analysis of variance: p = 0.054). Low-dose safflower oil also had a slight, but nonsignificant, beneficial effect on graft vessel disease when compared to control rabbits. The same trends were observed in the degree of histologic rejection (0 = none to 3 = severe) in fish oil- and safflower oil-treated animals. Rejection score correlated weakly but significantly (p = 0.0001) with mean luminal occlusion (r = 0.52) and intimal thickness (r = 0.46). Therefore allograft coronary disease in this model appeared to exhibit an unfavorable, direct-dose response to fish oil and safflower oil, independent of effects on plasma lipids.(ABSTRACT TRUNCATED AT 400 WORDS)

    View details for Web of Science ID A1991GB58000010

    View details for PubMedID 1867523



    Two hundred fifty-two patients underwent operation for type A aortic dissection at Stanford University Medical Center from 1963 to 1987 and Duke University Medical Center from 1975 to 1988. Sixty-seven percent had an acute type A dissection and 33% had a chronic type A dissection. In addition to repair or replacement of the ascending aorta, 121 patients (48%) required an aortic valve procedure. Valve resuspension was performed in 46 (39 acute type A and 7 chronic type A), with an operative mortality rate of 13% +/- 5% (+/- 70% confidence limits), and aortic valve replacement in 75 (36 acute type A and 39 chronic type A), with an operative mortality rate of 20% +/- 5% (p = not significant versus resuspension). The operative mortality rate for patients requiring only repair or replacement of the ascending aorta was 32% +/- 4%. Indications for valve replacement included coexistent (nonacute) aortic valve disease, Marfan's syndrome, annuloaortic ectasia, and cases in which successful resuspension could not be accomplished. The overall actuarial survival rate for all patients was 59% +/- 3% (+/- 1 standard error of the mean), 40% +/- 4%, and 25% +/- 5% at 5, 10, and 15 years, respectively. Survival rates at these same times for patients with valve resuspension were 67% +/- 8%, 52% +/- 10%, and 26% +/- 19%, respectively; for patients who required aortic valve replacement, these survival rates were 70% +/- 5%, 39% +/- 8%, and 21% +/- 11%; finally, patients who received only an ascending aortic procedure had survival probabilities of 51% +/- 5%, 37% +/- 6%, and 23% +/- 6% (p = not significant versus resuspension versus aortic valve replacement). Multivariate analysis showed advanced age (p less than 0.001), previous cardiac or aortic operation (p less than 0.001), more preoperative dissection complications (p = 0.002), and earlier operative date (p = 0.038) to be the only significant, independent factors that increased the likelihood of early or late death. The type of aortic valve procedure (resuspension versus aortic valve replacement versus none) was not a significant predictor of mortality. Two of 46 patients with valve resuspension required late aortic valve replacement (freedom from aortic valve replacement: 100% and 80% +/- 13% at 5 and 10 years, respectively), as did 4 of 75 patients with initial aortic valve replacement (freedom from repeat aortic valve replacement: 98% +/- 2% and 73% +/- 13%, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)

    View details for Web of Science ID A1991FW77300009

    View details for PubMedID 2072730



    To assess the importance of the intact mitral subvalvular apparatus for left ventricular (LV) energetics, data from nine open-chest ejecting canine hearts were analyzed using piezoelectric crystals to measure LV volume. After mitral valve replacement with preservation of all chordae tendineae, baseline LV function was assessed during transient caval occlusion: A quadratic fit of the LV end-systolic pressure-volume data was used to determine the curvilinear end-systolic pressure-volume relationship (ESPVR). All chordae were then divided with exteriorized snares. Reassessment revealed deterioration of global LV pump function: (a) the coefficient of nonlinearity, decreased (less negative) by 90% (P = 0.06); (b) slope of the curvilinear ESPVR at the volume axis intercept, decreased by 75% (P = 0.01); and V100, end-systolic volume at 100 mmHg end-systolic pressure, increased by 42% (P less than 0.02). Similarly, preload recruitable stroke work fell significantly (-14%) and Vw1,000 (end-diastolic volume [EDV] at stroke work [SW] of 1,000 rose by 17% (P less than 0.04). With respect to LV energetics, the total mechanical energy generated by the ventricle decreased, as indicated by a decline in the slope of the pressure volume area (PVA)-EDV relationship (120 +/- 13 [mean +/- SD] vs. 105 +/- 13 mmHg, P less than 0.001). Additionally, comparison of LV SW and PVA from single beats with matched EDV showed that the efficiency of converting mechanical energy to external work (SW/PVA) declined by 14% (0.65 +/- 0.13 vs. 0.56 +/- 0.08, P less than 0.03) after chordal division. While effective systemic arterial elastance, Ea, also fell significantly (P = 0.03) after the chordae were severed, the Ea/Ees ratio (Ees = slope of the linear ESPVR) increased by 124% (0.91 +/- 0.53 vs. 2.04 +/- 0.87, P = 0.001) due to a proportionally greater decline in Ees. This indicates a mismatch in ventriculo-arterial interaction, deviating from that required for maximal external output (viz., Ea/Ees = 1). These adverse effects of chordal division may be related to the observed changes in LV geometry (i.e., eccentricity). We conclude that the intact mitral subvalvular apparatus is important in optimizing LV energetics and ventriculo-vascular coupling in addition to the enhancement of LV systolic performance.

    View details for Web of Science ID A1991EQ97600033

    View details for PubMedID 1985098

  • TREATMENT OF PATIENTS WITH AORTIC DISSECTION PRESENTING WITH PERIPHERAL VASCULAR COMPLICATIONS ANNALS OF SURGERY Fann, J. I., Sarris, G. E., Mitchell, R. S., Shumway, N. E., Stinson, E. B., Oyer, P. E., Miller, D. C. 1990; 212 (6): 705-713


    The incidence of peripheral vascular complications in 272 patients with aortic dissection during a 25-year span was determined, as was outcome after a uniform, aggressive surgical approach directed at repair of the thoracic aorta. One hundred twenty-eight patients (47%) presented with acute type A dissection, 70 (26%) with chronic type A, 40 (15%) with acute type B, and 34 (12%) with chronic type B dissections. Eighty-five patients (31%) sustained one or more peripheral vascular complications: Seven (3%) had a stroke, nine (3%) had paraplegia, 66 (24%) sustained loss of a peripheral pulse, 22 (8%) had impaired renal perfusion, and 14 patients (5%) had compromised visceral perfusion. Following repair of the thoracic aorta, local peripheral vascular procedures were unnecessary in 92% of patients who presented with absence of a peripheral pulse. The operative mortality rate for all patients was 25% +/- 3% (68 of 272 patients). For the subsets of individuals with paraplegia, loss of renal perfusion, and compromised visceral perfusion, the operative mortality rates (+/- 70% confidence limits) were high: 44% +/- 17% (4 of 9 patients), 50% +/- 11% (11 of 22 patients), and 43% +/- 14% (6 of 14 patients), respectively. The mortality rates were lower for patients presenting with stroke (14% +/- 14% [1 of 7 patients]) or loss of peripheral pulse (27% +/- 6% [18 of 66 patients]). Multivariate analysis revealed that impaired renal perfusion was the only peripheral vascular complication that was a significant independent predictor of increased operative mortality risk (p = 0.024); earlier surgical referral (replacement of the appropriate section of the thoracic aorta) or more expeditious diagnosis followed by surgical renal artery revascularization after a thoracic procedure may represent the only way to improve outcome in this high-risk patient subset. Early, aggressive thoracic aortic repair (followed by aortic fenestration and/or abdominal exploration with or without direct visceral or renal vascular reconstruction when necessary) can save some patients with compromised visceral perfusion; however, once visceral infarction develops the prognosis is also poor. Increased awareness of these devastating complications of aortic dissection and the availability of better diagnostic tools today may improve the survival rate for these patients in the future. The initial surgical procedure should include repair of the thoracic aorta in most patients.

    View details for Web of Science ID A1990EN33200009

    View details for PubMedID 2256762

    View details for PubMedCentralID PMC1358256

  • COMPARISON OF MEDICAL AND SURGICAL THERAPY FOR UNCOMPLICATED DESCENDING AORTIC DISSECTION CIRCULATION Glower, D. D., Fann, J. I., SPEIER, R. H., Morrison, L., White, W. D., Smith, L. R., Rankin, J. S., Miller, D. C., Wolfe, W. G. 1990; 82 (5): 39-46
  • THE REVERSIBILITY OF CANINE VEIN-GRAFT ARTERIALIZATION CIRCULATION Fann, J. I., Sokoloff, M. H., Sarris, G. E., Yun, K. L., Kosek, J. C., Miller, D. C. 1990; 82 (5): 9-18
  • Global and regional left ventricular systolic performance in the in situ ejecting canine heart. Importance of the mitral apparatus. Circulation Sarris, G. E., Fann, J. I., Niczyporuk, M. A., Derby, G. C., Handen, C. E., Miller, D. C. 1989; 80 (3): I24-42


    The importance of the intact mitral apparatus in left ventricular (LV) systolic performance has been indirectly suggested by clinical studies of chordal-preserving mitral valve replacement (MVR) or reconstruction. The importance of the intact mitral apparatus has been clearly demonstrated in isovolumic experimental preparations but has not been demonstrated unequivocally in ejecting hearts. Therefore, this question was assessed independently of load in an in situ, open-chest ejecting canine heart preparation (n = 9). Three orthogonal LV dimensions were measured by sonomicrometry. During MVR with complete chordal preservation, snares were placed around the anterior and posterior papillary muscles. After the hearts were weaned from cardiopulmonary bypass, LV function was assessed by caval occlusion to alter LV preload abruptly. The slopes of the end-systolic--pressure-volume (end-systolic elastance, Ees) and stroke-work--end-diastolic volume (preload-recruitable stroke work, PRSW) relations were used to measure global LV systolic function; similarly, the slopes of the end-systolic--pressure-dimension (regional end-systolic elastance, rEes) and stroke-work--end-diastolic dimension changes in regional LV systolic performance. All chordae were then divided by pulling the snares. Immediate reassessment revealed deterioration of global LV function: Ees declined by 72% (14.1 +/- 11.2 mm Hg/ml [mean +/- SD] vs. 3.9 +/- 3.5 mm Hg/ml, p less than 0.001), and PRSW declined by 39% (129 +/- 37 vs. 79 +/- 29 mm Hg, p = 0.0001). Regional LV function was also adversely affected but somewhat selectively: rEes decreased significantly in all three LV dimensions (p less than or equal to 0.03), but rPRSW decreased significantly (-21%) only in the anteroposterior minor LV axis (89 +/- 19 vs. 70 +/- 15 mm Hg, p = 0.005) and in the septal-lateral axis (-19%, p = NS). These data demonstrate the importance of the intact mitral apparatus on LV systolic performance in ejecting hearts, particularly in the LV regions subtended by the papillary muscles.

    View details for PubMedID 2766532

  • MECHANISMS RESPONSIBLE FOR INHIBITION OF VEIN-GRAFT ARTERIOSCLEROSIS BY FISH OIL CIRCULATION Sarris, G. E., Fann, J. I., Sokoloff, M. H., Smith, D. L., LOVEDAY, M., Kosek, J. C., Stephens, R. J., Cooper, A. D., May, K., Willis, A. L., Miller, D. C. 1989; 80 (3): 109-123
  • SURGICAL-MANAGEMENT OF ACUTE AORTIC DISSECTION COMPLICATED BY STROKE CIRCULATION Fann, J. I., Sarris, G. E., Miller, D. C., Mitchell, R. S., Oyer, P. E., Stinson, E. B., Shumway, N. E. 1989; 80 (3): 257-263
  • Mechanisms responsible for inhibition of vein-graft arteriosclerosis by fish oil. Circulation Sarris, G. E., Fann, J. I., Sokoloff, M. H., Smith, D. L., LOVEDAY, M., Kosek, J. C., Stephens, R. J., Cooper, A. D., May, K., Willis, A. L. 1989; 80 (3): I109-23


    Favorable changes in lipoproteins, inhibition of platelet aggregation, reduction of serum thromboxane (TX), altered plasma-membrane fluidity, and reduced production of growth factors (mitogens) have all been implicated as possibly being involved in the inhibition of arteriosclerosis by fish oil (FO), which is rich in omega 3 fatty acids; however, causal relations are mostly lacking. Several putative mechanisms responsible for the salutary effects of FO were investigated in a canine model of accelerated vein-graft arteriosclerosis. Venoarterial autografts (N = 192) were implanted in 48 hypercholesterolemic dogs divided into six groups: group A, control; B, FO (as MaxEPA, 200 mg/kg/day eicosapentaenoic acid); C, aspirin (ASA, 50 mg/kg/day); D, TX synthetase inhibitor (TXSI [CGS-12970], 10 mg/kg/day); E, FO + ASA; and F, FO + TXSI. At sacrifice 3 months later, there was no significant difference in plasma lipoproteins, hepatic low density lipoprotein-receptor concentration, red blood cell fragility, bleeding time, or platelet count compared with controls; the decrease in platelet aggregation (30 +/- 5% [mean +/- SEM]) was similar in all treatment groups. Arterialized vein-graft intimal thickening was significantly inhibited by FO (with or without ASA), while ASA alone was ineffective. Conversely, serum TX was significantly lower only in the ASA and FO + ASA groups. Serum mitogenic activity was higher at 3 months in the control group versus all treatment groups. Compared with baseline values, serum mitogenic activity rose significantly over time in the control and the TXSI groups, and an increase or rising trend was present in all other treatment groups except for the FO-treated animals. Thus, the salutary biologic effect of FO in this hypercholesterolemic model of arterialized vein grafts may have been more related to in vivo inhibition of platelet-mitogen growth factor release than to changes in lipoproteins, low density lipoprotein receptors, platelet function, or eicosanoid metabolism. These observations underscore the need for further studies to clarify the interactions between FO (omega 3 fatty acids) and paracrine cellular mitogenic factors in the context of atherosclerosis prevention.

    View details for PubMedID 2766520



    The effects of fish oil on the development of arteriosclerosis were assessed using a special susceptible strain (SEA) of Japanese quail (Coturnix coturnix japonica). Sixty four quail were randomly divided into two groups and placed on isocaloric and approximately isocholesterolic (2% by weight) diets. Group A (control) was supplemented with 10% beef tallow oil, while group B received 10% Menhaden fish oil. The birds were sacrificed at 10 weeks (early) and 15-16 weeks (late). Based on semiquantitative histological grading of the arteriosclerotic lesions in the proximal aorta and brachiocephalic arteries, a score from 1 (no lesion) to 5 (severe, diffuse lesions) was assigned. A total of 57 quail were evaluated (seven died prior to scheduled sacrifice). At the early period, the mean arteriosclerosis scores for group A (n = 8) and group B (n = 8) were 3.3 (SD 1.0) and 1.9(1.0) respectively (p less than 0.017); 63% of the quail in group A and 13% of those in group B had a score greater than or equal to 3 (p less than 0.25, NS). At the late period, the scores for group A (n = 20) and group B (n = 21) were 3.8(0.6) and 2.6(0.9), respectively (p less than 0.001); 95% of the birds in group A and 43% of those in group B had a score greater than or equal to 3 (p less than 0.005). Histopathological examination of the arteriosclerotic lesions revealed disruption of the innermost elastic lamina, increased proteoglycan deposition in the medial interlamellar spaces, and the distinct involvement of macrophage like cells. Compared to human disease, arteriosclerosis in the quail is marked by distinct similarities, as well as differences. The SEA strain of Japanese quail appears to be a practical model for the study of arteriosclerosis; fish oil reduces the severity of disease in these birds when fed a high cholesterol diet.

    View details for Web of Science ID A1989AE50600011

    View details for PubMedID 2598217



    To investigate the regional variability in arterial and venous endothelial prostacyclin (PGI2) biosynthesis, we obtained 1-cm segments of carotid arteries, external jugular veins, femoral arteries and veins, iliac arteries and veins, inferior venae cavae (IVC), and aortas from 17 dogs. Vessel luminal PGI2 production was measured in the basal state by radioimmunoassay of 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha). A total of 90 arterial specimens (57, 19, and 14 segments, respectively, of femoral/carotid arteries, iliac arteries, and aorta) and 41 venous specimens (15, 10, and 16 segments, respectively, of femoral/jugular veins, iliac veins, and IVC) were analyzed. Overall, arterial endothelial 6-keto-PGF1 alpha was higher than venous (8.1 +/- 0.5 ng/ml vs. 4.9 +/- 0.7 ng/ml, p less than 0.0004); 6-keto-PGF1 alpha levels were greater in the arteries than in their corresponding veins [femoral/carotid arteries (6.3 +/- 0.4 ng/ml) vs. femoral/jugular vein (2.1 +/- 0.4 ng/ml), p less than 0.0002; iliac arteries (9.3 +/- 1.0 ng/ml) vs. iliac veins (4.8 +/- 0.9 ng/ml), p less than 0.005; aorta (14.0 +/- 1.6 ng/ml) vs. IVC (7.5 +/- 1.4 ng/ml), p less than 0.006].(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1989U695400012

    View details for PubMedID 2655571



    The perioperative management of premature infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) complicated by pulmonary insufficiency continues to be a challenge. Definitive repair is usually delayed or staged and a gastrostomy is initially placed to prevent reflux aspiration. In patients with decreased pulmonary compliance, gastrostomy placement results in decreased intragastric pressure leading to a loss of ventilatory pressure via the tracheoesophageal fistula. A technique using the principle of underwater seal to maintain effective ventilatory pressure after gastrostomy placement is described, and two illustrative cases are presented. After acute respiratory decompensation in these patients, the gastrostomy tube was connected to underwater seal resulting in improved respiratory status. The underwater seal is allowed to intermittently "bubble," thereby permitting partial gastric decompression. This technique maintains effective ventilatory pressure after gastrostomy placement in premature infants with EA/TEF and pulmonary insufficiency until definitive therapy can be achieved.

    View details for Web of Science ID A1988L764300006

    View details for PubMedID 3351723

  • Endocardial activation mapping and endocardial pace-mapping using a balloon apparatus Am J Cardiol Fann JI, Loeb JM, LoCicero J, Frederiksen JW, Moran JM, Michaelis LL 1985; 55: 1076-1083
  • Intraoperative endocardial activation mapping and intraoperative endocardial pace-mapping using a new balloon electrode Surg Forum Fann JI, Loeb JM, LoCicero J, Frederiksen JW, Moran JM 1984; 35: 273-275