Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

What is in the Dash? An Examination of the Life and Contributions of John B. Flege, Jr., MD.

It is, indeed, a privilege to stand here before you this morning to give the annual Flege Lecture.  Dr. Sande Starnes has kindly supplied me with a list of prior visiting professors, who previously have had the honor to deliver this talk. When we examine the names of those who have been so honored, and note their many accomplishments, I cannot help but remember the words of Winston Churchill, who, when speaking of another person, could well have been speaking of me, when he described "a modest little person, with much to be modest about."

Update on Outcomes of a Novel Pathway for Thoracic Surgery Training.

BACKGROUND: The Joint Surgery-Thoracic Surgery (JS-TS) pathway began as a pilot program to grant both general surgery (GS) residency and thoracic surgery (TS) fellowship credit for 12 months of the PGY-4 and 5 years. This review updates the outcomes of this novel program. STUDY DESIGN: GS and TS programs in all approved JS-TS institutions were contacted for data collection, including JS-TS enrollee demographics and GS and TS case logs (CLs). National GS and TS CL data, and program and institutional data were publicly available. Enrollee case numbers were compared with those of their contemporaries. The American Board of Surgery and American Board of Thoracic Surgery provided certification data. Only enrollees who completed GS through 2019 were included. RESULTS: There were 90 JS-TS enrollees in 14 institutions. Two enrollees withdrew and 1 had not completed TS at the time of data collection leaving 87 for analysis. GS CLs were available for all 87 enrollees. TS CLs were available for all 62 enrollees who completed fellowship in 2016 or later. In GS, enrollees recorded fewer cases than their contemporary PGY-5s nationally in all domains except thoracic and endocrine. In TS, mean enrollee case numbers exceeded those of national contemporaries in every major category. Sixty-two JS-TS enrollees have achieved American Board of Surgery certification. Eighty-two enrollees are American Board of Thoracic Surgery certified with 5 currently in the certification process. CONCLUSIONS: The JS-TS pathway has proven a successful alternative route for TS training and could be a blueprint for other specialties considering novel avenues to specialty training.

Perceptions and expectations of cardiothoracic residents and attending surgeons.

BACKGROUND: With our specialty going through a critical phase of re-evaluation and adaptation, our aim was to evaluate and compare the perceptions and expectations among residents and faculty regarding cardiothoracic training. METHODS: A content-validated, 13-item survey was distributed electronically from August 14 to August 24, 2010 to 728 cardiothoracic surgery residents, recent program graduates (on or after June 2006), cardiothoracic surgery chairpersons, and program directors identified in the Cardiothoracic Surgery Network database. RESULTS: The response rate was 34% (244 of 728). Of the respondents, 76% reported being "satisfied" or "very satisfied" with their program. Faculty willingness to teach in the operating room was ranked as the most valuable aspect of a training program, and strict adherence to the 80-h work week ranked as least valuable. Most respondents believed that a resident performing at least 75% of a case was acceptable for low-complexity procedures (92% of residents, 77% of attending physicians) and at least 25% for high-complexity procedures (91% of residents, 73% of attending physicians). However, residents wanted to perform more of the operations than the attending physicians considered necessary (P < 0.05). Finally, 63% of respondents (73% of residents, 56% of attending physicians) indicated that the increasing scrutiny of outcomes has adversely affected training. Other differences between the residents' and attending physicians' perceptions regarded the importance of participation in preoperative and postoperative care, what constitutes "scut work," and the value of auxiliary staff. CONCLUSIONS: Reconciling residents' expectations with the realities of duty-hour restrictions and high-stakes procedures will require the development of novel educational approaches to improve resident learning.

Current use of intrapleural tissue plasminogen activator in the treatment of complex pleural processes: a review of the literature and report of 9 cases.

Intrapleural tissue plasminogen activator is increasingly being utilized to treat complex pleural processes, such as complicated pleural effusions and empyemas, without surgical intervention. This technique is especially useful for patients with numerous co-morbidities or who are poor surgical candidates. We present our experience in treating nine adult patients with intrapleural tissue plasminogen activator for complex pleural processes. Patients were treated with one to eight doses until their condition resolved or surgical intervention was necessary. Seven patients had complete resolution, two patients required surgical intervention, and there were no complications from therapy. A review of all available literature on the use of intrapleural tissue plasminogen activator in adults is presented, comparing the various methods and techniques used by others.

Twist1 promotes heart valve cell proliferation and extracellular matrix gene expression during development in vivo and is expressed in human diseased aortic valves.

During embryogenesis the heart valves develop from undifferentiated mesenchymal endocardial cushions (EC), and activated interstitial cells of adult diseased valves share characteristics of embryonic valve progenitors. Twist1, a class II basic-helix-loop-helix (bHLH) transcription factor, is expressed during early EC development and is down-regulated later during valve remodeling. The requirements for Twist1 down-regulation in the remodeling valves and the consequences of prolonged Twist1 activity were examined in transgenic mice with persistent expression of Twist1 in developing and mature valves. Persistent Twist1 expression in the remodeling valves leads to increased valve cell proliferation, increased expression of Tbx20, and increased extracellular matrix (ECM) gene expression, characteristic of early valve progenitors. Among the ECM genes predominant in the EC, Col2a1 was identified as a direct transcriptional target of Twist1. Increased Twist1 expression also leads to dysregulation of fibrillar collagen and periostin expression, as well as enlarged hypercellular valve leaflets prior to birth. In human diseased aortic valves, increased Twist1 expression and cell proliferation are observed adjacent to nodules of calcification. Overall, these data implicate Twist1 as a critical regulator of valve development and suggest that Twist1 influences ECM production and cell proliferation during disease.

A Teacher Affects Eternity; He Can Never Tell Where His Influence Stops: A Reassessment of the Contributions of Barney Brooks, A Consummate Educator.

Barney Brooks, MD, was the first Professor of Surgery in the newly reconstituted Vanderbilt University School of Medicine in 1925, a position he held until 1951. He was born on the remote plains of Texas and came from obscure beginnings, but through much hard work and determination, he rose to occupy a position of prominence and was a leader in surgery of national scope. Of his major contributions, he considered teaching to be of the utmost importance, and it was for his efforts in teaching that he was most widely known. His reputation as a stern taskmaster was well deserved, but there are other aspects of this most complex man that bear a closer look. An examination of his archived correspondence is revealing, and it shows him to have been a caring and compassionate individual who formed lasting bonds with medical students and residents, members of his faculty, and others. Thus, his life and contributions to surgery and surgical education should be remembered and celebrated.

In Your Own Words: Toward a More Perfect Union of Patient Care and Education.

Communication with patients and their families is a challenge for busy trainees. It is essential, however, that these trainees learn effective communication skills to create rapport with their patients, to add to their own satisfaction in caring for these patients and to use these conversations to constantly reassess their plans for treating their patients. Reflecting on the plans for and the outcomes of the care of their patients will also significantly enhance the educational value of the participation of trainees in this patient care, while simultaneously improving the care of both their current and their future patients. Finally, gaining facility in elaborating on their plans for and the delivery of patient care will help trainees become more articulate and thoughtful practitioners.

Surgical Training and the Early Specialization Program: Analysis of a National Program.

BACKGROUND: The Early Specialization Program (ESP) in surgery was designed by the American Board of Surgery, the American Board of Thoracic Surgery, and the Residency Review Committees for Surgery and Thoracic Surgery to allow surgical trainees dual certification in general surgery (GS) and either vascular surgery (VS) or cardiothoracic surgery (CTS) after 6 to 7 years of training. After more than 10 years' experience, this analysis was undertaken to evaluate efficacy. STUDY DESIGN: American Board of Surgery and American Board of Thoracic Surgery records of VS and CTS ESP trainees were queried to evaluate qualifying exam and certifying exam performance. Case logs were examined and compared with contemporaneous non-ESP trainees. Opinions of programs directors of GS, VS, and CTS and ESP participants were solicited via survey. RESULTS: Twenty-six CTS ESP residents have completed training at 10 programs and 16 VS ESP at 6 programs. First-time pass rates on American Board of Surgery qualifying and certifying exams were superior to time-matched peers; greater success in specialty specific examinations was also found. Trainees met required case minimums for GS despite shortened time in GS. By survey, 85% of programs directors endorsed satisfaction with ESP, and 90% endorsed graduate readiness for independent practice. Early Specialization Program participants report increased mentorship and independence, greater competence for practice, and overall satisfaction with ESP. CONCLUSIONS: Individuals in ESP programs in VS and CTS were successful in passing GS and specialty exams and achieving required operative cases, despite an accelerated training track. Programs directors and participants report satisfaction with the training and confidence that ESP graduates are prepared for independent practice. This documented success supports ESP training in any surgical subspecialty, including comprehensive GS.

Recurrent primary cardiac malignant fibrous histiocytoma following orthotopic heart transplantation.

Malignant fibrous histiocytoma (MFH) is an extremely rare primary cardiac tumor. We describe a young patient who underwent orthotopic heart transplantation for an unresectable right ventricular MFH and presented 7 years later with a local recurrence in the native right atrium. This was treated by complete resection of the right atrial tumor and adjuvant chemotherapy. This case represents the only reported long-term survival following cardiac transplantation for MFH and describes our management strategy for local recurrence in this patient.

Modeling the effects of functional performance and post-transplant comorbidities on health-related quality of life after heart transplantation.

BACKGROUND: Health-related quality of life and functional performance are important outcome measures following heart transplantation. This study investigates the impact of pre-transplant functional performance and post-transplant rejection episodes, obesity and osteopenia on post-transplant health-related quality of life and functional performance. METHODS: Functional performance and health-related quality of life were measured in 70 adult heart transplant recipients. A composite health-related quality of life outcome measure was computed via principal component analysis. Iterative, multiple regression-based path analysis was used to develop an integrated model of variables that affect post-transplant functional performance and health-related quality of life. RESULTS: Functional performance, as measured by the Karnofsky scale, improved markedly during the first 6 months post-transplant and was then sustained for up to 3 years. Rejection Grade > or =2 was negatively associated with health-related quality of life, measured by Short Form-36 and reversed Psychosocial Adjustment to Illness Scale scores. Patients with osteopenia had lower Short Form-36 physical scores and obese patients had lower functional performance. Path analysis demonstrated a negative direct effect of obesity (beta = - 0.28, p < 0.05) on post-transplant functional performance. Post-transplant functional performance had a positive direct effect on the health-related quality of life composite score (beta = 0.48, p < 0.001), and prior rejection episodes grade > or =2 had a negative direct effect on this measure (beta = -0.29, p < 0.05). Either directly or through effects mediated by functional performance, moderate-to-severe rejection, obesity and osteopenia negatively impact health-related quality of life. These findings indicate that efforts should be made to devise immunosuppressive regimens that reduce the incidence of acute rejection, weight gain and osteopenia after heart transplantation.

Late cardiac reoperation after cardiac transplantation.

BACKGROUND: The intermediate and long-term results of cardiac transplantation continue to improve. Subsequent cardiac procedures may be required to extend patient survival and protect graft function. METHODS: The medical records of all adult and pediatric cardiac transplant recipients who underwent a subsequent cardiac procedure at our institution were reviewed. RESULTS: Three hundred sixty patients have undergone primary orthotopic transplantation in our institution. Seventeen patients (12 adults, 5 children) underwent a subsequent procedure requiring cardiopulmonary bypass including cardiac retransplantation (10), coronary artery bypass grafting (3), ascending aortic replacement (2), tricuspid valve repair (1), and myotomy and myomectomy (1 patient). Mean interval from time of transplantation to second procedure was 8.3 years. There was one perioperative death. Two patients, both retransplants, died late postoperatively at 22 and 84 months, respectively. Overall mean follow-up in the late survivors is 26.6 months. All survivors are currently asymptomatic and doing well. CONCLUSIONS: A variety of subsequent cardiac procedures, in addition to retransplantation, can be performed safely in carefully selected cardiac transplant recipients. The intermediate term results are gratifying in terms of survival and freedom from symptoms.

Left ventricular assist device implantation via left thoracotomy: alternative to repeat sternotomy.

Repeat sternotomy for left ventricular assist device insertion may result in injury to the right heart or patent coronary grafts, complicating intraoperative and postoperative management. In 4 critically ill patients, left thoracotomy was used as an alternative to repeat sternotomy. Anastomosis of the outflow conduit to the descending thoracic aorta provided satisfactory hemodynamic support.

A modified bronchial anastomosis technique for lung transplantation.

BACKGROUND: Low rates of major complications have been reported for the intussuscepting bronchial anastomotic technique but stenosis, malacia, and granulation tissue at the anastomosis may cause clinically important morbidity. We hypothesized that a modification of the telescoping technique that improves bronchial wall apposition might be associated with improved bronchial healing and clinical outcomes. METHODS: The telescoping horizontal mattress "U-stitch" suture technique was modified to incorporate figure-of-eight sutures placed in the cartilaginous wall between each of three intussuscepting U stitches. Serial videotape records of 152 individual anastomoses (99 modified, 53 telescoped) in 118 consecutive operative survivors were retrospectively reviewed by examiners blinded with respect to technique used. Stenosis, airway instability, mucosa quality, and devascularized luminal tissue were graded at 4 to 14 days (initial), 4 to 12 weeks (early), and 6 to 12 months (late) after transplantation. RESULTS: The incidence of anastomotic stenosis was significantly lower using the modified technique at the initial (p = 0.025) and late (p = 0.015) observations. In the initial phase airway instability (p = 0.015) and devascularization grades (p = 0.001) were also significant lower in the modified group. There were no significant differences in mucosal condition between techniques. The modified telescoping technique was associated with significant survival advantage (mean 17.7%; p = 0.029) by multivariate analysis. The incidence of major airway complications (dehiscences and stenoses required stents) tended to be lower (3% versus 6%) in the modified group. CONCLUSIONS: The modified telescoping bronchial anastomosis technique is associated with improved early and late bronchial healing and higher 5-year survival without increased major airway complications.

Cardiac surgery after renal transplantation.

Renal transplantation remains a mainstay of therapy for end-stage renal disease. Cardiac disease has a high prevalence in this patient population. This study reviews the factors and outcomes associated with cardiac surgery in renal transplant recipients. We performed a retrospective review of all patients at our institution with a functioning renal allograft at the time of their cardiac surgical procedure. Between June 1971 and April 2000, 2343 patients underwent renal transplantation at Vanderbilt University Medical Center. Twenty-six patients with a functioning renal allograft subsequently underwent a cardiac procedure requiring cardiopulmonary bypass. There were 11 women and 15 men. Twenty-four patients underwent coronary bypass, one had a double valve replacement, and one had a combined coronary bypass/valve replacement. The interval from renal transplant to heart surgery ranged between 0.6 and 227 months (mean 79.1). Operative mortality was zero but there were two hospital deaths: one due to multisystem organ failure and one due to pulmonary embolism. Six additional patients died late with only one due to heart disease. Four patients required perioperative dialysis, and one of these went on to require permanent dialysis. Two additional patients returned to dialysis late postoperatively. The requirement for acute perioperative dialysis was predicted by preoperative creatinine, hematocrit, and intraoperative urine output. The overall survival is 69 per cent (18 of 26) with a median follow-up of 38 months. The majority of long-term survivors have minimal cardiac symptoms. Standard cardiac surgery procedures can be performed with relative safety in patients with functioning renal allografts. The incidence of perioperative and late development of renal failure requiring dialysis is low. The long-term survival and symptomatic improvement achieved are favorable and warrant continued performance of cardiac surgery in patients with functioning renal allografts.

Homage: education and life lessons as taught by Dr James D. Hardy.

Dr James D. Hardy served as Chairman of the Department of Surgery at the University of Mississippi Medical Center Jackson, Mississippi, from 1955 to 1987. During his tenure, he had an unprecedented effect on the education of medical students, residents, and professionals in his field. Not only did he speak and write voluminously about medical education and the roles both teacher and student play in this interaction but also emphasized the importance of the family unit to the academic physician. This article serves to highlight Dr Hardy's thoughts about discipline, research, and personal experience as they pertain to medical education, as well as to impart some of his wisdom about life, family, and personal well-being.

Thoracic surgical resident education: a costly endeavor.

BACKGROUND: We sought to define an accurate measure of thoracic surgical education costs. METHODS: Program directors from six distinct and differently sized and geographically located thoracic surgical training programs used a common template to provide estimates of resident educational costs. These data were reviewed, clarifying questions or discrepancies when noted and using best estimates when exact data were unavailable. Subsequently, a composite of previously published cost-estimation products was used to capture accurate cost data. Data were then compiled and averaged to provide an accurate picture of all costs associated with thoracic surgical education. RESULTS: Before formal accounting was performed, the estimated average for all programs was approximately $250,000 per year per resident. However, when formal evaluations by the six programs were performed, the annual cost of resident education ranged from $330,000 to $667,000 per year per resident. The average cost of $483,000 per year was almost double the initial estimates. Variability was noted by region and size of program. Faculty teaching costs varied from $208,000 to $346,000 per year. Simulation costs ranged from $0 to $80,000 per year. Resident savings to program ranged from $0 to $135,000 per year and averaged $37,000 per year per resident. CONCLUSIONS: Thoracic surgical education costs are considerably higher than initial estimates from program directors and probably represent an unappreciated source of financial burden for cardiothoracic surgical educational programs.

Man is fashioned, not born: the contributions of George J. Heuer to surgical education.

George Heuer undertook his medical education and residency training in surgery at Johns Hopkins. He then joined the surgical faculty under Halsted. He became Chair of Surgery at the University of Cincinnati in 1922, where he developed the second formal surgical training program modeled on Halsted's principles. Subsequently, he became Chair of Surgery at Cornell where he founded another surgical residency. His training programs stressed broad and thorough experience, and he championed increasing resident responsibility and independence. The demonstrated efficacy of his surgical residencies assisted greatly in the formation of subsequent resident training programs across this country.