High-quality cardiac surgery through teamwork.

The high-quality cardiothoracic surgery program is primed for mindful effective surgery. The challenge lies in attaining mindful skills and efficiency. Herein is one journey toward high departmental quality over two decades.

Prothrombin Complex Concentrate Reduces Blood Product Utilization in Heart Transplantation.

BACKGROUND: Current practices for the reversal of warfarin before cardiac surgery include the use of vitamin K and fresh frozen plasma (FFP) to reduce the risk of bleeding. Although the 2010 International Society of Heart and Lung Transplantation guidelines acknowledge the use of prothrombin complex concentrate (PCC), there is no clear consensus on its efficacy. The objective of this study was to assess the efficacy of four-factor (4-F) PCC administration in patients requiring warfarin reversal before heart transplantation by determining blood product utilization perioperatively. METHODS: Twenty-one patients who received 4-F PCC for warfarin reversal before heart transplantation were compared to a similar cohort of 39 patients who did not receive 4-F PCC, from January 2011 to July 2015. Blood product utilization was collected retrospectively for the 24-hour preoperative, intraoperative, and 48-hour postoperative periods. RESULTS: Patients receiving 4-F PCC required fewer blood products in all three time periods. In the 24-hour preoperative period, 22 (56%) patients in the control group and 2 (10%) patients in the 4-F PCC groups received blood products (p<0.001). Intraoperatively, all patients received blood products. The 4-F PCC group required fewer units of packed red blood cells (median 3 vs 7 units, p<0.001) and FFP (median 4 vs 9 units, p<0.001). In the 48-hour postoperative period, 20 (51%) patients in the control group and 5 (24%) patients in the 4-F PCC group received blood products (p=0.04). CONCLUSIONS: 4-F PCC is associated with reduced blood product utilization 24 hours preoperatively and intraoperatively. Historically, the majority of patients require FFP for warfarin reversal preoperatively. In this single-center study, a significant reduction in the need for FFP was demonstrated with the use of 4-F PCC.

Rapid Discovery of Functional Small Molecule Ligands against Proteomic Targets through Library-Against-Library Screening.

Identifying "druggable" targets and their corresponding therapeutic agents are two fundamental challenges in drug discovery research. The one-bead-one-compound (OBOC) combinatorial library method has been developed to discover peptides or small molecules that bind to a specific target protein or elicit a specific cellular response. The phage display cDNA expression proteome library method has been employed to identify target proteins that interact with specific compounds. Here, we combined these two high-throughput approaches, efficiently interrogated approximately 10(13) possible molecular interactions, and identified 91 small molecule compound beads that interacted strongly with the phage library. Of 19 compounds resynthesized, 4 were cytotoxic against cancer cells; one of these compounds was found to interact with EIF5B and inhibit protein translation. As more binding pairs are confirmed and evaluated, the "library-against-library" screening approach and the resulting small molecule-protein domain interaction database may serve as a valuable tool for basic research and drug development.

A contemporary analysis of pulmonary hypertension in patients undergoing mitral valve surgery: Is this a risk factor?

OBJECTIVE: Pulmonary hypertension (PHT) has been considered a risk factor for mortality in cardiac surgery. Among mitral valve surgery (MVS) patients, we sought to determine if severe PHT increases mortality risk and if patients who undergo concomitant tricuspid valve surgery (TVS) incur additional risk. METHODS: Preoperative PHT was assessed in 1571 patients undergoing MVS, from 2004 to 2013. Patients were stratified into PHT groups as follows (mm Hg): none (<35); moderate (35-49); severe (50-79); and extreme (≥80). Propensity-score matching resulted in a total of 430 patients, by PHT groups, and 384 patients, by TVS groups. RESULTS: Patients with severe PHT had higher mortality, both 30-day (4% PHT vs 1% no PHT, P < .02) and late (defined as survival at 5 years): 75.5% severe versus 91.9% no PHT (P < .001). In propensity-score-matched groups, severe PHT was not a risk factor for 30-day (3% each, P = 1.0) or late mortality (86.2% severe vs 87.1% no PHT; P = .87). TVS did not increase 30-day (4.7% TVS vs 4.2% no TVS, P = .8) or late mortality (78.7% TVS vs 75.3% no TVS, P = .90). Late survival was lower in extreme PHT (75.4% vs no PHT 91.5%, P = .007), and a trend was found in 30-day mortality (11% extreme vs 3% no PHT, P = .16). CONCLUSIONS: Mortality in MVS is unaffected by severe PHT or the addition of TVS, yet extreme PHT remains a risk factor. Severe PHT (50-79 mm Hg) should not preclude surgery; concomitant TVS does not increase mortality.

"Top Gun" competition: motivation and practice narrows the technical skill gap among new cardiothoracic surgery residents.

BACKGROUND: Adoption of simulation skills training in cardiothoracic (CT) surgery remains a challenge. This study sought to determine whether a "Top Gun" competition would encourage simulator use and improve technical skills among first-year CT residents. METHODS: A coronary anastomosis simulation module with instructional video was sent to 96 first-year CT residents in traditional programs who were then invited to participate in a Top Gun competition. Residents uploaded a video recording of their baseline anastomosis using the simulator. After 6 weeks of practice under faculty supervision, each trainee uploaded a final video. All submissions were rated in blinded fashion by three CT surgeons. Twelve components were scored on a 5-point Likert scale (1 = poor; 5 = excellent); also, an overall pass-fail grade was given. Five trainees with the highest final scores were invited to compete at a live Top Gun competition. RESULTS: Seventeen trainees submitted a baseline anastomosis video for evaluation; 15 submitted a final video. Overall average scores improved from 3.24 ± 0.61 to 4.01 ± 0.33 (p < 0.001). Performance of the bottom 50% increased (1.11 ± 0.57) relative to the top 50% (0.43 ± 0.31), resulting in no detectable score difference after training (p = 0.14). Overall average time (minutes:seconds) decreased from 11:10 (range, 5:56 to 18:58) to 9:04 (range, 5:52 to 16:23; p < 0.01). Residents achieving a pass from all three raters increased from 13% (2 of 15) to 73% (11 of 15; p < 0.002). Thirteen of 15 residents completed a survey. Residents performed an average of 23 anastomoses (range, 10 to 40). The majority (10 of 13) agreed or strongly agreed that practicing on simulators will improve a trainee's technical skill acquisition. CONCLUSIONS: Focused training results in improved technical skills in vessel anastomosis, especially for residents with lower baseline skills. Simulation, as with any educational endeavor, requires the motivation of the trainee, commitment of the faculty educator, and a defined training curriculum.

Practice improves performance on a coronary anastomosis simulator, attending surgeon supervision does not.

OBJECTIVES: Enthusiasm for simulation early in cardiothoracic surgery training is growing, yet evidence demonstrating its utility is limited. We examined the effect of supervised and unsupervised training on coronary anastomosis performance in a randomized trial among medical students. METHODS: Forty-five medical students were recruited for this single-blinded, randomized controlled trial using a low-fidelity simulator. After viewing an instructional video, all participants attempted an anastomosis. Subsequently, the participants were randomized to 1 of 3 groups: control (n = 15), unsupervised training (n = 15), or supervised training with a cardiothoracic surgeon or fellow (n = 15). Both the supervised and unsupervised groups practiced for 1 hour per week. After 4 weeks, the participants repeated the anastomosis. All pre- and posttraining performances were videotaped and rated independently by 3 cardiothoracic surgeons blinded to the randomization. All raters scored 13 assessment items on a 1 to 5 (low-high) scale along with an overall pass/fail rating. RESULTS: After the training period, all 3 groups showed significant improvements in composite scores (control: +0.52 ± 0.69 [P = .014], unsupervised: +1.05 ± 0.48 [P < .001], and supervised: +1.10 ± 0.84 [P < .001]). Compared with control group, both supervised (P = .005) and unsupervised trainees (P = .005) demonstrated a significant improvement. Between the supervised and unsupervised groups there were no statistically significant differences in composite scores. CONCLUSIONS: Practice on low-fidelity simulators enabled trainees to improve on a broad range of skills; however, the additional effect of attending-level supervision is limited. In an era of increasing staff surgeon responsibilities, unsupervised practice may be sufficient for inexperienced trainees.

Natural orifice translumenal endoscopic surgery (NOTES(®)): a technical review.

INTRODUCTION: The clinical NOTES literature continues to grow. This review quantifies the published human NOTES experience to date, examines instrument use in detail, and compiles available perioperative outcomes data. METHODS: A PubMed search for all articles describing human NOTES cases was performed. All articles providing a technical description of procedures, excluding cases limited to diagnostic procedures, specimen extraction, fluid drainage or gynecological procedures, were reviewed. Two reviewers systematically cataloged the technical details of each procedure and performed a frequency analysis of instrument use in each type of case. Available outcomes data were also compiled. RESULTS: Forty-three discrete articles were reviewed in detail, describing a total of 432 operations consisting of transvaginal (n = 355), transgastric (n = 58), transesophageal (n = 17), and transrectal (n = 2) procedures, with 90% of cases performed in hybrid fashion with laparoscopic assistance. Cholecystectomy (84% of cases) was the most common procedure. Analysis of key steps included choice of endoscope, establishment of peritoneal access, dissection, specimen extraction, and closure of the access site. Analysis of instrument use during transvaginal cholecystectomy revealed variation in the choice of endoscope and the technique for establishment of access. A majority of these procedures relied heavily on the use of rigid and transabdominal instrumentation. Closure of the vaginotomy site was found to be well standardized, performed with an open suturing technique. Similar analysis for transgastric procedures revealed consistency in the choice of flexible endoscope as well as access and closure techniques. Perioperative outcomes from NOTES procedures were reported, but the data are currently limited due to small case numbers. CONCLUSIONS: NOTES is most commonly performed using a hybrid, transvaginal approach. Although some aspects of these procedures appear to be well standardized, there is still significant variability in technique. More outcomes data with standardized reporting are needed to determine the actual risks and benefits of NOTES.