Creating and Maintaining a Successful Service Line in an Academic Medical Center at the Dawn of Value-Based Care: Lessons Learned From the Heart and Vascular Service Line at UMass Memorial Health Care.

The service line (SL) model has been proven to help shift health care toward value-based services, which is characterized by coordinated, multidisciplinary, high-quality, and cost-effective care. However, academic medical centers struggle with how to effectively set up SL structures that overcome the organizational and cultural challenges associated with simultaneously delivering the highest-value care for the patient and advancing the academic mission. In this article, the authors examine the evolution of UMass Memorial Health Care's heart and vascular service line (HVSL) from 2006 to 2011 and describe the impact on its success of multiple strategic decisions. These include key academic physician leadership recruitments and engagement via a matrixed governance and management model; development of multidisciplinary teams; empowerment of SL leadership through direct accountability and authority over programs and budgets; joint educational and training programs; incentives for academic achievement; and co-localization of faculty, personnel, and facilities. The authors also explore the barriers to success, including the need to overcome historical departmental-based silos, cultural and training differences among disciplines, confusion engendered by a matrixed reporting structure, and faculty's unfamiliarity with the financial and organizational skills required to operate a successful SL. Also described here is the impact that successful implementation of the SL has on creating high-quality services, increased profitability, and contribution to the financial stability and academic achievement of the academic medical center.

Partial anomalous pulmonary venous connection in adults: a simplified approach.

Partial anomalous pulmonary venous connection with infradiaphragmatic drainage into the inferior vena cava (scimitar syndrome) constitutes a rare diagnosis in adults. Diagnosis is suggested by plain chest roentgenogram and confirmed by computed tomography angiography or magnetic resonance imaging. Reported operations for scimitar syndrome are complex, often requiring circulatory arrest. Reoperation for pulmonary vein stenosis is a troubling complication. We report an effective simplified operation for use in adults.

Successful repair of aortic and mitral incompetence induced by methylsergide maleate: confirmation by intraoperative transesophageal echocardiography.

Methylsergide maleate, an effective anti-migraine medication, has a well-documented association with left-sided cardiac valve dysfunction. Prior reports have described cardiac valve dysfunction in patients using methylsergide chronically for a minimum of 6 years, with surgical intervention consisting of valve replacement for patients with intractable congestive heart failure. We report a 51-year-old woman who developed severe mitral and aortic valvular dysfunction after taking methylsergide maleate for migraine headaches for a period of 19 months, and who subsequently underwent aortic and mitral valve repair with excellent short-term results.

Transesophageal Echocardiography with Pathological Correlation in Severe Valvular Disease Associated with Fenfluramine-Phentermine.

We describe the case of severe diffuse multivalvular disease associated with fenfluramine-phentermine (Fen-Phen) in a 52-year-old patient who presented to the echocardiography laboratory for evaluation of a new heart murmur and ultimately required isolated aortic valve replacement. The patient was known to have a transthoracic echocardiogram 1 year before starting the diet pill combination that showed no significant valvular disease. Pathological evaluation of the excised aortic valve was consistent with that described with Fen-Phen use. Transesophageal echocardiography played an important role in defining unique features associated with the valvular disease and in intraoperative management of the patient.