Improving Surgical Scene Semantic Segmentation through a Deep Learning Architecture with Attention to Class Imbalance.

This article addresses the semantic segmentation of laparoscopic surgery images, placing special emphasis on the segmentation of structures with a smaller number of observations. As a result of this study, adjustment parameters are proposed for deep neural network architectures, enabling a robust segmentation of all structures in the surgical scene. The U-Net architecture with five encoder-decoders (U-Net5ed), SegNet-VGG19, and DeepLabv3+ employing different backbones are implemented. Three main experiments are conducted, working with Rectified Linear Unit (ReLU), Gaussian Error Linear Unit (GELU), and Swish activation functions. The applied loss functions include Cross Entropy (CE), Focal Loss (FL), Tversky Loss (TL), Dice Loss (DiL), Cross Entropy Dice Loss (CEDL), and Cross Entropy Tversky Loss (CETL). The performance of Stochastic Gradient Descent with momentum (SGDM) and Adaptive Moment Estimation (Adam) optimizers is compared. It is qualitatively and quantitatively confirmed that DeepLabv3+ and U-Net5ed architectures yield the best results. The DeepLabv3+ architecture with the ResNet-50 backbone, Swish activation function, and CETL loss function reports a Mean Accuracy (MAcc) of 0.976 and Mean Intersection over Union (MIoU) of 0.977. The semantic segmentation of structures with a smaller number of observations, such as the hepatic vein, cystic duct, Liver Ligament, and blood, verifies that the obtained results are very competitive and promising compared to the consulted literature. The proposed selected parameters were validated in the YOLOv9 architecture, which showed an improvement in semantic segmentation compared to the results obtained with the original architecture.

Preoperative Alcohol Use, Postoperative Pain, and Opioid Use After Coronary Artery Bypass Surgery.

OBJECTIVES: Chronic alcohol use is associated with chronic pain and increased opioid consumption. The association between chronic alcohol use and acute postoperative pain has been studied minimally. The authors' objective was to explore the association among preoperative alcohol use, postoperative pain, and opioid consumption after coronary artery bypass grafting (CABG). DESIGN: A retrospective cohort study. SETTING: At a single academic medical center. PARTICIPANTS: Patients having isolated CABG. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, comorbidities, and baseline alcohol consumption were recorded. Primary outcomes were mean pain score and morphine milligram equivalent (MME) consumption on postoperative day 0. Among 1,338 patients, there were 764 (57.1%) who had no weekly preoperative alcohol use, 294 (22.0%) who drank ≤1 drink per week, 170 (12.7%) who drank 2-to-7 drinks per week, and 110 (8.2%) who drank 8 or more drinks per week. There was no significant difference in mean pain score on postoperative day 0 in patients who consumed different amounts of alcohol (no alcohol = 5.3 ± 2.2, ≤1 drink = 5.2 ± 2.1, 2 to 7 drinks = 5.3 ± 2.3, 8 or more drinks = 5.4 ± 1.9, p = 0.66). There was also no significant difference in median MME use on postoperative day 0 in patients who consumed different amounts of alcohol (no alcohol = 22.5 mg, ≤1 drink = 21.1 mg, 2-to-7 drinks = 24.8 mg, 8 or more drinks = 24.5 mg, p = 0.14). CONCLUSIONS: There is no apparent association among mild-to-moderate preoperative alcohol consumption and early postoperative pain and opioid use in patients who underwent CABG.

A Novel Robotic Controller Using Neural Engineering Framework-Based Spiking Neural Networks.

This paper investigates spiking neural networks (SNN) for novel robotic controllers with the aim of improving accuracy in trajectory tracking. By emulating the operation of the human brain through the incorporation of temporal coding mechanisms, SNN offer greater adaptability and efficiency in information processing, providing significant advantages in the representation of temporal information in robotic arm control compared to conventional neural networks. Exploring specific implementations of SNN in robot control, this study analyzes neuron models and learning mechanisms inherent to SNN. Based on the principles of the Neural Engineering Framework (NEF), a novel spiking PID controller is designed and simulated for a 3-DoF robotic arm using Nengo and MATLAB R2022b. The controller demonstrated good accuracy and efficiency in following designated trajectories, showing minimal deviations, overshoots, or oscillations. A thorough quantitative assessment, utilizing performance metrics like root mean square error (RMSE) and the integral of the absolute value of the time-weighted error (ITAE), provides additional validation for the efficacy of the SNN-based controller. Competitive performance was observed, surpassing a fuzzy controller by 5% in terms of the ITAE index and a conventional PID controller by 6% in the ITAE index and 30% in RMSE performance. This work highlights the utility of NEF and SNN in developing effective robotic controllers, laying the groundwork for future research focused on SNN adaptability in dynamic environments and advanced robotic applications.

Current Transthoracic Supra-Aortic Trunk Surgical Reconstruction Has Similar 30-Day Cardiovascular Outcomes Compared to Extra-Anatomic Revascularization but With Higher Morbidity Burden.

BACKGROUND: Operative risk for supra-aortic trunk (SAT) surgical revascularization for occlusive disease, particularly transthoracic reconstruction (TR), remains ill-defined. This study sought to describe and compare 30-day outcomes of TR and extra-anatomic (ER) SAT surgical reconstruction for an occlusive indication across the United States over a contemporary 15-year period. METHODS: Using the National Surgical Quality Improvement Program, TR and ER performed during 2005-2019 were identified. Procedures performed for nonocclusive indications and those concomitant with coronary or valve operations were excluded. Rates of stroke, death, myocardial infarction (MI) and these as composite outcome (S/D/M) were compared. Logistic regression with stabilized inverse probability weighting (IPW) was used to compare groups via average treatment effect (ATE) while adjusting for covariate imbalances. RESULTS: Over the 15-year period, 166 TR and 1,900 ER patients were identified. The majority of ERs were carotid-subclavian bypass (n = 1,344; 70.7%) followed by carotid-carotid bypass (n = 261; 13.7%) and subclavian/carotid transpositions (n = 123; 6.5%). TR consisted of aorto-SAT bypass (n = 120; 72.3%) and endarterectomy (n = 46; 27.7%). The median age was 64 years for TR and 65 years in ER (P = 0.039). Those undergoing TR were more often women (69.0% vs. 56.9%; P = 0.001) and less likely to have undergone previous cardiac surgery (9.2% vs. 20.8%; P = 0.006). TR were also less frequently hypertensive (68.1% vs. 75.4%; P = 0.038) and had statistically lower preoperative creatinine levels (0.86 vs 0.91; P = 0.002). Unadjusted rates of MI (0.6% vs. 1.3%; P = 0.72) and stroke (3.6% vs. 1.9%; P = 0.15) were similar between groups with mortality (3.6% vs. 1.5%; P = 0.05) and S/D/M (6.6% vs. 3.9%; P = 0.10) trending higher with TR. IPWs could be calculated for 1,754 patients (148 TR; 1,606 ER). The estimated probability of S/D/M was 3.8% in the ER group and 6.2% in TR; no difference was seen in ATE (2.4%; 95% confidence interval [CI]: -1.5 to 6.2; P = 0.23). No differences were seen in individual component ATEs (stroke: 3.0% vs. 1.7%; ATE = 1.3%; 95% CI: -3.9 to 1.3; P = 0.32; mortality: 3.8% vs. 1.4%; ATE = 2.4%; 95% CI: -5.6 to 0.7; P = 0.13). Secondary outcomes showed TR patients were more likely to have non-home discharge (18.7% vs. 6.6%; ATE = 12.1%; 95% CI: 5.0-19.2; P < 0.001) and longer lengths of stay (6.1 vs. 4.0; ATE = 2.2 days; 95% CI: 0.9-3.4; P < 0.001). Moreover, TR patients were more likely to require transfusion (22.7% vs. 5.0%; ATE = 17.7%; 95% CI: 10.2-25.2; P < 0.001) and develop sepsis (2.7% vs. 0.2%; ATE = 2.5%; 95% CI: 0.1-5.0; P = 0.04). CONCLUSIONS: Transthoracic and extra-anatomic surgical reconstruction of the SATs for occlusive disease have similar operative cardiovascular risk. However, morbidity tends to be higher with TR due to higher transfusion requirements, sepsis risk, and need for facility stay. These results suggest ER as a first-line approach in those with proper disease anatomy is reasonable with lower morbidity, while TR remains justified in appropriate patients.

Dietary Exposure to Environmentally Relevant Levels of Chemical Contaminants Reduces Growth and Survival in Juvenile Chinook Salmon.

Chemical pollution can degrade aquatic ecosystems. Chinook salmon in contaminated habitats are vulnerable to health impacts from toxic exposures. Few studies have been conducted on adverse health outcomes associated with current levels and mixtures of contaminants. Fewer still address effects specific to the juvenile life-stage of salmonids. The present study evaluated contaminant-related effects from dietary exposure to environmentally relevant concentrations and mixture profiles in juvenile Chinook salmon from industrialized waterways in the U.S. Pacific Northwest using two end points: growth assessment and disease susceptibility. The dose and chemical proportions were reconstituted based on environmental sampling and analysis using the stomach contents of juvenile Chinook salmon recently collected from contaminated, industrialized waterways. Groups of fish were fed a mixture with fixed proportions of 10 polychlorinated biphenyls (PCBs), 3 dichlorodiphenyltrichloroethanes (DDTs), and 13 polycyclic aromatic hydrocarbons (PAHs) at five concentrations for 35 days. These contaminant compounds were selected because of elevated concentrations and the widespread presence in sediments throughout industrialized waterways. Fork length and otolith microstructural growth indicators were significantly reduced in fish fed environmentally relevant concentrations of these contaminants. In addition, contaminant-exposed Chinook salmon were more susceptible to disease during controlled challenges with the pathogen Aeromonas salmonicida. Our results indicate that dietary exposure to contaminants impairs growth and immune function in juvenile Chinook salmon, thereby highlighting that current environmental exposure to chemicals of potential management concern threatens the viability of exposed salmon.

Bioinspired Photoreceptors with Neural Network for Recognition and Classification of Sign Language Gesture.

This work addresses the design and implementation of a novel PhotoBiological Filter Classifier (PhBFC) to improve the accuracy of a static sign language translation system. The captured images are preprocessed by a contrast enhancement algorithm inspired by the capacity of retinal photoreceptor cells from mammals, which are responsible for capturing light and transforming it into electric signals that the brain can interpret as images. This sign translation system not only supports the effective communication between an agent and an operator but also between a community with hearing disabilities and other people. Additionally, this technology could be integrated into diverse devices and applications, further broadening its scope, and extending its benefits for the community in general. The bioinspired photoreceptor model is evaluated under different conditions. To validate the advantages of applying photoreceptors cells, 100 tests were conducted per letter to be recognized, on three different models (V1, V2, and V3), obtaining an average of 91.1% of accuracy on V3, compared to 63.4% obtained on V1, and an average of 55.5 Frames Per Second (FPS) in each letter classification iteration for V1, V2, and V3, demonstrating that the use of photoreceptor cells does not affect the processing time while also improving the accuracy. The great application potential of this system is underscored, as it can be employed, for example, in Deep Learning (DL) for pattern recognition or agent decision-making trained by reinforcement learning, etc.

Effect of Cardiopulmonary Bypass on SARS-CoV-2 Vaccination Antibody Levels.

Background Adults undergoing heart surgery are particularly vulnerable to respiratory complications, including COVID-19. Immunization can significantly reduce this risk; however, the effect of cardiopulmonary bypass (CPB) on immunization status is unknown. We sought to evaluate the effect of CPB on COVID-19 vaccination antibody concentration after cardiac surgery. Methods and Results This prospective observational clinical trial evaluated adult participants undergoing cardiac surgery requiring CPB at a single institution. All participants received a full primary COVID-19 vaccination series before CPB. SARS-CoV-2 spike protein-specific antibody concentrations were measured before CPB (pre-CPB measurement), 24 hours following CPB (postoperative day 1 measurement), and approximately 1 month following their procedure. Relationships between demographic or surgical variables and change in antibody concentration were assessed via linear regression. A total of 77 participants were enrolled in the study and underwent surgery. Among all participants, mean antibody concentration was significantly decreased on postoperative day 1, relative to pre-CPB levels (-2091 AU/mL, P<0.001). Antibody concentration increased between postoperative day 1and 1 month post CPB measurement (2465 AU/mL, P=0.015). Importantly, no significant difference was observed between pre-CPB and 1 month post CPB concentrations (P=0.983). Two participants (2.63%) developed symptomatic COVID-19 pneumonia postoperatively; 1 case of postoperative COVID-19 pneumonia resulted in mortality (1.3%). Conclusions COVID-19 vaccine antibody concentrations were significantly reduced in the short-term following CPB but returned to pre-CPB levels within 1 month. One case of postoperative COVID 19 pneumonia-specific mortality was observed. These findings suggest the need for heightened precautions in the perioperative period for cardiac surgery patients.

Postdoctoral National Institutes of Health F32 Grants: Broken Pipeline in the Development of Surgeon-Scientists.

OBJECTIVE: We examined trainees in surgery and internal medicine who received National Institutes of Health (NIH) F32 postdoctoral awards to determine their success rates in obtaining future NIH funding. BACKGROUND: Trainees participate in dedicated research years during residency (surgery) and fellowship (internal medicine). They can obtain an NIH F32 grant to fund their research time and have structured mentorship. METHODS: We collected NIH F32 grants (1992-2021) for Surgery Departments and Internal Medicine Departments from NIH RePORTER, an online database of NIH grants. Nonsurgeons and noninternal medicine physicians were excluded. We collected demographic information on each recipient, including gender, current specialty, leadership positions, graduate degrees, and any future NIH grants they received. A Mann-Whitney U test was used for continuous variables, and a χ 2 test was utilized to analyze categorical variables. An alpha value of 0.05 was used to determine significance. RESULTS: We identified 269 surgeons and 735 internal medicine trainees who received F32 grants. A total of 48 surgeons (17.8%) and 339 internal medicine trainees (50.2%) received future NIH funding ( P < 0.0001). Similarly, 24 surgeons (8.9%) and 145 internal medicine trainees (19.7%) received an R01 in the future ( P < 0.0001). Surgeons who received F32 grants were more likely to be department chair or division chiefs ( P =0.0055 and P < 0.0001). CONCLUSIONS: Surgery trainees who obtain NIH F32 grants during dedicated research years are less likely to receive any form of NIH funding in the future compared with their internal medicine colleagues who received F32 grants.

Impact of thoracic endovascular aortic repair timing on outcomes after uncomplicated type B aortic dissection in the Society for Vascular Surgery Vascular Quality Initiative postapproval project for dissection.

OBJECTIVE: The timing of thoracic endovascular aortic repair (TEVAR) after the onset of uncomplicated acute type B aortic dissection (uTBAD) remains controversial. The objective of this study was to evaluate the Society for Vascular Surgery Vascular Quality Initiative (VQI) postapproval study (VQI PAS) data for the impact of TEVAR timing for uTBAD on early and late outcomes, including mortality, procedural complications, and long-term reintervention. METHODS: The VQI PAS used for this analysis includes a total of 606 patients. Patients with uTBAD (defined as those without rupture or malperfusion) exclusive of cases categorized as emergent (N = 206) were divided into groups defined by the Society for Vascular Surgery/Society of Thoracic Surgeons reporting guidelines based on the timing of treatment after the onset of dissection: within 24 hours (N = 8), 1 to 14 days (N = 121), and 15 to 90 days (N = 77). Univariate and multivariable analysis were used to determine differences between timing groups for postoperative mortality, in-hospital complications, and reintervention. RESULTS: Demographics and comorbid conditions were very similar across the 3 TEVAR timing groups. Notable differences included a higher prevalence of baseline elevated creatinine (>1.8 mg/dL)/chronic end-stage renal disease and designation as "urgent" in the <24-hour group, as well as a higher rate of preoperative ß-blocker therapy in the 1- to 14-day group. Postoperative stroke, congestive heart failure, and renal ischemia were more common in the <24-hour group without an increase in mortality. Unadjusted 30-day mortality across groups was lowest in the early TEVAR group (0%, 3.3%, and 5.2%; P = .68), as was 1-year mortality (0%, 8.3%, and 18.2%; P = .06), although not statistically different at any time point. Reintervention out to 3 years was not different between the groups. Multivariable analysis demonstrated the need for a postoperative therapeutic lumbar drain to be the only a predictive risk factor for mortality (hazard ratio = 7.595, 95% confidence interval: 1.730-33.337, P = .007). When further subdivided into patients treated 1 to 7 days or 8 to 14 days after dissection, findings were similar. CONCLUSIONS: Patients with uTBAD treated within 24 hours were unusual (N = 8), too small for valid statistical comparison, and likely represent a high-risk subgroup, which is manifested in a higher risk of complications. Although there was a trend toward improved survival in the acute (1- to 14-day) phase, outcomes did not differ compared with the subacute (15- to 90-day) phase with relation to early mortality, postoperative complications, or 1-year survival. These data suggest that the proper selection of patients for early TEVAR can result in equivalent survival and early outcomes.

Delirium is associated with failure to rescue after cardiac surgery.

Objective: Postoperative delirium after cardiac surgery is associated with long-term cognitive decline and mortality. We investigated whether increased ICU Confusion Assessment Method scores were associated with greater 30-day mortality and failure to rescue after cardiac surgery. Methods: We studied 4030 patients who underwent a Society of Thoracic Surgeons index operation at the University of Virginia Health System from 2011 to 2021. We obtained all ICU Confusion Assessment Method scores recorded during patients' admission and summarized scores for the first 7 postoperative days. Univariate and multivariable logistic regression analyzed the association between ICU Confusion Assessment Method score/delirium presence and postoperative complications, operative mortality, and failure to rescue. Results: Any episode of ICU Confusion Assessment Method screen-positive delirium and nearly all components of the score were associated with increased 30-day mortality on univariate analysis. We found that a single episode of delirium was associated with increased mortality. Feature 2 (inattention) had the strongest association with poorer outcomes, including failure to rescue in our analysis, as were patients with higher peak Richmond Agitation Sedation Scale scores. Patients with higher mean Richmond Agitation Sedation Scale scores had an association with decreased failure to rescue. Conclusions: A single episode of delirium, as measured using ICU Confusion Assessment Method scores, is associated with increased mortality. Inattention and higher peak Richmond Agitation Sedation Scale scores were associated with failure to rescue. Screening may clarify diagnosing delirium and assessing its implications on mortality and failure to rescue. Our findings suggest the importance of identifying and managing risk factors for delirium to improve patient outcomes and reduce mortality and failure to rescue rates.

Impact of preoperative versus postoperative dialysis on left ventricular assist device outcomes: An analysis from the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support database.

Objective: Chronic kidney disease and renal failure are common in patients being considered for left ventricular assist device support. We sought to evaluate the outcomes of patients undergoing left ventricular assist device implantation with preoperative dialysis and those with new-onset postoperative renal failure requiring dialysis. Methods: All patients (n = 14,090) undergoing primary left ventricular assist device implantation who were listed in the Interagency Registry for Mechanically Assisted Circulatory Support database (2014-2019) were evaluated. Landmark analysis then stratified patients alive at 1 month by preoperative dialysis and at 1 month postoperatively, preoperative dialysis only, postoperative dialysis only, and no dialysis. Results: Of 14,090 patients undergoing left ventricular assist device implantation, patients on dialysis (400%, 3%) preoperatively had significantly higher mortality at 1 month (18% vs 6%, P < .0001). However, of patients on preoperative dialysis, 131 (32.8%) no longer required dialysis at 1 month postoperatively and had long-term survival similar to patients who never required dialysis (no dialysis vs recovered, P = .13). Long-term survival was significantly worse in patients with persistent dialysis and new dialysis at 1 month postoperatively (P < .0001). Time to first stroke, major nondevice infection, any bleeding event, and gastrointestinal bleeding were all worse in patients on preoperative or postoperative dialysis (all P < .0001). Device infection, malfunction, or thrombosis was not associated with dialysis status (P > .05). Negative predictors of recovery include biventricular assist device (odds ratio, 0.20) and inotropes 1 week postimplant (odds ratio, 0.19). Conclusions: Preoperative renal failure is associated with 3 times higher mortality and worse morbidity in patients receiving a left ventricular assist device. However, one-third of patients with preoperative dialysis will recover renal function postimplant with similar long-term survival and quality of life as those without dialysis.

Patching an aortic tear using the side-arm and surrounding skirt of a physician-modified ascending aortic graft.

BACKGROUND AND AIM OF STUDY: Aortic complications during cannulation must be managed urgently and often require hypothermic circulatory arrest. We report a unique management strategy to repair an aortic tear without dissection by modifying a Dacron ascending aortic graft with side-arm. CASE PRESENTATION: A 32-year-old female patient undergoing reoperative cardiac surgery suffered an unexpected aortic tear during cannulation for cardiopulmonary bypass. The tear was repaired by utilizing a physician-modified ascending aortic graft with side-arm, in which the surrounding skirt of the side-arm was cut from the circumferential graft to patch the defect. The patient was rewarmed with the side-arm serving as arterial inflow for the bypass circuit, and the remainder of the operation proceeded without complication. CONCLUSION: This type of aortic repair for aortic tears without dissection can offer the patient the benefit of avoiding multiple aortotomies in a weakened aorta, reducing circulatory arrest time, and re-establishing a central cannulation strategy for cardiopulmonary bypass.

Aortic valve biologic protheses: A cohort comparison of premature valve failure.

BACKGROUND: Recent reports suggest an increased rate of early structural valve degeneration (SVD) in the Trifecta bioprosthesis (Abbott Cardiovascular). We sought to compare the intermediate-term outcomes of the Magna (Edwards Life Sciences) and Trifecta valves. METHODS: All surgical aortic valve replacements (SAVRs) with Trifecta or Magna/Magna Ease bioprostheses at an academic medical center were extracted from an institutional database. Patients who survived until after discharge (2011-2019) were included. The primary outcome was valve failure for any reason requiring reintervention or contributing to death, identified by reintervention or review of cause of death. Time to failure was estimated with Kaplan-Meier analysis and Cox Proportional Hazards Modeling. RESULTS: Out of 1444 patients, 521 (36%) underwent Trifecta and 923 (64%) underwent Magna implantation with a median follow-up of 27.6 months. Trifecta patients had larger median valve size (25 vs. 23 mm, p < .001) and lower median gradient (8.0 vs. 10.9 mmHg, p < .001). Trifecta patients had higher 48-month estimated failure rates (20.2 ± 7.6% vs. 2.6 ± 0.7%, p < .0001), with failure rates of 21.4 versus 9.2 failures per 1000 person-years (p < .001). After risk-adjustment, Trifecta patients had a 5.3 times hazard of failure (95% confidence interval: 2.78-12.34, p < .001) compared to Magna patients. Only Trifecta valves failed due to sudden aortic regurgitation, 8 out of 521 (1.5%). CONCLUSION: Despite lower postoperative mean gradients, the Trifecta bioprosthesis may have an increased risk of intermediate-term SVD. Further research is warranted to confirm the potential for sudden valve failure.

Retrograde type A dissection in the Vascular Quality Initiative thoracic endovascular aortic repair for dissection postapproval project.

BACKGROUND: Retrograde dissection (RD) can be a serious complication after thoracic endovascular aortic repair (TEVAR), with retrograde type A dissection (RTAD) particularly life-threatening. Prior studies have suggested that treatment timing, anatomic characteristics, device selection, and procedural conduct of TEVAR performed for type B aortic dissection could mitigate the occurrence of RD. The Vascular Quality Initiative TEVAR for Dissection Registry is an ongoing project meant to satisfy Food and Drug Administration requirements for postmarket approval surveillance of the Gore conformable TAG thoracic endoprosthesis (W.L. Gore & Associates, Flagstaff, Ariz), Medtronic Valiant thoracic stent graft (Medtronic, Santa Rosa, Calif), and Cook Medical dissection devices (Cook Medical, Bloomington, Ind) and provides a unique source of evaluation for RTAD in a prospectively collected real-world registry. METHODS: A total of 588 consecutive patients at 49 institutions had undergone TEVAR for acute (<30 days; n = 336) and chronic (≥30 days; n = 252) type B aortic dissection were included. The occurrence of RD as reported by the participating centers and de-identified source documents were reviewed and confirmed independently by two of us (A.W.B. and G.W.). The demographics, procedural and device data, and anatomic considerations were evaluated, and the devices were grouped in a de-identified manner as Gore, Medtronic, and other. RESULTS: The mean follow-up was 889 days (median, 658 days), and 408 patients had completed follow-up data available for >1 year. A total of 19 patients with RD (3.2%) were identified, 9 of whom had been treated for acute and 10 for chronic dissection, a 2.7% and 4.0% incidence, respectively (P = .48, acute vs chronic). Of the 19 RD cases, 15 were RTAD, 6 after treatment of acute and 9 after treatment of chronic dissection, a 1.8% and 3.6% incidence, respectively (P = .19, acute vs chronic). Five cases of RD had occurred intraoperatively (four of which were RTAD). The median time to RD and RTAD was 62 and 69 days, respectively (range, 0 to 1600 days). Of the 15 patients with RTAD, 12 had undergone surgical repair and 2 had not undergone repair; the treatment of one was unknown. The overall mortality was 33.3% (5 of 15). The factors associated with RTAD included more extensive dissection (mean, 5.6 zones without RTAD vs 8.5 zones with RTAD; P = .001), female sex (28.3% female without RTAD vs 53.3% with RTAD; P = .04), and non-White race (62.7% White without RTAD vs 33.3% White with RTAD; P = .05). Mean oversizing was not significantly different for those without RTAD compared with that for those with RTAD (14.0% vs 14.2%; P = .92). The device type was anonymized in this project; however, we found no significant differences between the Gore, Medtronic, and all other devices. CONCLUSIONS: The rate of RD in the present real-world postapproval project was consistent with that from previously reported studies, including highly controlled pivotal studies. Device type was not predictive of RD, and the newly identified risk factors for RTAD include more extensive dissection and a trend toward a greater risk for female sex and non-White race.

Progression to Transplant Under the New Heart Allocation System: The Society of Thoracic Surgeons Intermacs Database.

BACKGROUND: Under the new heart allocation policy patients needing durable left ventricular assist devices receive lower priority on the transplant list. We sought to identify predictors of successful heart transplant after durable device implant as a means to inform patient care in the current era. METHODS: All patients (N = 25,164) undergoing primary durable left ventricular device implant in The Society of Thoracic Surgeons Intermacs database (2010-2019) were evaluated. Patients identified as bridge to transplant (BTT; n = 5242) or bridge to candidacy (n = 6248) were analyzed with the endpoint of transplant before (n = 10,588) and after (n = 902) the change in the heart allocation system on October 18, 2018. Multivariable hazard modeling was used to assess risk-adjusted time to event associations. RESULTS: Of 11,490 patients, 45.5% progressed to transplant (BTT, 53.0%; bridge to candidacy, 36.6%), most by 14 months after left ventricular assist device implant. Under the new allocation system progression to transplant was significantly lower at 14 months (18.6% vs 34.8%, P < .001). Factors associated with successful BTT before the allocation change included BTT status, white race, and married. Under the new allocation system BTT status (hazard ratio, 1.79; 95% confidence interval, 1.19-2.69; P < .0054) remained a positive predictor, whereas blood type O (hazard ratio, 0.43; 95% confidence interval, 0.28-0.65; P < .0001) remained a negative predictor. CONCLUSIONS: Despite having priority in the previous allocation system, less than half of BTT and bridge to candidacy patients progressed to transplant. Under the current system these numbers are further reduced. Heart teams should consider the implications of longer wait times for a durable left ventricular assist device when determining the optimal bridging strategy.

Access to Left Ventricular Assist Device: Travel Time Does Not Tell The Whole Story.

BACKGROUND: Negative health effects of traveling longer distances for surgical services have been reported. Given the high complexity of multidisciplinary care required for management of Left Ventricular Assist Device (LVAD) implantation, only 4 of 18 centers in our state perform these operations. Given the limited access we hypothesized increased travel time would adversely affect postoperative outcomes and 30-d mortality. METHODS: A statewide Society of Thoracic Surgeons database was queried to identify patients undergoing Heartmate II/III and HVAD implantation, and 725 patients were identified. Travel time was calculated by zip code. Patients were stratified into regional and distant groups by the upper quartile of travel time (1-h). Preoperative variables and outcomes were compared between the groups. Multivariate analysis was performed to evaluate the impact of travel time in risk-adjusted models of 30-d mortality. RESULTS: Median patient travel time to their LVAD center in our state is 32 min (mean 53 ± 65 min, 46 ± 71 miles). Patients in the distant group (n = 191) had lower median incomes, higher self-pay status, higher rates of medical comorbid disease. Despite these differences there was no difference between the groups in ICU and/or hospital length of stay, readmission, postoperative complications, or 30-d mortality. Multivariate regression demonstrated insurance status, age, and prior surgery predicted 30-d mortality, but not travel time. CONCLUSIONS: Despite only four centers in the state performing LVAD implantation, travel time was strongly associated with preoperative risk, and socioeconomic status but not postoperative outcomes or 30-d mortality. Therefore, increasing access should focus on insurance, and patient characteristics not travel time.

Heparin Insensitivity and Thrombotic Risk Associated With Sequential Uses of Prothrombin Complex Concentrate and Andexanet Alfa for Apixaban Reversal During Acute Type A Aortic Dissection Repair: A Case Report.

The management of patients on direct oral anticoagulants (DOACs) who require emergent cardiac surgery is slowly evolving. The introduction of andexanet alfa, a novel antidote for apixaban and rivaroxaban, added a specific reversal agent to our armamentarium, but its safety and efficacy are still being investigated. We report 2 patients on DOAC treatment who required emergency cardiac surgery. Both received perioperative andexanet alfa together with prothrombin complex concentrate (PCC) at some time during 6 hours before operative management. Heparin resistance was noted in each instance, and pump thrombosis developed in 1 case.

Cerebrovascular Events in Patients With Centrifugal-Flow Left Ventricular Assist Devices: Propensity Score-Matched Analysis From the Intermacs Registry.

BACKGROUND: Ischemic and hemorrhagic cerebrovascular accidents remain common among patients with centrifugal-flow left ventricular assist devices, despite improvements in survival and device longevity. We compared the incidence of neurologic adverse events (NAEs) associated with 2 contemporary centrifugal-flow left ventricular assist devices: the Abbott HeartMate3 (HM3) and the Medtronic HeartWare HVAD (HVAD). METHODS: Using the Society of Thoracic Surgeons Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs), we collected data on adult patients who received a centrifugal-flow left ventricular assist device as a primary isolated implant between January 1, 2017, and September 30, 2019. Major NAEs were defined as transient ischemic attack, ischemic cerebrovascular accident, or hemorrhagic cerebrovascular accident. The association of HVAD with risk of NAE in the first year after implant was evaluated using propensity score matching to balance for preimplant risk factors. After matching, freedom from first major NAE in the HM3 and HVAD cohorts was compared with Kaplan-Meier curves. A secondary analysis using multivariable multiphase hazard models was used to identify predictors of NAE, which uses a data-driven parametric fit of the early declining and constant phase hazards and the associations of risk factor with either phase. RESULTS: Of 6205 included patients, 3129 (50.4%) received the HM3 and 3076 (49.6%) received the HVAD. Median follow-up was 9 and 12 months (HM3 and HVAD, respectively). Patients receiving HVAD had more major NAEs (16.4% versus 6.4%, P<0.001) as well as each subtype (transient ischemic attack: 3.3% versus 1.0%, P<0.001; ischemic cerebrovascular accident: 7.7% versus 3.4%, P<0.001; hemorrhagic cerebrovascular accident: 7.2% versus 2.0%, P<0.001) than did patients receiving HM3. A propensity-matched cohort balanced for preimplant risk factors showed that HVAD was associated with higher probabilities of major NAEs (% freedom from NAE 82% versus 92%, P<0.001). Device type was not significantly associated with NAEs in the early hazard phase, but HVAD was associated with higher incidence of major NAEs during the constant hazard phase (hazard ratio, 5.71 [CI, 3.90-8.36]). CONCLUSIONS: HM3 is associated with lower hazard of major NAEs than is HVAD beyond the early postimplantation period and during the constant hazard phase. Defining the explanation for this observation will inform device selection for individual patients.

Decreased Growth Rate Associated with Tissue Contaminants in Juvenile Chinook Salmon Out-Migrating through an Industrial Waterway.

The industrial waterway in Portland Harbor, Oregon, is a migration corridor for a distinct population segment of Chinook Salmon (Upper Willamette River) currently protected by the U.S. Endangered Species Act. Juveniles are exposed to a suite of contaminants during outmigration including polycyclic aromatic hydrocarbons (PAHs), polychlorinated biphenyls (PCBs), and dichlorodiphenyltrichloroethanes. We collected natural origin subyearling Chinook salmon from sites in and around the industrial harbor to evaluate growth (otolith microstructural analysis) in relation to measured chemical concentrations in tissue. A reduced growth rate was associated with higher tissue contaminant concentrations, particularly mixtures represented by PAHs and certain PCBs, which were elevated in juvenile Chinook collected throughout sites within Portland Harbor relative to those captured upstream. First-year growth is an established predictor of individual survival and eventual reproductive success in Chinook salmon. Therefore, our results indicate that legacy pollution may be limiting the population abundance of threatened Willamette River Chinook salmon, and future habitat remediation or restoration actions may benefit ongoing species recovery efforts.