Transcatheter Aortic Valve Replacement Improves Quality of Life and Ventricular Function With Low-Flow/Low-Gradient Aortic Stenosis.

Background: D2 aortic stenosis (AS) is the highest risk AS subtype with worse operative and mortality outcomes. This study aimed to investigate the quality of life (QoL) and left ventricular ejection fraction (LVEF) in patients with classic (D2 subtype) low-flow/low-gradient AS who underwent transcatheter aortic valve replacement (TAVR). Methods: In total, 634 patients with severe AS underwent TAVR at our institution from 2014 to 2020, of whom 76 met criteria for classic D2 AS with reduced LVEF. Echocardiographic and clinical outcomes including mortality, stroke, pacemaker placement (PPM), and readmission at baseline were compared with those at 30 days and 1 year. QoL data were extracted from the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Results: The average baseline Society of Thoracic Surgeons risk score for patients with D2 AS was 7.66 ± 6.76. Patients with D2 AS reported improved QoL post-TAVR. The average baseline KCCQ-12 score was 39.5 ± 20, with improvement to 68.9 ± 20.6 at 30 days (P < .01) and 74.9 ± 17.5 at 1 year (P < .01). Mortality was 0% at 30 days and 18.4% at 1 year. The average baseline LVEF was 36.1 ± 9.4. Left ventricular function improved to 43.5 ± 12.9 (P <.001) at 30 days and 46.3 ± 11.2 (P = .03) at 1 year. Complications post-TAVR at 30 days included stroke (1.3%) and PPM (11.8%). Patients with D2 AS exhibited higher baseline conduction defects including atrial fibrillation and higher postoperative PPM than those with other subtypes. Conclusions: Patients with D2 AS had significantly improved LVEF and QoL following TAVR at 30 days and 1 year. Postoperative rates of new PPM were higher than other subtypes, while stroke, dialysis, and mortality were lower than expected, supporting the benefit of TAVR in this high-risk group.

Practice patterns of female cardiothoracic surgeons older than age 58 years: Are we making progress?

OBJECTIVE: Women remain a small minority of cardiothoracic surgeons, and within adult cardiac surgery, the gender gap widens. This study examines the career pathway and trajectory of female adult cardiac surgeons. METHODS: Female cardiothoracic surgeons were identified from the American Board of Thoracic Surgery diplomates over 58 years. Publicly available information was obtained to determine years in practice, practice type, academic and leadership title(s), and location of practice. RESULTS: The average number of years in practice for female adult cardiac surgeons was 13.1. Those categorized as adult cardiac surgeons composed 25.4% (n = 90) of all female cardiothoracic diplomates and 134 (37.9%) were categorized as other subspecialty practice. Of the adult cardiac surgeons, 33.3% (n = 30) practiced privately and the remainder in academic practice. Academic titles were held by 47.8% (43 out of 90) and 30% (27 out of 90) held a position of leadership. Of those in academic practice, 25% (11 out of 42) are titled professor, whereas 43% (18 out of 42) are assistant professors. Most commonly, those in positions of leadership held the title "director," which reflects 37% (10 out of 27) of individuals. Practice locations were distributed throughout the United States, with the highest number in the northeast (26.7%). CONCLUSIONS: Only a small portion of female cardiothoracic surgeons pursue a career in adult cardiac surgery compared to their male counterparts. From 1999 to 2009, 1300 individuals were board certified cardiothoracic surgeons, of whom only 103 (7.9%) were female. Of these, the majority of female cardiothoracic surgeons entered academic practice. Although the overall number of practicing female adult cardiac surgeons has increased with a growth rate of 10.7%, this number remains extremely low. A discrepancy remains between gender representation of academic titles and leadership positions. Although the field has increased female representation over the past few decades, work remains to ensure all potential talent is encouraged and supported.

Cardiac surgery in nonagenarians: Rethinking operative strategies in the era of TAVR and TMVR.

As growth of the elderly population continues to increase alongside improvements in percutaneous and minimally invasive interventions, cardiac surgeons question the role of high-risk surgery in treating these patients. TAVR has transformed the management of symptomatic severe aortic stenosis in elderly patients and has become standard therapy for patients greater than 80 years of age. With improvements in procedural risks and technical complications for both transcatheter valves and percutaneous interventions, should we rethink the operative strategies for octogenarians and nonagenarians, particularly as they apply to concurrent high-risk operations?

Minimally Invasive versus Full Sternotomy SAVR in the Era of TAVR: An Institutional Review.

In the era of advancing transcatheter aortic valve replacement (TAVR) technology, traditional open surgery remains a valuable intervention for patients who are not TAVR candidates. We sought to compare perioperative variables and postoperative outcomes of minimally invasive and full sternotomy surgical aortic valve replacement (SAVR) at a single institution. A retrospective analysis of 113 patients who underwent isolated SAVR via full sternotomy or upper hemi-sternotomy between January 2015 and December 2019 at the University of Utah Hospital was performed. Preoperative comorbidities and demographic information were not different among groups, with the exception of diabetes, which was significantly more common in the full sternotomy group (p = 0.01). Median procedure length was numerically shorter in the minimally invasive group but was not significant following the Bonferroni correction (p = 0.047). Other perioperative variables were not significantly different. The two groups showed no difference in the incidence of postoperative adverse events (p = 0.879). As such, minimally invasive SAVR via hemi-sternotomy remains a safe and effective alternative to full sternotomy for patients who meet the criteria for aortic valve replacement.

Surgical management of catheter-related right atrial thrombus with superior vena cava syndrome A Case Report.

There are no consensus guidelines on the management of catheter-related right atrial thrombus. We present the case of a 29-year-old female with end-stage renal disease who was found to have a large right atrial thrombus associated with her tunneled dialysis catheter during preoperative workup for renal transplant. She exhibited signs and symptoms of superior vena cava syndrome and NYHA class III congestive heart failure. She was successfully treated with surgical thrombectomy and demonstrated rapid resolution of her symptoms postoperatively.

Cardiac Surgery and Postoperative Renal Allograft Failure.

BACKGROUND: Although cardiac surgery among renal allograft recipients is relatively safe, less is known about the impact of cardiac surgery on the functioning renal allograft. This study assessed postoperative renal failure among renal transplant recipients undergoing cardiac surgery. METHODS: The study population was identified by matching medical record numbers from the United Network for Organ Sharing Kidney Transplant Database to a cardiovascular surgery database and The Society of Thoracic Surgeons Adult Cardiac Surgery Database for the authors' institution from January 1992 through August 2018. RESULTS: One hundred seventy-nine renal transplant recipients with a functioning allograft underwent cardiac surgery a mean of 6.4 ± 5.6 years after renal transplantation. Thirty (17.6%) of the 170 patients either died or had allograft failure during the first postoperative year. Receiver-operating characteristics curve analysis using Cox regression demonstrated an optimal cutoff point for preoperative serum creatinine predicting postoperative allograft loss is 1.9 mg/dL (hazard ratio 3; 95% confidence interval, 1.5 to 6.9) with a model C statistic of 0.642. CONCLUSIONS: The current study affirms findings in the literature that cardiac surgery in renal transplant recipients carries acceptable perioperative morbidity and mortality. Renal transplant recipients who underwent cardiac surgery had a constant hazard of renal allograft loss similar to that of the general transplant population. A preoperative serum creatinine value greater than 1.9 mg/dL increases the risk for long-term renal allograft loss after cardiac surgery.

Repair of right pulmonary artery transection after blunt trauma.

Acute pulmonary artery transection after blunt trauma is presumed to be a fatal injury. We report a case of right pulmonary artery transection successfully repaired with cardiopulmonary bypass and primary end-to-end anastomosis.

Satellite pulmonary nodule in the same lobe (T4N0) should not be staged as IIIB non-small cell lung cancer.

BACKGROUND: Treatment of non-small cell lung cancer depends on stage. Patients with T4 lesions represent a heterogeneous group. METHODS: A case-control study of patients with pathologically proven, node-negative T4 lesions (T4 N0 M0) was conducted. Patients with T4 disease were stratified as T4 from a satellite nodule (T4-satellite) or T4 from local invasion (T4-invasion). T4-satellite patients were matched 1:4 for sex and histology with resected control patients with stage IA, IB, and IIA non-small cell lung cancer and matched 1:3 with stage II non-small cell lung cancer. Survival and the maximal standardized uptake value on F-18 fluorodeoxyglucose-positron emission tomography scans were compared. RESULTS: There were 337 patients, 26 patients with T4-satellite lesions, 25 with T4-invasion lesions, and 286 controls (104 patients with T1 N0 M0, 104 with T2 N0 M0, and 78 with T1 N1 M0 or T2 N1 M0 lesions). The two T4 groups were similar for age, race, sex, and neoadjuvant therapy rates. The 5-year survival was 80% for the T1 N0 M0 patients, 68% for T2 N0 M0, 57% for T4-satellite N0 M0, 45% for T1 N1 M0 or T2 N1 M0, and 30% for the T4-invasion N0 M0 patients (p = 0.016). Multivariate analysis showed that only the type of T4 impacted survival (p = 0.011). The median maximal standardized uptake values of the cancers were 4.2 for T1 N0 M0, 4.8 for T4-satellite, 5.4 for T2 N0 M0, 7.8 for T1 N1 M0 or T2 N1 M0, and 8.8 for the T4-invasion patients. CONCLUSIONS: Larger studies are needed; however, patients with T4-satellite non-small cell lung cancer who undergo complete resection have survival and maximal standardized uptake values similar to patients with stage IB and stage IIA lesions. Their survival is significantly better than those with T4-invasion. Patients with T4-satellite N0 M0 lesions should not be classified as stage IIIB and should not be grouped with patients with T4-invasion, and resection should be considered.

Argatroban, bivalirudin, and lepirudin do not decrease clot propagation and strength as effectively as heparin-activated antithrombin in vitro.

BACKGROUND: Heparin-induced thrombocytopenia is a potentially limb- and life-threatening response to heparin exposure. Direct thrombin inhibitors (DTIs) have been reported to provide anti-coagulation for cardiopulmonary bypass; however, clot formation within the cardiopulmonary bypass circuit has been reported after the administration of DTIs. We present a case of thrombosis of the cardiopulmonary bypass circuit and, ultimately, death after argatroban administration. An in vitro thrombelastographic assessment of the effects of DTIs on clot kinetics was consequently performed to determine potential causes for this complication. METHODS: Normal human plasma was unmodified or exposed to heparin (1, 2, 3 U/ml), argatroban (5, 10, 50 microg/ml), bivalirudin (12, 20, 120 microg/ml), or lepirudin (3, 6, 10 microg/ml) before activation with tissue factor/kaolin in a thrombelastograph. Clot initiation (R, reaction time), propagation (MTG, maximum thrombus generation), and strength (MG, maximum elastic modulus) were determined. Analysis of variance was performed, with p < 0.05 considered significant. RESULTS: Compared with unmodified plasma, heparin significantly prolonged R and essentially reduced MTG and MG to the limits of detection in an activity-dependent fashion. In general, the DTIs tested prolonged R in a concentration-dependent fashion but did not diminish MTG or MG nearly as well as heparin. The only exception was 10 microg/ml lepirudin, which eliminated coagulation. CONCLUSIONS: DTIs demonstrated a significant prolongation of clot initiation but poor attenuation of propagation and strength. Further in vitro and clinical investigations to design a heparin-equivalent regimen to provide anti-coagulation for patients with heparin-induced thrombocytopenia are indicated.

Pelvic fracture in the elderly is associated with increased mortality.

OBJECTIVE: The elderly population is currently the fastest growing sector in America. The purpose of this study was to examine the age-related outcome in patients after blunt pelvic injury. METHODS: All patients admitted with a pelvic fracture during a 5-year period were identified from the trauma registry. Data retrieval included: demographics, shock (BP < 90 mm Hg) on admission, injury severity score (ISS), abbreviated injury score (AIS) for head, chest, and abdomen, intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. All pelvic fracture patterns were classified. Patient data were then stratified by age for comparison: young (< 55 years) and elderly (> or = 55 years). Statistical analysis was performed using the Student t test, Wilcoxon rank-sum test, multiple logistic regression analysis, and chi-square test with significance set at P <.05. RESULTS: Three hundred five patients sustained a pelvic fracture (young [n = 248, 81.3%]; elderly [n = 57, 18.7%]). The only predictor of mortality was age. The 2 groups differed by gender (elderly = 54.4% females; young = 62.5% males) but not frequency of shock, ISS, or AIS for head, chest, and abdomen. Motor vehicle collision was the most common mechanism of injury (elderly = 68.4%; young = 73.8%). Lateral compression was the most common fracture pattern in both groups (elderly = 54.4%; young = 45.6%). There was no difference in transfusion (elderly = 2.5 +/- 0.7 vs young = 2.0 +/- 0.3; ns) but the elderly group was more frequently admitted to the ICU (elderly = 61.4% vs young = 46.8%; P =.065). Significantly more of the elderly group had a diagnosis of cardiovascular disease (43.9% vs 10.1%, P <.001) and diabetes mellitus (10.5% vs 2.4%, P <.014). Mortality was significantly greater in the elderly group (12.3% vs 2.3%). CONCLUSION: Elderly patients sustaining a pelvic fracture were more likely to have a lateral compression fracture pattern, longer hospital LOS, and die despite aggressive resuscitation. This difference in outcome should help trauma surgeons recognize that the elderly patient sustaining a pelvic fracture is at increased risk of death.