Remembering Dr. Frank Shannon
May 15, 1952 – July 29, 2024
Dear friends,
Dr. Frank Shannon passed away on July 29, 2024, at the age of 72. Dr. Shannon was a highly skilled cardiac surgeon and a visionary leader. As a founding member of the Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) Quality Collaborative, he was instrumental in the adoption of Phase of Care Mortality Analysis (POCMA) in Michigan. His dedication to improving patient care and outcomes was unwavering.
Dr. Shannon’s commitment to the MSTCVS community and his efforts to enhance the quality of cardiac care will be greatly missed. His legacy of clinical excellence, innovative research, and mentorship has left a lasting impact on many.
Visitation will be held on Friday, August 2, 2024, from 3:00 PM to 9:00 PM at A.J. Desmond & Sons Funeral Home – Vasu, Rodgers, Connell Chapel (32515 Woodward Avenue, Royal Oak, MI 48073). A Funeral Mass in Dr. Shannon’s honor will take place on Saturday, August 3, 2024, at 10:00 AM at Holy Name Catholic Church (630 Harmon Street, Birmingham, MI 48009), with visitation beginning at 9:30 AM.
In lieu of flowers, memorial tributes may be made out to the American Heart Association or the American Cancer Society.
Please visit the funeral chapel website for updates or to leave fond memories or condolences to the Shannon family.
Regards,
The MSTCVS Quality Collaborative
Publications
July 2021
Failure to rescue: variation in mortality after cardiac surgery
Milan Milojevic, MD; Chris Bond, MD; Chang He, MS; Francis L Shannon, MD; Melissa Clark, MSN; Patricia F. Theurer, MSN; Richard L Prager, MD
Objectives: Measures to prevent surgical complications are critical components of optimal patient care, and adequate management when complications occur is equally crucial in efforts to reduce mortality. This study aims to elucidate clinical realities underlying in-hospital variations in failure to rescue (FTR) after cardiac surgery.
Methods: Using a statewide database for a quality improvement program, we identified 62 450 patients who had undergone adult cardiac surgery between 2011 and 2018 in 1 of the 33 Michigan hospitals performing adult cardiac surgery. The hospitals were first divided into tertiles according to their observed to expected (O/E) ratios of 30-day mortality: low-mortality tertile (O/E 0.46–0.78), intermediate-mortality tertile (O/E 0.79–0.90) and high-mortality tertile (O/E 0.98–2.00). We then examined the incidence of 15 significant complications and the rates of death following complications among the 3 groups.
Results: A total of 1418 operative deaths occurred in the entire cohort, a crude mortality rate of 2.3% and varied from 1.3% to 5.9% at the hospital level. The death rates also diverged significantly according to mortality score tertiles, from 1.6% in the low-mortality group to 3.2% in the high-mortality group (P < 0.001). Hospitals ranked in a high- or intermediate-mortality tertile had similar rates of overall complications (21.3% and 20.7%, P = 0.17), while low-mortality hospitals had significantly fewer complications (16.3%) than the other 2 tertiles (P < 0.001). FTR increased in a stepwise manner from low- to high-mortality hospitals (8.3% vs 10.0% vs 12.7%, P < 0.001, respectively). Differences in FTR were related to survival after cardiac arrest, multi-system organ failure, prolonged ventilation, reoperation for bleeding and severe acute kidney disease that requires dialysis.
Conclusions: This study demonstrates that timely recognition and appropriate treatment of complications are as important as preventing complications to further reduce operative mortality in cardiac surgery. FTR tools may provide vital information for quality improvement initiatives.
March 2021
Surgical Explantation of Transcatheter Aortic Valve Bioprostheses: A Statewide Experience
Alexander A. Brescia, MD, MSc; G. Michael Deeb, MD; Stephane Leung Wai Sang, MD, MSc; Daizo Tanaka, MD; P. Michael Grossman, MD; Devraj Sukul, MD, MSc; Chang He, MS; Patricia F. Theurer, MSN; Melissa Clark, MSN; Francis L. Shannon, MD; Stanley J. Chetcuti, MD; Shinichi Fukuhara, MD
Background:
Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) since its initial approval in 2011, the frequency and outcomes of surgical explantation of TAVR devices (TAVR-explant) is poorly understood.
Methods:
Patients undergoing TAVR-explant between January 2012 and June 2020 at 33 hospitals in Michigan were identified in the Society of Thoracic Surgeons Database and linked to index TAVR data from the Transcatheter Valve Therapy Registry through a statewide quality collaborative. The primary outcome was operative mortality. Indications for TAVR-explant, contraindications to redo TAVR, operative data, and outcomes were collected from Society of Thoracic Surgeons and Transcatheter Valve Therapy databases. Baseline Society of Thoracic Surgeons Predicted Risk of Mortality was compared between index TAVR and TAVR-explant.
Results:
Twenty-four surgeons at 12 hospitals performed TAVR-explants in 46 patients (median age, 73). The frequency of TAVR-explant was 0.4%, and the number of explants increased annually. Median time to TAVR-explant was 139 days and among known device types explanted, most were self-expanding valves (29/41, 71%). Common indications for TAVR-explant were procedure-related failure (35%), paravalvular leak (28%), and need for other cardiac surgery (26%). Contraindications to redo TAVR included need for other cardiac surgery (28%), unsuitable noncoronary anatomy (13%), coronary obstruction (11%), and endocarditis (11%). Overall, 65% (30/46) of patients underwent concomitant procedures, including aortic repair/replacement in 33% (n=15), mitral surgery in 22% (n=10), and coronary artery bypass grafting in 16% (n=7). The median Society of Thoracic Surgeons Predicted Risk of Mortality was 4.2% at index TAVR and 9.3% at TAVR-explant (P=0.001). Operative mortality was 20% (9/46) and 76% (35/46) of patients had in-hospital complications. Of patients alive at discharge, 37% (17/37) were discharged home and overall 3-month survival was 73±14%.
Conclusions:
TAVR-explant is rare but increasing, and its clinical impact is substantial. As the utilization of TAVR expands into younger and lower-risk patients, providers should consider the potential for future TAVR-explant during selection of an initial valve strategy.
December 2019
Transcatheter Versus Surgical Aortic Valve Replacement Episode Payments and Relationship to Case Volume
Alexander A. Brescia, MD; John D. Syrjamaki, MPH; Scott E. Regenbogen, MD; Gaetano Paone, MD, MHSA; Andrew L. Pruitt, MD; Francis L. Shannon, MD; Theodore J. Boeve, MD; Himanshu J. Patel, MD; Michael P. Thompson, PhD; Patricia F. Theurer, MSN; James M. Dupree, MD, MPH; Karen M. Kim, MD; Richard L. Prager, MD; Donald S. Likosky, PhD
Background: Transcatheter aortic valve replacement (TAVR) has increased in volume as an alternative to surgical aortic valve replacement (SAVR). Comparisons of total episode expenditures, although largely ignored thus far, will be key to the value proposition for payers.
Methods: We evaluated 6,359 Blue Cross Blue Shield of Michigan and Medicare fee-for-service beneficiaries undergoing TAVR (17 hospitals, n = 1,655) or SAVR (33 hospitals, n = 4,704) in Michigan between 2012 and 2016. Payments through 90 post-discharge days between TAVR and SAVR were price-standardized and risk-adjusted. Centers were divided into terciles of procedural volume separately for TAVR and SAVR, and payments were compared between lowest and highest terciles.
Results: Payments (± SD) were higher for TAVR than SAVR ($69,388 ± $22,259 versus $66,683 ± $27,377, p < 0.001), while mean hospital length of stay was shorter for TAVR (6.2 ± 5.6 versus 10.2 + 7.5 days, p < 0.001). Index hospitalization payments were $4,374 higher for TAVR (p < 0.001), whereas readmission and post-acute care payments were $1,150 (p = 0.001) and $739 (p = 0.004) lower, respectively, and professional payments were similar. For SAVR, high-volume centers had lower episode payments (difference: 5.0%, $3,255; p = 0.01) and shorter length of stay (10.0 ± 7.5 versus 11.1 ± 7.9 days, p = 0.002) than low volume centers. In contrast, we found no volume–payment relationship among TAVR centers.
Conclusions: Episode payments were higher for TAVR, despite shorter length of stay. Although not a driver for TAVR, center SAVR volume was inversely associated with payments. These data will be increasingly important to address value-based reimbursement in valve replacement surgery.
June 2018
Evolving trends in aortic valve replacement: A statewide experience
Karen M. Kim, MD; Francis Shannon, MD; Gaetano Paone, MD, MHSA; Shelly Lall, MD; Sanjay Batra, MD; Theodore Boeve, MD; Alphonse DeLucia, MD; Himanshu J. Patel, MD; Patricia F. Theurer, MSN; Chang He, MS; Melissa J. Clark, MSN; Ibrahim Sultan, MD; George Michael Deeb, MD; Richard L. Prager, MD
Background: Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for the treatment of aortic stenosis in patients at intermediate, high, and extreme risk for mortality from SAVR. We examined recent trends in aortic valve replacement (AVR) in Michigan.
Methods: The Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC) database was used to determine the number of SAVR and TAVR cases performed from January 2012 through June 2017. Patients were divided into low, intermediate, high, and extreme risk groups based on STS predicted risk of mortality (PROM). TAVR patients in the MSTCVS-QC database were also matched with those in the Transcatheter Valve Therapy Registry to determine their Heart Team-designated risk category.
Results: During the study period 9517 SAVR and 4470 TAVR cases were performed. Total annual AVR volume increased by 40.0% (from 2086 to 2920), with a 13.3% decrease in number of SAVR cases (from 1892 to 1640) and a 560% increase in number of TAVR cases (from 194 to 1280). Greater than 90% of SAVR patients had PROM≤8%.
While >70% of TAVR patients had PROM ≤ 8%, they were mostly designated as high or extreme risk by a Heart Team.
Conclusions: During the study period, SAVR volume gradually declined and TAVR volume dramatically increased. This was mostly due to a new group of patients with lower STS PROM who were designated as higher risk by a Heart Team due to characteristics not completely captured by the STS PROM score.
May 2016
The Midterm Impact of Transcatheter Aortic Valve Replacement on Surgical Aortic Valve Replacement in Michigan
Himanshu J. Patel, MD; Morley A. Herbert, PhD; Gaetano Paone, MD, MHSA; John C. Heiser, MD; Francis L. Shannon, MD; Patricia F. Theurer, RN, BSN; Gail F. Bell, RN, MSN; Richard L. Prager, MD
Background: We characterized the midterm impact of transcatheter aortic valve replacement (TAVR) on surgical aortic valve replacement (SAVR) volume, patient profiles, and outcomes in Michigan.
Methods: We analyzed data obtained after SAVR (n =15,288) and TAVR (n= 1,783) using the Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative from 2006 to 2015. During this period, 17 of 33 hospitals developed TAVR programs.
Results: Annual SAVR volume increased by 38.1% at TAVR hospitals and by 20.4% at non-TAVR hospitals, (ptrend < 0.001). In TAVR hospitals, the Society of Thoracic Surgeons (STS) Predicted Risk of Mortality (PROM) decreased before (4.7% 5.1%) and after (3.5% 3.6%) initiation of TAVR (p < 0.001). Rates of 30-day mortality (pre-TAVR, 3.9% vs post-TAVR, 2.7%; p < 0.001) and renal failure (pre-TAVR, 5.2% vs post-TAVR, 3.3%; p < 0.001) butnot stroke (pre-TAVR, 1.9% vs post-TAVR, 1.7%; p= 0.47) were lower after TAVR implementation. Length of stay decreased from 9.0 to 8.5 days (p < 0.001). When analyzing high-risk patients undergoing SAVR (ie, PROM >8%), neither mortality, stroke, nor renal failure was different (all p > 0.15). Despite a reduction in the STS-PROM, non-TAVR hospitals did not display changes in mortality, stroke, or renal failure for either the entire or the high-risk SAVR cohorts after initiation of TAVR in Michigan.
Conclusions: TAVR implementation in Michigan has dramatically increased overall SAVR volume. This phenomenon has occurred with a concomitant decrease in preoperative risk profile and has improved early SAVR outcomes, particularly at TAVR hospitals, but surprisingly not in patients considered at high preoperative risk. As TAVR use increases, these issues may be further clarified and elucidated.
May 2015
Red Blood Cells and Mortality After Coronary Artery Bypass Graft Surgery: An Analysis of 672 Operative Deaths
Gaetano Paone, MD, MHSA; Morley A. Herbert, PhD; Patricia F. Theurer, BSN; Gail F. Bell, MSN; Jaelene K. Williams, MSN; Francis L. Shannon, MD; Donald S. Likosky, PhD; Richard L. Prager, MD
Background: Prior studies have implicated transfusion as a risk factor for mortality in coronary artery bypass graft surgery (CABG). To further our understanding of the true association between transfusion and outcome, we specifically analyzed the subgroup of patients who died after undergoing CABG.
Methods: A total of 34,362 patients underwent isolated CABG between January 2008 and September 2013 and were entered into a statewide collaborative database; 672 patients (2.0%) died and form the basis for this study. Univariate analysis compared preoperative and intraoperative variables, as well as postoperative outcomes, between those with and without transfusion in both unadjusted cohorts and those matched by predicted risk of mortality (PROM). Mortality was further evaluated with phase of care analysis.
Results: Of the 672 deaths, 566 patients (84.2%) received a transfusion of red blood cells. The PROM was 7.5% for the transfused patients versus 4.3% for those not transfused (p < 0.001). Transfused patients were older, more often female, had more emergency, on-pump, and redo procedures, and had a lower preoperative and on-bypass nadir hematocrit. Most other demographics were similar between the groups. Postoperatively, transfused patients were ventilated longer, had more renal and multisystem organ failure, and were more likely to die of infectious and pulmonary causes after longer intensive care unit and overall lengths of stay.
Conclusion: Significant differences in PROM and the postoperative course leading to death between those with and without transfusion suggest the role of transfusion may be secondary to other patient-related factors. Recognizing that the relationship between transfusion and outcome after CABG remains incompletely understood, these findings are suggestive of a complex interaction of many variables.
March 2013
Analyzing “Failure to Rescue”: Is This an Opportunity for Outcome Improvement in Cardiac Surgery?
Haritha G. Reddy, BA; Terry Shih, MD; Michael J. Englesbe, MD; Francis L. Shannon, MD; Gaetano Paone, MD, MHSA; Gail F. Bell, MSN; Richard L. Prager, MD
Background: In the setting of a statewide quality collaborative approach to the review of cardiac surgical mortalities in intensive care units (ICUs), variations in complication-related outcomes became apparent. Utilizing “failure to rescue” methodology (FTR; the probability of death after a complication), we compared FTR rates after adult cardiac surgery in low, medium, and high mortality centers from a voluntary, 33-center quality collaborative.
Methods: We identified 45,904 patients with a Society of Thoracic Surgeons predicted risk of mortality who underwent cardiac surgery between 2006 and 2010. The 33 centers were ranked according to observedto-expected ratios for mortality and were categorized into 3 equal groups. We then compared rates of complications and FTR.
Results: Overall unadjusted mortality was 2.6%, ranging from 1.5% in the low-mortality group to 3.6% in the high group. The rate of 17 complications ranged from 19.1% in the low group to 22.9% in the high group while FTR rates were 6.6% in the low group, 10.4% in the medium group, and 13.5% in the high group (p < 0.001). The FTR rate was significantly better in the low mortality group for the majority of complications (11 of 17) with the most significant findings for cardiac arrest, dialysis, prolonged ventilation, and pneumonia.
January 2012
A Method to Evaluate Cardiac Surgery Mortality: Phase of Care Mortality Analysis
Francis L. Shannon, MD; Frank L. Fazzalari, MD, MBA; Patricia F. Theurer, BSN; Gail F. Bell, MSN; Kathleen M. Sutcliffe, PhD; Richard L. Prager, MD
Background: This is a study of a method of mortality review, adopted by the Michigan Society of Thoracic and Cardiovascular Surgeons, to enhance understanding of mortality and potentially avoidable deaths after cardiac surgery, utilizing a voluntary statewide database.
Methods: A system to categorize mortality was developed utilizing a phase of care mortality analysis approach as well as providing criteria to classify mortality as potentially “avoidable.” For each mortality, the operating surgeon categorized a cardiac surgery mortality trigger into 1 of 5 time frames: preoperative, intraoperative, intensive care unit (ICU), postoperative, and discharge.
Results: A total of 53,674 adult cardiac operations were performed from January 1, 2006 to June 30, 2010 with a crude mortality of 3.5% (1,905 of 53,674). Of the mortalities analyzed, 35% (618 of 1,780) were preoperative, 25% (451 of 1,780) were ICU, 19% (333 of 1,780) were intraoperative, 11% (198 of 1,780) were floor, and 10% (180 of 1,780) were discharge phase. “Avoidable” mortality triggers occurred in 53% (174 of 333) of the intraoperative, 41% (253 of 618) and (184 of 451) of the preoperative and ICU phases, 42% (83 of 198) of the floor, and 19% (35 of 180) of the discharge phase. Overall potentially avoidable mortality was 41% (729 of 1780). Thirty-six percent (644 of 1,780) of the mortalities were coronary artery bypass grafting patients and 29% (188 of 644) of these were in the preoperative phase, with a mean predicted risk of 16%.
March 2009
Cardiac Surgeons and the Quality Movement: the Michigan Experience
Richard L Prager, Frederick R Armenti, Joseph S Bassett, Gail F Bell, Daniel Drake, Eric C Hanson, John C Heiser, Scott H Johnson, F B Plasman, Francis L Shannon, David Share, Patty Theurer, Jaelene Williams
The Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) was founded in 1965 during an era when many national, regional, and state speciality societies were beginning. The first meeting of what was initially called the Michigan Society of Thoracic Surgeons was held on September 21, 1965 in Detroit in conjunction with the Michigan State Medical Society (personal communication, Allen Silbergleit, MD, PhD, Historian, Michigan Society of Thoracic and Cardiovascular Surgeons, August 2008). The initial meeting was attended by 17 of the 60 board certified thoracic surgeons in Michigan. Dr Cameron Haight, Head of the Section of Thoracic Surgery at the University of Michigan in Ann Arbor, was the President of the society.
As one of the first state thoracic organizations, plans were implemented for an annual meeting, which in the initial years often occurred in conjunction with the American College of Surgeons Michigan Chapter meeting. In the mid-1980s the Michigan Society of Thoracic Surgeons created its own meeting time and moved the annual meeting to resort areas in northern Michigan in late summer. Recognizing the evolution of the speciality of Thoracic Surgery, in 1988 the name of the organization was changed from the Michigan Society of Thoracic Surgeons to the Michigan Society of Thoracic and Cardiovascular Surgeons. Today, the Society has over 100 board-certified thoracic surgeon members, as well as associate members, including data managers, physician assistants, and perfusionists.
Since its inception in 1965 the society has had yearly meetings with the initial focus of these meetings on case presentations, as well as providing an opportunity for house officers from Michigan programs in general surgery, and the two thoracic surgical residency programs to present scientific papers. Presentations from invited cardiac and thoracic surgeon guests with expertise in various areas have become a part of the meeting programs in recent years.