- Cardiac Anesthesia
- Perioperative Transesophageal Echocardiography
Clinical Professor, Anesthesiology, Perioperative and Pain Medicine
Associate Dean, Post Graduate Medical Education and Continuing Medical Education, Stanford School of Medicine (2018 - Present)
Member, Wellbeing Committee, Stanford Hospital and Clinics (2018 - Present)
Program Director, Adult Cardiothoracic Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Stanford School of Medicine (2017 - Present)
Vice-Chief of Education, Division Cardiothoracic Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Stanford School of Medicine (2015 - Present)
Director, Perioperative Echocardiography Services and Education, Department of Anesthesiology, Critical Care, and Pain Medicine, Stanford School of Medicine (2013 - Present)
Residency: Brigham and Women's Hospital Harvard Medical School (2005) MA
Internship: Brigham and Women's Hospital Harvard Medical School (2002) MA
Board Certification: American Board of Anesthesiology, Anesthesia (2006)
Medical Education: Harvard Medical School (2001) MA
Graduate and Fellowship Programs
Cardiac Anesthesia (Fellowship Program)
- Are anesthesiology societies at risk of becoming obsolete? Perspectives on challenges and opportunities for moving forward. International anesthesiology clinics 2020
- A Review of Perioperative Analgesic Strategies in Cardiac Surgery INTERNATIONAL ANESTHESIOLOGY CLINICS 2018; 56 (4): E56–E83
- Preface INTERNATIONAL ANESTHESIOLOGY CLINICS 2018; 56 (4): 1–2
International anesthesiology clinics
2018; 56 (4): 1–2
View details for PubMedID 30204601
A Review of Perioperative Analgesic Strategies in Cardiac Surgery.
International anesthesiology clinics
2018; 56 (4): e56–e83
View details for PubMedID 30204605
The Heart of the Matter: Increasing Quality and Charge Capture from Intraoperative Transesophageal Echocardiography.
A & A case reports
2016; 6 (8): 249-252
Although transesophageal echocardiography is routinely performed at our institution, there is no easy way to document the procedure in the electronic medical record and generate a bill compliant with reimbursement requirements. We present the results of a quality improvement project that used agile development methodology to incorporate intraoperative transesophageal echocardiography into the electronic medical record. We discuss improvements in the quality of clinical documentation, technical workflow challenges overcome, and cost and time to return on investment. Billing was increased from an average of 36% to 84.6% when compared with the same time period in the previous year. The expected recoupment of investment for this project is just 18 weeks.
View details for DOI 10.1213/XAA.0000000000000169
View details for PubMedID 27082233
Factors Contributing to Adverse Perioperative Events in Adults with Congenital Heart Disease: A Structured Analysis of Cases from the Closed Claims Project
CONGENITAL HEART DISEASE
2015; 10 (1): 21-29
Prior investigations have suggested that the rapidly growing population of adults with congenital heart disease is at increased risk of perioperative morbidity and mortality, but information is limited on the nature of those perioperative factors that may relate to adverse outcomes. We sought to use a national claims database to describe the contribution of perioperative factors to adverse outcomes and compare contributing factors in cardiac vs. noncardiac operations.The study is a retrospective in-depth structured analysis of cases from the Anesthesia Closed Claims Project database.We examined the largest national anesthesia malpractice claims database.We included all claims cases involving adult patients with congenital heart disease (CHD).Patients in this retrospective analysis were classified by type of surgery (cardiac or noncardiac).Perioperative factors contributing to an adverse event were assessed by an expert panel of cardiac anesthesiologists.Of 21 confirmed cases, 11 (52%) involved cardiac procedures and 10 (48%) noncardiac procedures. The most common factors contributing to the adverse event in cardiac cases were surgical technique (73% of cases) and intraoperative anesthetic care (55%), whereas in noncardiac cases, postoperative monitoring/care (50%), CHD (50%) and preoperative assessment or optimization (40%) were most common. The factors contributing to the patient injury differed similarly: in cardiac cases, the most common factors were intraoperative anesthetic care (55%) and surgical technique (45%) compared with postoperative monitoring/care (50%) and CHD (50%) in noncardiac cases.Within the limitations of a small number of events in a claims-based database, this study offers advantages of being a national, structured analysis of real cases to provide detailed information on phenomena that are otherwise abstract and hypothesized by expert opinion. These results should help affirm the role of anesthesiologists in acquiring and executing expertise as consultants in perioperative medicine for adults with congenital heart disease patients.
View details for DOI 10.1111/chd.12188
View details for Web of Science ID 000349462600010
View details for PubMedID 24869762
Factor VIII Inhibitor Bypass Activity and Recombinant Activated Factor VII in Cardiac Surgery
JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA
2014; 28 (5): 1221-1226
Postcardiopulmonary bypass hemorrhage remains a serious complication of cardiac surgery. Given concerns regarding adverse effects of blood product transfusion and limited efficacy of current antifibrinolytics, procoagulant medications, including recombinant factor VIIa (rFVIIa) and factor eight inhibitor bypass activity (FEIBA), increasingly have been used in managing refractory bleeding. While effective, these medications are associated with thromboembolic complications. This study compared the efficacy and risk of adverse events of rFVIIa and FEIBA in cardiac surgical patients with refractory bleeding.This retrospective study evaluated 168 patients who underwent cardiac surgery and received either FEIBA or rFVIIa to manage postbypass hemorrhage. Demographic, clinical, and outcomes data were collected and statistical analysis performed to compare thromboembolic event rates, relative efficacy, and 30-day mortality following administration of these medications.Single university hospital.Patients undergoing cardiac surgery.None.Sixty-one patients received rFVIIa, and 107 received FEIBA. Demographics, surgical procedures, and preoperative anticoagulation were similar between the cohorts; however, the rFVIIa cohort had longer durations of cardiopulmonary bypass (305.1 v 243.8 min, p<0.01). There were no significant differences in the number of thromboembolic events, 30-day mortality, or rates of revision surgery. Neither group demonstrated a clear relationship between dosage and occurrence of thromboembolic events. The rFVIIa cohort received more platelets than the FEIBA cohort (3.13 v 1.67 units, p = 0.01), but transfusion rates of other blood products were similar.This study suggests that rFVIIa and FEIBA have similar efficacy and adverse event profiles in managing intractable postbypass hemorrhage in cardiac surgical patients. Further prospective studies are required.
View details for DOI 10.1053/j.jvca.2014.04.015
View details for Web of Science ID 000343188500009
Perioperative management of combined carotid and coronary artery bypass grafting procedures.
2014; 32 (3): 699-721
The objective of this review is to provide a high level overview on current thinking for treatment of patients with combined carotid and coronary artery disease given that these patients are at higher risk of adverse cardiac events, stroke, and death. This review discusses (1) the current literature addressing perioperative stroke risk in the setting of coronary artery bypass graft, (2) the literature regarding different surgical approaches when both carotid and coronary revascularization are being considered, and (3) the data available to guide optimal management of this complex patient population to minimize complications regardless of the surgical approach taken.
View details for DOI 10.1016/j.anclin.2014.05.005
View details for PubMedID 25113728
Congenital anomalies of the aortic arch in acute type-a aortic dissection: implications for monitoring, perfusion strategy, and surgical repair.
Journal of cardiothoracic and vascular anesthesia
2014; 28 (3): 467-472
To assess whether management of acute Stanford type-A aortic dissection differs in patients with congenital anomalies of the aortic arch compared with standard institutional practice.Retrospective analysis of all consecutive patients from 2001 through 2011.Quaternary referral center for surgical management of thoracic aortic disease.All patients with arch anomalies who underwent surgery for acute Stanford type-A aortic dissection during the study period (n = 43).Surgical management, anesthetic monitoring, and perfusion strategy were analyzed in a retrospective fashion. No new interventions were undertaken as part of this study.Management differed most in patients with an aberrant right subclavian artery (n = 5), because the institutional standard of right axillary artery cannulation with left upper extremity arterial pressure monitoring was not possible. In patients with one of two "bovine" arch patterns (n = 32), management differed in the conduct of selective antegrade cerebral perfusion, which could include clamping above or below the takeoff of the left common carotid artery (and, therefore, produced unilateral or bilateral antegrade cerebral perfusion). All patients with a connective tissue disorder exhibited a bovine arch pattern. Management of patients with a right arch (n = 3) reflected the opposite of management for normal anatomy (for patients with traditional mirror-image branching) or opposite that of the aberrant right subclavian group (for patients who had a corresponding aberrant left subclavian artery).Rational management reflected the anatomic variations observed. These results support the importance of interdisciplinary planning, especially in an emergency, to optimize outcome.
View details for DOI 10.1053/j.jvca.2013.12.001
View details for PubMedID 24731741
- Tricuspid regurgitation jet velocity suggestive of severe pulmonary hypertension. Journal of cardiothoracic and vascular anesthesia 2014; 28 (2): 433-434
Comparative Study of Factor Eight Inhibitor Bypass Activity and Recombinant Activated Factor VII in Refractory Post-Cardiopulmonary Bypass Bleeding
Scientific Sessions of the American-Heart-Association/Resuscitation Science Symposium
LIPPINCOTT WILLIAMS & WILKINS. 2011
View details for Web of Science ID 000299738708362
Safety of Transesophageal Echocardiography
JOURNAL OF THE AMERICAN SOCIETY OF ECHOCARDIOGRAPHY
2010; 23 (11): 1115-1127
Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed.
View details for DOI 10.1016/j.echo.2010.08.013
View details for Web of Science ID 000283437300001
View details for PubMedID 20864313
- Cardiopulmonary Bypass in 2009: Achieving and Circulating Best Practices ANESTHESIA AND ANALGESIA 2009; 108 (5): 1368-1370
- Intraoperative monitoring of elephant trunk kinking with transesophageal echocardiography JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA 2007; 21 (4): 584-586