sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY April 2017 | Archived Issues

Sustaining Engagement, Finding Fulfillment as a Physician

By Bruce Gewertz, MD
Surgeon-in-Chief, Chair of the Department of Surgery

The topic of physician burnout is now inescapable. The issue has been written about extensively in the popular press and medical journals in recent years, while numerous specialty societies in medicine have addressed it in lectures and panel discussions at national meetings.

» Read more

Two Minutes With …

Michael Nurok

This question-and-answer feature will help you get to know some of the faculty in the Cedars-Sinai Department of Surgery. This month's installment features Michael Nurok, MD, PhD, medical director of the Cardiac-Surgical Intensive Care Unit.



» Read more

Brainworks Program Aims to Inspire Next Generation

BrainWorks

Cedars-Sinai neurosurgeons welcomed students from several Los Angeles-area middle schools for the daylong Brainworks Program, now in its 19th year. The program aims to inspire the next generation of neurosurgeons, scientists and researchers. This year, students were given the opportunity to use a new high-definition imaging device to perform simulated surgery.

» Read more

Hotz Helps Teach at Trauma Nurses Conference

Heidi Hotz, RN, trauma program manager, was part of the invited faculty for the 2017 Society of Trauma Nurses Annual Conference, which was recently held in St. Louis. Along with other national trauma nurse leaders, Hotz, a former president of the organization, helped teach a trauma nursing leadership workshop on April 5.

» Read more

Circle of Friends Honorees for March

CoF

The Circle of Friends program honored 378 people in March. Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai.

» Read more

How Cells React to Injury From Open-Heart Surgery

Investigators at the Cedars-Sinai Heart Institute have learned how cardiac muscle cells react to a certain type of injury that can be caused by open-heart surgery. The findings point to a new potential way to help these hearts recover more completely.

» Read more

FDA Issues Update on Erythropoiesis-Stimulating Agents

The U.S. Food and Drug Administration recently dropped the Risk Evaluation and Mitigation Strategy requirements for the erythropoiesis-stimulating agent (ESA) products Epogen/Procrit and Aranesp. ESAs are used to treat anemia resulting from chronic kidney disease, chemotherapy and certain treatments for human immunodeficiency virus, and to reduce the number of blood transfusions during and after certain major surgeries.

» Read more

CS-Link Tip: CURES Update

cs-link logo

Under CURES, the Controlled Substance Utilization Review and Evaluation System, healthcare practitioners are supposed to check the designated database within 24 hours before prescribing a controlled substance to a patient the first time. CURES can be accessed through CS-Link™.

» Read more

Sustaining Engagement, Finding Fulfillment as a Physician

By Bruce Gewertz, MD
Surgeon-in-Chief, Chair of the Department of Surgery

"That which does not kill us makes us stronger."
  — Friedrich Nietzche, German philosopher

The topic of physician burnout is now inescapable. The issue has been written about extensively in the popular press and medical journals in recent years, while numerous specialty societies in medicine have addressed it in lectures and panel discussions at national meetings.

Disturbing data support the concern for this phenomenon. Physician depression and suicide rates far exceed those of a matched population, with particularly high rates among female physicians (twice national averages). Over the past decade, surveys by the American College of Surgeons found that up to 40 percent of surgeons had significant signs of depression, and nearly two-thirds felt their work did not allow for a rewarding personal life.

One of the costs of this occupational stress has been the early retirement of many middle-aged physicians, which is particularly worrisome in several surgical subspecialties predicted to be in greater demand with the aging of the baby boomer population.

The drivers of burnout are becoming more clear. A recent study by Christine Sinsky, MD, and colleagues, funded by the American Medical Association (Annals of Internal Medicine, 2016; 165:753-760), measured the allocation of time in ambulatory practice among physicians in family medicine, internal medicine, cardiology and orthopedics, who were practicing in Illinois, New Hampshire, Virginia and Washington state.

The data is compelling: For every hour in which physicians provided direct clinical interaction, they spent two hours updating electronic health records and doing other desk work! This reality contradicts the simple yet thoughtful recommendation of Shanaree Brown and Richard Gunderman, MD, PhD (Academic Medicine, 2006; 81:577-582): "To increase fulfillment of physicians, we need to ensure that the intrinsically fulfilling aspects of the work are accentuated, not suppressed."

I think we can agree that the time distribution documented in the AMA study cannot possibly lead to much fulfillment.

Having had the privilege to chair two distinguished departments of surgery for more than 25 years, I have opinions on this subject. And as you know, "surgeons are occasionally wrong, but never in doubt."

Too many "burnout" discussions have an unfortunate side effect of casting physicians as victims. Yes, we have new and important challenges to our autonomy and daily functions, but portraying surgeons as victims seems incompatible with our personalities and personal commitments. I would rather recast the problem in a more positive light: Instead of talking about how to avoid burnout, let's figure out ways to find and sustain more fulfillment from the environments in which we find ourselves.

Fault does not lie with our personal characteristics. Physicians as a group do not lack resilience or "grit." Indeed, the gantlet of medical school and residencies we passed through testifies to that fact. Efforts to improve our character so we can better withstand the challenges we face are unlikely to work or to be well received. This is not to say that the issue should be ignored. Indeed, our candid discussion regarding attitudes and behaviors that might help us deal with stress at work can be effective and uplifting.

The only real solutions lie within the fabric of our institutions. As noted by Tait Shanafelt, MD, and John Noseworthy, MD, (Mayo Clinic Proceedings, 2017 Jan;92(1):129-146) there are substantial limitations to self-improvement strategies. These researchers argue that maintenance of an engaged and emotionally balanced physician staff requires meaningful organizational changes. To this end, they strongly suggest regular assessment of physician wellbeing, the careful weighing of incentives to avoid overwork and, most important, strengthening the leadership skills in these areas.

Empower caregivers to spend more time tending to patients and less time typing! What is elusive is determining how to accomplish this goal, given the demands for our services and the documentation now required by the medical-industrial complex.

Finding solutions for each highly specific practice situation will require your input. This month's faculty survey is one place to start. Even more to the point, our department leadership will be incented to address this problem with adjustments to our workplace. We need to redouble our efforts to structure clinic workflows to put doctors and patients together while reducing time spent on documentation requirements. New technologies being pioneered in our innovation center may help, including enhanced voice recognition programs and other platforms. Another essential ingredient is our own determination to provide strong and well-reasoned "surgical" input to solve these problems.

Two Minutes With …

This question-and-answer feature will help you get to know some of the faculty in the Cedars-Sinai Department of Surgery.

Michael Nurok, MD, PhD, medical director of the Cardiac-Surgical Intensive Care Unit

Where did you grow up?

I was born in South Africa, but my family moved around a lot when I was young. My earliest memories are of living in Durban, South Africa, and Ferrara, Italy. We finally settled in the United States, but then I moved back to South Africa when I was 17 for university and medical school.

Why did you decide to specialize in anesthesiology and IM/critical care?

In medical school, I worked with a team of exercise physiologists who studied elite athletes. I became interested in the way that the understanding of the extremes of exercise physiology applied to the extremes of pathophysiology (critical illness).

I then did my PhD looking at pre-hospital resuscitation in France, where anesthesiologists run much of critical care both in the pre-hospital and hospital setting. During the doctorate, I applied for anesthesia residencies in the United States.

After training I did fellowships in thoracic anesthesia and then cardiac anesthesia in Boston, and then took a faculty position. The fellowship director at Brigham and Women's Hospital (now a good friend), rightfully convinced me that I should do another fellowship in critical care. Unknown to me was that he had negotiated this with my wife ahead of time. It has been one of the best career choices I've made.

If you were not a physician, what other career would you choose?

Hard to say. Most likely an attorney focused on international aid work or human rights.

If you could spend the day doing one thing, what would it be?

I've picked up surfing since moving to Los Angeles. It's a great way to be in the moment and feel a sense of flow. That said, I'm a mountaineering enthusiast so I would probably choose a day climbing a peak or backcountry skiing.

What's at the top of your bucket list?

I've been fortunate to do many of the things I've wanted, so I don't really have a bucket list. The moments where you connect with your family or old friends are really precious. And so, more opportunities to do that are what I look forward to most.

Brainworks Program Aims to Inspire Next Generation

Students from four Los Angeles-area middle schools visited Cedars-Sinai this month to take part in the Brainworks Program, which seeks to inspire the next generation of neurosurgeons and scientists.

Somewhere among the beaming young faces at Cedars-Sinai earlier this month, there may well have been a future neurosurgeon or scientist.

That's the central idea behind the Brainworks Program, which welcomed about 135 middle school students from four Los Angeles-area schools on March 20. The annual program, now in its 19th year, aims to inspire the next generation.

For the first time, this year's students had the opportunity to use a new high-definition imaging device to perform simulated surgery and see the inside of the brains of patient simulators. The humanlike simulators have pulses and can eat, breathe, speak and blink.

The activity was just one aspect of the program, hosted by Keith L. Black, MD, chair of the Department of Neurosurgery and director of the Maxine Dunitz Neurosurgical Institute.

Black started Brainworks in 1998 to help cultivate the same kind of passion for science that he discovered as a boy. He greeted the students and introduced them to techniques in neurosurgery.

"Brainworks came about because we wanted to expose as many young minds as possible to how exciting science is and especially how fascinating the brain is," said Black. "Once they experience performing virtual surgery on a robot and look at tumors under a microscope, they start to believe that becoming a neurosurgeon or neuroscience researcher is in reach."

Students received hands-on experience with a virtual surgery station equipped with 3-D imaging, microscopes and a phantom skull. In addition to looking over a surgical station with instruments from the operating room, students also learned about therapeutic applications for brain tumor patients.

A nationally recognized leader in clinical and translational research in cerebrovascular studies, Nestor Gonzalez, MD, gave a keynote presentation to the student group. One student asked if he gets nervous when performing surgery, especially when the stakes can be life or death.

"There's always a bit of stress because we're concerned about the patient," said Gonzalez. "I want the patient to do well, but that stress allows you to be a perfectionist. It makes you aware of everything in the best possible way."

Hotz Helps Teach at Trauma Nurses Conference

Heidi Hotz, RN, trauma program manager, was part of the invited faculty for the 2017 Society of Trauma Nurses Annual Conference, which was recently held in St. Louis. Along with other national trauma nurse leaders, Hotz, a former president of the organization, helped teach a trauma nursing leadership workshop on April 5.

Hotz's workshop was designed to assist trauma professionals improve their knowledge of leadership principles. Her program supports Cedars-Sinai's mission to educate healthcare professionals, promote clinical excellence and provide trauma system leadership nationally.

Circle of Friends Honorees for March

The Circle of Friends program honored 378 people in March.

Circle of Friends allows grateful patients to make a donation in honor of the physicians, nurses, caregivers and others who have made a difference during their time at Cedars-Sinai. When a gift is made, the person being honored receives a custom lapel pin and a letter of acknowledgement.

Click here for more information about the program and for a list of past honorees.

  • Rachel Abuav, MD
  • Kenneth Adashek, MD
  • David E. Aftergood, MD
  • Keith L. Agre, MD
  • David B. Agus, MD
  • Thomas G. Ahn, MD
  • Michael J. Alexander, MD
  • Farin Amersi, MD
  • Neel A. Anand, MD
  • Sandra E. Anderson
  • Ronald M. Andiman, MD
  • John B. Andrews, MD
  • Renette Grace D. Antonio, RN
  • Thomas Apostle, DO
  • Arash Asher, MD
  • David Austin, MD
  • Babak Azarbal, MD
  • George Baghdassarian
  • Shirin Bagheri, MD
  • Parvaneh Bahmani, MD
  • Esther Baik, MD
  • C. Noel Bairey Merz, MD
  • Mark Bamberger, MD
  • Babak R. Bamshad, MD
  • Siamak Barkhordarian, MD
  • Beverly A. Barlongo, BSN, RN-C
  • Tranell V. Barron, RN
  • Peiman Berdjis, MD
  • Arash Bereliani, MD
  • Jason A. Berkley, DO
  • Satinder J. Bhatia, MD
  • Kurtis Birch, MD
  • Kade T. Birkeland, PharmD
  • Keith L. Black, MD
  • Swaraj Bose, MD
  • Earl W. Brien, MD
  • Barry J. Brock, MD
  • Tara A. Brooke, RN
  • Michael Brousseau, MD
  • Neil A. Buchbinder, MD
  • Matthew H. Bui, MD, PhD
  • Miguel A. Burch, MD
  • Christiane Michele J. Burnison, MD
  • Michael A. Bush, MD
  • David S. Cannom, MD
  • James L. Caplan, MD
  • Jeffrey F. Caren, MD
  • Ilana Cass, MD
  • Dorrie Chang, MD
  • Kirk Y. Chang, MD
  • Piyaporn Chantravat, RN
  • Cheryl G. Charles, MD
  • Timothy Charlton, MD
  • George Chaux, MD
  • Sant P. Chawla, MD
  • Derek Cheng, MD
  • Wendy W. Cheng, MD
  • Ray M. Chu, MD
  • Andrew Chuang, MD
  • Sumeet S. Chugh, MD
  • Alice P. Chung, MD
  • Arnold C. Cinman, MD
  • Paul Cohart, MD
  • Hart C. Cohen, MD
  • J. Louis Cohen, MD
  • Jason S. Cohen, MD
  • Myles J. Cohen, MD
  • William B. Cohen, MD
  • Steven D. Colquhoun, MD
  • Stephen T. Copen, MD
  • Stephen R. Corday, MD
  • David Cossman, MD
  • Alice C. Cruz, MD
  • Donald C. Dafoe, MD
  • Ram C. Dandillaya, MD
  • Catherine M. Dang, MD
  • Dudley S. Danoff, MD
  • Hal C. Danzer, MD
  • Mark M. Davidson, MD
  • Robert M. Davidson, MD
  • Robert W. Decker, MD
  • Zenaida DeJesus, RN
  • Premal J. Desai, MD
  • Stephen C. Deutsch, MD
  • Nicholas Di Domenico, MD
  • Vanessa C. Diaz, RN
  • Alice R. Dick, MD
  • Jack Ditlove, MD
  • Suhail Dohad, MD
  • Noam Z. Drazin, MD
  • J. Kevin Drury, MD
  • Julie A. Dunhill, MD
  • Cheryl L. Dunnett, MD
  • Ashkan Ehdaie, MD
  • Karyn Eilber, MD
  • Yaron Elad, MD
  • Joshua D. Ellenhorn, MD
  • Shahrooz Eshaghian, MD
  • Shervin Eshaghian, MD
  • Fardad Esmailian, MD
  • Richard Essner, MD
  • Dennis W. Evangelatos, MD
  • Moses J. Fallas, MD
  • Joel D. Feinstein, MD
  • David E. Fermelia, MD
  • Robert A. Figlin, MD
  • Sarah E. Figueroa, RN
  • David M. Filsoof, MD
  • Christopher R. Fitzgerald, MD
  • Brian L. Flyer, MD
  • Charles A. Forscher, MD
  • Arnold S. Friedman, MD
  • Larry Froch, MD
  • Gerhard J. Fuchs, MD
  • Clark B. Fuller, MD
  • Kristi M. Funk, MD
  • Viliam Furdik, MD
  • Steven S. Galen, MD
  • Eli S. Gang, MD
  • Elayne K. Garber, MD
  • Avrom Gart, MD
  • Ivor L. Geft, MD
  • Leena C. Gibson, MD
  • Armando E. Giuliano, MD
  • Julian A. Gold, MD
  • Richard N. Gold, MD
  • Neil J. Goldberg, MD
  • Sherry L. Goldman, RN, NP
  • Pearl Joy B. Gonzales
  • Nestor Gonzalez, MD
  • Jeffrey S. Goodman, MD
  • Martin N. Gordon, MD
  • Stephen L. Graham, MD
  • Jeffrey R. Gramer, MD
  • Violette G. Gray, MD
  • Leland M. Green, MD
  • Jon B. Greenfield, MD
  • Lloyd B. Greig, MD
  • James Ha, MD
  • Antoine Hage, MD
  • Melinda A. Hakim, MD
  • Behrooz Hakimian, MD
  • David S. Hallegua, MD
  • Solomon I. Hamburg, MD
  • Sabrina Hameed, RN
  • Omid Hamid, MD
  • Michele A. Hamilton, MD
  • Stephanie J. Handler, MD
  • John G. Harold, MD
  • Michael D. Harris, MD
  • Julia M. Harrison, RN
  • Jeffrey S. Helfenstein, MD
  • Theresa C. Henderson, MD
  • Andrew E. Hendifar, MD
  • Heather Henry, BSN, RN-BC, CCRN
  • Allen S. Ho, MD
  • Ivan Ho, MD
  • David M. Hoffman, MD
  • Martin L. Hopp, MD
  • Gabriel E. Hunt Jr., MD
  • Asma Hussaini, MS, PA-C
  • Joseph Isaacson, MD
  • Kristin Jacobs, MS, CEP
  • Marney Jakubowicz, LVN
  • Bojana Jankovic, MD
  • Jay L. Jordan, MD
  • Stanley C. Jordan, MD
  • Peter Julien, MD
  • Steven Kamara, MD
  • David J. Kanani, MD
  • Christopher Kang, MD
  • Saibal Kar, MD
  • Beth Y. Karlan, MD
  • Ronald P. Karlsberg, MD
  • David Kawashiri, MD
  • Stephen P. Kay, MD
  • Ilan Kedan, MD, MPH
  • Walter F. Kerwin, MD
  • Raj Khandwalla, MD
  • Ali Khoynezhad, MD, PhD
  • Hyung L. Kim, MD
  • Irene Kim, MD
  • Lucy Kim, LCSW, ACM
  • Sang D. Kim, MD
  • Jeanlee King-Baettig, RN
  • Michelle M. Kittleson, MD, PhD
  • Robert Klapper, MD
  • Jon A. Kobashigawa, MD
  • Karen Kornreich, MD
  • Stephanie Koven, MD
  • Michael A. Kropf, MD
  • Lyle D. Kurtz, MD
  • Stuart H. Kuschner, MD
  • Marie Kristine A. Lacar, RN
  • Noel B. Lara, RN
  • Letitia Lau, MD
  • Gary E. Leach, MD
  • Thomas J. Learch, MD
  • Ella Louise Leggett
  • Walter Lemankiewicz, RN
  • Roger L. Lerner, MD
  • Ronald S. Leuchter, MD
  • Michael Levesque, MD
  • Meldon C. Levy, MD
  • Andrew J. Li, MD
  • Charlene T. Lichtash, MD
  • Daniel Lieber, MD
  • Arthur E. Lipper, MD
  • Milton Little, MD
  • Howard L. Liu, MD
  • Simon K. Lo, MD
  • Joseph Loewy, MD
  • Maryanne Loyola
  • Lorraine N. Lubin, MD
  • Patrick D. Lyden, MD
  • Fataneh Majlessipour, MD
  • Rajendra Makkar, MD
  • Alberto J. Mallari
  • Adam N. Mamelak, MD
  • Laila Massie, RN
  • Ruchi Mathur, MD
  • David N. Matsumura, MD
  • Bryan M. May, RN
  • Philomena McAndrew, MD
  • Robert J. McKenna Jr., MD
  • Sharron L. Mee, MD
  • Hovik S. Mekhjian, PharmD
  • Farhad Melamed, MD
  • Leslie Memsic, MD
  • Maria C. Mendoza
  • Noah Merin, MD
  • Erin Meschter, MD
  • Kiarash Michel, MD
  • Amin Joseph Mirhadi, MD
  • Alain Mita, MD
  • Monica M. Mita, MD, MDSc
  • Cyrus Mody, MD
  • Avinash Mondkar, MD
  • Charles N. Moon, MD
  • Beth A. Moore, MD
  • Wendy M. Morell, RN
  • Manual N. Moreno Perez
  • Nena Musto, RN
  • Mamoo Nakamura, MD
  • Ashkan L. Naraghi, MD
  • Ronald B. Natale, MD
  • Sofia Nava, RN
  • Ricardo Navas, MD
  • Ronen Nazarian, MD
  • Kristin Nesburn, MD
  • David G. Ng, MD
  • Nicholas N. Nissen, MD
  • Paul W. Noble, MD
  • Edward Kazuhisa Nomoto, MD
  • Sun Jung Oh, MD
  • Farah Omidbakhsh
  • Rosa Orellana
  • Jay S. Orringer, MD
  • Adrian G. Ostrzega, MD
  • Guy D. Paiement, MD
  • Megan L. Palermo, RN
  • Shi-Hui Pan, PharmD
  • Stephen J. Pandol, MD
  • Dorothy J. Park, MD
  • Chirag G. Patil, MD
  • A. Randolph Pearlstein, MD
  • Brad Penenberg, MD
  • Deena Perotti, MD
  • Brian Perri, DO
  • Tiffany Perry, MD
  • Glenn B. Pfeffer, MD
  • Alistair Phillips, MD
  • Edward H. Phillips, MD
  • Mark Pimentel, MD
  • Julie I. Pinero, RN
  • Alicia Porter, RN
  • Samuel J. Porter, MD
  • Edwin M. Posadas, MD
  • Irving Posalski, MD
  • Anna Claire Puhky, RN
  • Susan M. Rabizadeh, MD
  • Shervin Rabizadeh, MD
  • David S. Ramin, MD
  • Soroush A. Ramin, MD
  • Danny Ramzy, MD, PhD
  • Rajeev K. Rao, MD
  • Alexandre Rasouli, MD
  • Ali Rezaie, MD
  • Madison F. Richardson, MD
  • Harvey S. Richmond, MD
  • Bobbie J. Rimel, MD
  • Sepehr Rokhsar, MD
  • Grace A. Romulo
  • Robert M. Rose, MD
  • Sonja Louisa Rosen, MD
  • Barry E. Rosenbloom, MD
  • Fred P. Rosenfelt, MD
  • Ruth "Virginia" Russell, MD
  • Amy S. Rutman, MD
  • Stephen A. Sacks, MD
  • Wendy L. Sacks, MD
  • Gloria D. Salapare, RN
  • Vivian L. Salle, RN
  • Howard M. Sandler, MD, MS
  • Gregory P. Sarna, MD
  • Jay N. Schapira, MD, FACP, FAHA, FCCP, FACC
  • Kevin Scher, MD
  • Daniela Schiesaro, RN
  • Wouter I. Schievink, MD
  • Deborah Schmidt
  • Scott Serden, MD
  • Cigal T. Shaham, MD
  • Alan E. Shapiro, MD
  • Omid A. Shaye, MD
  • Michael M. Shehata, MD
  • John L. Sherman, MD
  • Randolph Sherman, MD
  • Arvind M. Shinde, MD
  • Vivian N. Shirvani, MD
  • Daniel Shouhed, MD
  • Nancy L. Sicotte, MD
  • Robert J. Siegel, MD
  • John W. Sigler
  • Allan W. Silberman, MD, PhD
  • Alan G. Silverman, MD
  • Steven M. Simons, MD
  • R. Kendrick "Ken" Slate, MD
  • Jason Snibbe, MD
  • Tourage Soleimani, MD
  • Karyn Morse Solky, MD
  • Mitchell J. Spirt, MD
  • Andrew Ira Spitzer, MD
  • Jasminka Stegic, MS, ANP-BC, CCRN
  • Jay J. Stein, MD
  • Theodore N. Stein, MD
  • Jerrold H. Steiner, MD
  • Daniel J. Stone, MD
  • Leslie Stricke, MD
  • Ronald Sue, MD
  • Joseph Sugerman, MD
  • Charles D. Swerdlow, MD
  • Steven Sykes, MD
  • Lillian Szydlo, MD
  • Steven W. Tabak, MD
  • Michele Tagliati, MD
  • Victor F. Tapson, MD
  • Stephan R. Targan, MD
  • David B. Thordarson, MD
  • Janessa Tiu, RN
  • Hitoshi "Tommy" Tomizawa, MD, MPH
  • Sam S. Torbati, MD
  • Dietra Torres
  • Tram T. Tran, MD
  • Alfredo Trento, MD
  • Leo Treyzon, MD, MS
  • Richard Tuli, MD, PhD
  • Mark K. Urman, MD
  • Irina A. Urusova, MD
  • Leticia O. Uy, RN, OCN
  • Akira Uyeki, MD
  • Michael B. Van Scoy-Mosher, MD
  • Swamy R. Venuturupalli, MD
  • Robert A. Vescio, MD
  • Ronald G. Victor, MD
  • Daniel J. Wallace, MD
  • Alan Weinberger, MD
  • Jonathan M. Weiner, MD
  • Michael H. Weisman, MD
  • John Williams III, MD
  • Donald A. Wiss, MD
  • Robert N. Wolfe, MD
  • Clement C. Yang, MD
  • Payam R. Yashar, MD
  • Karen Zaghiyan, MD
  • Evan M. Zahn, MD
  • Phillip C. Zakowski, MD
  • Raymond Zimmer, MD
  • Millard H. Zisser, MD

How Cells React to Injury From Open-Heart Surgery

Investigators at the Cedars-Sinai Heart Institute have learned how cardiac muscle cells react to a certain type of injury that can be caused by open-heart surgery. The findings point to a new potential way to help these hearts recover more completely.

The cells, known as cardiomyocytes, can be damaged by the process of stopping and starting the heart during surgeries that use cardiopulmonary bypass machines to take over the heart's functions. Hundreds of thousands of these operations are performed each year in the U.S. to replace failing hearts, bypass clogged arteries, fix leaky valves and more.

While most patients recover easily enough, some patients suffer long-term effects or even fatal heart failure from the stresses of the surgery.

In their study, published in the JCI Insight journal of the American Society for Clinical Investigation, the investigators scrutinized cardiac muscle cells in tissue samples taken from patients before and after open-heart surgeries. Their work demonstrates for the first time in human hearts that cardiac muscle cells react to this type of injury by both destroying and creating new mitochondria, the tiny energy factories inside each cell.

"By accelerating beneficial aspects of this process, doctors one day may be able to speed up healing from open-heart surgery," said Roberta Gottlieb, MD, director of Molecular Cardiobiology and professor of Medicine at the Cedars-Sinai Heart Institute. She was the principal investigator of the study.

Now, physicians try to protect the cardiac muscle during open-heart surgery by cooling it and infusing it with potassium to stop its contractions. The goal is to reduce the trauma produced by the one-two punch of first depriving the heart of blood (ischemia) and then flooding it with blood (reperfusion).

"Despite these measures, ischemia/reperfusion injury remains a major cause of complications after heart surgery," said Allen Andres, PhD, a research scientist in Gottlieb's laboratory and assistant professor of Medicine. He was the first author of the study, working with Robert Mentzer, MD, professor of Medicine, who initiated and designed the study.

Investigators have tried for decades to develop drugs to treat ischemia/reperfusion injury associated with cardiac surgeries, with little success, according to Gottlieb.

"There have been wonderful results in animal tests, but not in people," she said. "We need to have a better understanding of the beneficial and deleterious processes that characterize the human heart's response to ischemia and reperfusion."

Before beginning the study, the Cedars-Sinai investigative team had expected to find that cardiac muscle cells would dismantle some of the mitochondria after ischemia/reperfusion injury. This process was known to occur in the hearts of laboratory animals. Cells and cell structures in various parts of the body often self-destruct after their genetic material gets damaged by stress or other events.

The investigators were gratified to confirm that mitochondria self-destructed in the human heart too. But they were surprised to learn that human cardiac muscle cells also assembled new mitochondria in response to ischemia/reperfusion injury.

"We don't know if this mitochondrial production is good or bad news for the heart," Gottlieb said. "These could be better mitochondria or carry genetic defects. We intend to find out."

To learn more, the investigators are developing proposals to collect data on mitochondria from heart transplant patients over a period of months. And they are already investigating a pharmacological agent that shows promise in stimulating mitochondrial creation in animal models.

Researchers from Beaumont Hospital in Dearborn, Michigan, and the University of Alabama in Birmingham also contributed to this study. Research reported in this publication was supported by the National Institutes of Health under award numbers P01 HL112730, R01 HL132075 and R01 HL103859, and by the American Heart Association.

FDA Issues Update on Erythropoiesis-Stimulating Agents

The U.S. Food and Drug Administration (FDA) recently dropped the Risk Evaluation and Mitigation Strategy requirements for the erythropoiesis-stimulating agent (ESA) products Epogen/Procrit and Aranesp. ESAs are used to treat anemia resulting from chronic kidney disease, chemotherapy and certain treatments for human immunodeficiency virus, and to reduce the number of blood transfusions during and after certain major surgeries.

The FDA website has more information.

CS-Link Tip: CURES Update

Under CURES, the Controlled Substance Utilization Review and Evaluation System, healthcare practitioners are supposed to check the designated database within 24 hours before prescribing a controlled substance to a patient the first time. In addition, they are supposed to check again at least every four months, if treatment continues with the substance.

To get to CURES from CS-Link™, go to the upper toolbar, where you have WEB ACTIVITIES. Click on State Agencies. CURES is there.

Once you’ve looked up your patient, you can document. Type ".cures."

The list of exclusions is there. For example, you are exempt from checking the database if the patient is under hospice care, or providing post-operative or emergency department treatment with a nonrefillable supply lasting fewer than five days.

If you forget your password or get locked out, email cures@doj.ca.gov or call 916-227-3843.