Objective: Our enhanced recovery after cardiac surgery (ERAS Cardiac) program is an evidence-based interdisciplinary process, which has not previously been systematically applied to cardiac surgery in the United States.Methods: The Knowledge-to-Action Framework synthesized evidence-based enhanced recovery interventions and implementation of a designated ERAS Cardiac program. Standardized processes included (1) preoperative patient education, (2) carbohydrate loading 2 hours before general anesthesia, (3) multimodal opioid-sparing analgesia, (4) goal-directed perioperative insulin infusion, and (5) a rigorous bowel regimen. All cardiac anesthesiologists and surgeons agreed to follow the standardized pathway for adult cardiac surgery cases. The 1-year outcomes were compared between the 9 months pre-and post-ERAS Cardiac implementation using prospectively collected, retrospectively reviewed data.Results: Comparing the pre-(N ¼ 489) with the post-(N ¼ 443) ERAS Cardiac groups, median postoperative length of stay was decreased from 7 to 6 days (P <.01). Total intensive care unit hours were decreased from a mean of 43 to 28 hours (P <.01). The incidence of gastrointestinal complications was 6.8% pre-ERAS versus 3.6% post-ERAS implementation (P <.05). Opioid use was reduced by a mean of 8 mg of morphine equivalents per patient in the first 24 hours postoperatively (P <.01). Reintubation rate and intensive care unit readmission rate were reduced by 1.2% and 1.5%, respectively (P ¼ not significant). The incidence of hyperglycemic episodes was no different after ERAS Cardiac initiation. Patient satisfaction was 86.3% pre-ERAS versus 91.8% post-ERAS Cardiac implementation and work culture domain scores revealed increases in satisfaction across all measured indices, including patient focus, culture, and engagement.Conclusions: Initial clinical and survey data after the first year of a system-wide ERAS Cardiac program were associated with significantly improved perioperative outcomes. We believe this value-based approach to cardiac surgery can consistently result in earlier recovery, cost reductions, and increased patient/staff satisfaction.

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Donor alloreactive CD4 ؉ T cells are important to the pathogenesis of chronic graftversus-host disease (cGVHD), but specific subsets of CD4 ؉ T cells responsible for GVHD have not been defined. We hypothesized that cGVHD might be associated with a preponderance of CD4 ؉ effector memory cells (CCR7 ؊ /CD62L low , CD4 EM ). We analyzed CCR7 and CD62L expression on CD4 ؉ T cells from stem cell transplantation patients, who did or did not develop cGVHD, and healthy donors. Patients with cGVHD had a higher percentage of CD4 EM cells (35.5% ؎ 2.9%) than healthy donors (13.8% ؎ 0.7%; P < .0001) or patients without cGVHD that received a transplant (21.7% ؎ 2.1%; P < .01). Using corticosteroid dose as a surrogate marker for cGVHD severity, severe cGVHD was associated with a higher percentage of CD4 EM IntroductionChronic graft-versus-host disease (cGVHD) is the most common late complication of allogeneic stem cell transplantation. 1 Donorderived, alloreactive, postthymic CD4 ϩ T cells play an important role in pathogenesis of cGVHD, 2 however, the pathophysiology remains unclear.Human peripheral blood CD4 ϩ T cells can be divided into 3 populations: naive CD45RA ϩ CCR7 ϩ and 2 memory subsets, CD45RA Ϫ CCR7 ϩ (central memory) and CD45RA Ϫ CCR7 Ϫ (effector memory). Chemokine receptor CCR7 is pivotal for migration into secondary lymphoid organs. 3 Expression of CD62L (Lselectin), which also guides lymphocytes into lymphoid tissue, is tightly linked to CCR7 expression on memory CD4 ϩ T cells. 4 Central memory CD4 ϩ T cells are nonpolarized and retain the capacity to differentiate into either T-helper 1 (Th1) or Th2 when restimulated. Thus, they are effector precursors that regulate immune response. Conversely, effector memory cells are actively involved in inflammation and cytotoxicity. 5 When stimulated via T-cell receptor, central memory cells produce only interleukin 2 (IL-2). In contrast, effector memory cells produce high levels of interferon ␥ (IFN-␥), IL-4, and IL-5 and moderately reduced levels of IL-2 in vitro. 4 In healthy individuals, central memory CD4 ϩ T cells are predominant in peripheral blood. An imbalance of the central and effector memory CD4 ϩ T-cell ratio may result in autoimmune or alloimmune disease, but this has not been described.We examined expression of CCR7 and CD62L on CD4 ϩ T cells in cGVHD patients in order to characterize the balance of central and effector memory cells. Study designAll cGVHD patients received transplants using myeloablative or nonmyeloablative marrow conditioning from a 6 of 6 or 5 of 6 human leukocyte antigen (HLA)-matched related donor. All patients provided written informed consent for participation in a variety of institutional review board-approved NIH Clinical Center stem cell transplantation protocols.Fresh peripheral blood mononuclear cells (PBMCs) were obtained by Ficoll separation with lymphocyte separation medium (ICN Biomedicals Inc, Aurora, OH) from 36 adult healthy donors, 25 cGVHD patients, 20 patients after allogeneic stem cell transplantation without cGVHD...