Advancing the Role of Proton Therapy for Spine Metastases Through Diagnostic Scan-Based Planning.

Purpose: Many patients with metastatic cancer live years beyond diagnosis, and there remains a need to improve the therapeutic ratio of metastasis-directed radiation for these patients. This study aimed to assess a process for delivering cost-effective palliative proton therapy to the spine using diagnostic scan-based planning (DSBP) and prefabricated treatment delivery devices. Materials and Methods: We designed and characterized a reusable proton aperture system that adjusts to multiple lengths for spine treatment. Next, we retrospectively identified 10 patients scan treated with thoracic proton therapy who also had a diagnostic computed tomography within 4 months of simulation. We contoured a T6-T9 target volume on both the diagnostic scans (DS) and simulation scans (SS). Using the aperture system, we generated proton plans on the DS using a posterior-anterior beam with no custom range compensator to treat T6-T9 to 8 Gy × 1. Plans were transferred to the SS to compare coverage and normal tissue doses, followed by robustness analysis. Finally, we compared normal tissue doses and costs between proton and photon plans. Results were compared using the Wilcoxon signed-rank test. Results: Median D95% on the DS plans was 101% (range, 100%-102%) of the prescription dose. Median Dmax was 107% (range, 105%-108%). When transferred to SS, coverage and hot spots remained acceptable for all cases. Heart and esophagus doses did not vary between the DS and SS proton plans (P >.2). Robustness analysis with 5 mm X/Y/Z shifts showed acceptable coverage (D95% > 98%) for all cases. Compared with the proton plans, the mean heart dose was higher for both anterior-posterior/posterior-anterior and volumetric modulated arc therapy plans (P < .01). Cost for proton DSBP was comparable to more commonly used photon regimens. Conclusion: Proton DSBP is technically feasible and robust, with superior sparing of the heart compared with photons. Eliminating simulation and custom devices increases the value of this approach in carefully selected patients.

Off-pump surgical thrombectomy for subacute right atrial thrombus: A case report.

Right heart thrombi can be seen in a minority of patients with acute pulmonary embolism and are associated with an increased mortality risk. The optimal treatment option comprises thrombolysis or surgical thrombectomy either with catheterbased interventions or with open surgery. Open right atrial thrombectomy is usually performed under cardiopulmonary bypass due to the need for concomitant pulmonary embolectomy. Nevertheless, cardiopulmonary bypass has major drawbacks such as the risk of stroke, coagulopathy, and myocardial and respiratory dysfunction, particularly in high-risk patients. Herein, we report a case of successful off-pump surgical thrombectomy performed for the right atrial clot-in-transit following failure of the catheter-based intervention.

Extracorporeal membrane oxygenator as a bridge to definitive treatment in patients with persistent infective endocarditis.

Considering the worsening opioid epidemic, complicated infective endocarditis (IE) secondary to intravenous drug use (IVDU) that fails medical management is increasingly common. We present a 31-year-old patient post tricuspid valve replacement who relapsed with recurrent IE and secondary complications of severe tricuspid stenosis and regurgitation, ventricular septal defect (VSD), pulmonary emboli, right-sided heart failure with severe hepatic congestion, and cardiogenic shock. Despite maximal medical management, the patient remained in septic and cardiogenic shock with a potential disposition to hospice care. Upon consulting cardiothoracic surgery, she underwent a first-stage valvectomy with central Extracorporeal Membrane Oxygenation (ECMO) as a bridge to definitive treatment. After clearance of infection, she underwent a second-stage valve replacement, VSD repair, and final ECMO decannulation. Our case alludes to ECMO as a potential bridge for patients with complicated infective endocarditis who fail medical management and are high-risk candidates for immediate definitive surgical management.

Redo mitral valve surgery: A totally endoscopic, robotic-assisted approach for adhesiolysis and complex repair.

We describe our technique for totally endoscopic, robotic-assisted thoracic and pericardial adhesiolysis and redo complex mitral valve repair.

Double Papillary Muscle Relocation: A Totally Endoscopic, Robotic-Assisted Approach.

We detail our technique for totally endoscopic, robotic-assisted mitral valve repair with the reimplantation of a ruptured papillary muscle head supported by double papillary muscle relocation and mitral annuloplasty for the treatment of nonacute ischemic mitral regurgitation.

Unilateral percutaneous cannulation and endoaortic balloon management in robotic-assisted cardiac surgery: The least invasive approach.

Totally endoscopic, robotic-assisted cardiac surgery has been increasingly utilized for valvular surgery. Peripheral cannulation with endoaortic balloon occlusion offers a safe approach for initiation of cardiopulmonary bypass during such procedures. We present a step-by-step demonstration of unilateral percutaneous femoral cannulation, endoaortic balloon positioning, and decannulation in a patient undergoing totally endoscopic, robotic-assisted mitral valve repair.

Bovine Aortic Arch: A Result of Chance or Mandate of Inheritance?

Previous studies have shown that bovine arch incidence is higher in patients with thoracic aortic aneurysms than in patients without an aneurysm. Although thoracic aortic aneurysm disease is known to be familial in some cases, it remains unknown if bovine arch results from a genetic mutation, thus allowing it to be inherited. Our objective was to determine the heritability of bovine arch from phenotypic pedigrees. We identified 24 probands from an institutional database of 202 living patients with bovine arch who had previously been diagnosed with thoracic aortic aneurysm and who had family members with previous chest computed tomography or magnetic resonance imaging scans. Aortic arch configuration of all first-degree and second-degree relatives was determined from available scans. Heritability of bovine arch was estimated using maximum-likelihood-based variance decomposition methodology implemented by way of the SOLAR package (University of Maryland, Catonsville, Maryland). 43 relatives of 24 probands with bovine arch had preexisting imaging available for review. The prevalence of bovine arch in relatives with chest imaging was 53% (n = 23) and did not differ significantly by gender (male: 64.3%, female: 55.6%, p = 1). The bovine arch was shown to be highly heritable with a heritability estimate (h2) of 0.71 (p = 0.048). In conclusion, the high heritability of bovine arch in our sample population suggests a genetic basis.

Patterns of Surveillance Imaging for Incidentally Detected Ascending Aortic Aneurysms.

BACKGROUND: Ascending aortic aneurysms (AsAA) remain a silent killer for which timely intervention and surveillance intervals are critical. Despite this, little is known about the follow-up care patients receive after incidental detection of an AsAA. We examined the pattern of surveillance and follow-up care for these high-risk patients. METHODS: We identified patients at our institution with incidentally detected AsAAs (≥37 mm) between 2013 and 2016. We collected information on patients' aneurysms and clinical follow-up. Logistic regression models related aneurysm size and demographics to whether patients received follow-up imaging or referral. RESULTS: From 2013 to 2016, 261 patients were identified to have incidentally detected AsAAs among the 21,336 computed tomography scans performed at our institution. The median aneurysm size was 4.2 cm (interquartile range, 4 to 4.4). Only 18 (6.9%) of the identified patients were referred to a cardiac surgeon for evaluation, and only 37.9% of the identified patients had a follow-up chest computed tomography scan within 1 year of detection; 34% had an echocardiogram. The median follow-up duration for the study was 5 years. Logistic regression models showed that aneurysm size and family history were significant predictors of whether a patient was referred to a cardiac surgeon (odds ratio 10.34; 95% confidence interval, 2.3 to 47.9), but not whether the patients received follow-up imaging. CONCLUSIONS: Among 261 patients with incidentally detected AsAAs, only a third received any follow-up imaging within 1 year after detection, with very low clinical penetrance for expert referral. Surveillance of this high-risk patient population appears insufficient and may require standardization.

Widening volume and persistent outcome disparity in valve operations: New York statewide analysis, 2005-2016.

OBJECTIVES: Volume concentration of complex noncardiac operations to high-volume centers has been observed, but whether this is also occurring in cardiac surgery is unknown. We examined the relationship between volume concentration and mortality rates for valve surgery and coronary artery bypass grafting (CABG) between 2005 and 2016 in New York State. METHODS: We analyzed publicly available, hospital-level case volume and risk-adjusted mortality rates (RAMRs) from 2005 to 2016 for isolated CABG and isolated or concomitant valve operations performed in New York. We identified hospitals in the top- and bottom-volume quartiles for each procedure type and compared changes in percent market share and outcomes. Bivariate and univariate longitudinal analysis was used to evaluate the statistical significance of the temporal trend. RESULTS: Among 36 centers, percent market share of the top-volume quartile increased for valve cases from 54.4% to 59.4%, whereas CABG share increased from 41.4% to 44.3%. No significant changes were noted in market share for the bottom quartile. The top-volume quartile demonstrated significant trends in improving outcomes over the study period for both valve procedures (RAMR: -0.261%/year, P < .001) and CABG (RAMR: -0.071%/year, P = .018). No significant trends were noted in the bottom quartile for either procedure. CONCLUSIONS: In New York, over the last decade, highest-volume hospitals increased their market share for valve operations while maintaining lower mortality rates than lowest-volume hospitals. Valve volume is regionalizing in the setting of a persistent outcome gap between the highest- and lowest-volume hospitals, suggesting that volume-based referrals for specialized cardiac procedures may improve surgical mortality.

Socioeconomic disparities in surveillance and follow-up of patients with thoracic aortic aneurysm.

BACKGROUND: Thoracic aortic aneurysm (TAA) is a significant risk factor for aortic dissection and rupture. Guidelines recommend referral of patients to a cardiovascular specialist for periodic surveillance imaging with surgical intervention determined primarily by aneurysm size. We investigated the association between socioeconomic status (SES) and surveillance practices in patients with ascending aortic aneurysms. METHODS: We retrospectively reviewed records of 465 consecutive patients diagnosed between 2013 and 2016 with ascending aortic aneurysm ≥4 cm on computed tomography scans. Primary outcomes were clinical follow-up with a cardiovascular specialist and aortic surveillance imaging within 2 years following index scan. We stratified patients into quartiles using the area deprivation index (ADI), a validated percentile measure of 17 variables characterizing SES at the census block group level. Competing risks analysis was used to determine interquartile differences in risk of death before follow up with a cardiovascular specialist. RESULTS: Lower SES was associated with significantly lower rates of surveillance imaging and referral to a cardiovascular specialist. On competing risks regression, the ADI quartile with lowest SES had lower hazard of follow-up with a cardiologist or cardiac surgeon before death (hazard ratio: 0.46 [0.34, 0.62], p < .001). Though there were no differences in aneurysm size at time of surgical repair, patients in the lowest socioeconomic quartile were more frequently symptomatic at surgery than other quartiles (92% vs. 23%-38%, p < .001). CONCLUSION: Patients with lower SES receive less timely follow-up imaging and specialist referral for TAAs, resulting in surgical intervention only when alarming symptoms are already present.

Development and Validation of a Predictive Model to Identify Patients With an Ascending Thoracic Aortic Aneurysm.

Background Screening protocols do not exist for ascending thoracic aortic aneurysms (ATAAs). A risk prediction algorithm may aid targeted screening of patients with an undiagnosed ATAA to prevent aortic dissection. We aimed to develop and validate a risk model to identify those at increased risk of having an ATAA, based on readily available clinical information. Methods and Results This is a cross-sectional study of computed tomography scans involving the chest at a tertiary care center on unique patients aged 50 to 85 years between 2013 and 2016. These criteria yielded 21 325 computed tomography scans. The double-oblique technique was used to measure the ascending thoracic aorta, and an ATAA was defined as >40 mm in diameter. A logistic regression model was fitted for the risk of ATAA, with readily available demographics and comorbidity variables. Model performance was characterized by discrimination and calibration metrics via split-sample testing. Among the 21 325 patients, there were 560 (2.6%) patients with an ATAA. The multivariable model demonstrated that older age, higher body surface area, history of arrhythmia, aortic valve disease, hypertension, and family history of aortic aneurysm were associated with increased risk of an ATAA, whereas female sex and diabetes were associated with a lower risk of an ATAA. The C statistic of the model was 0.723±0.016. The regression coefficients were transformed to scores that allow for point-of-care calculation of patients' risk. Conclusions We developed and internally validated a model to predict patients' risk of having an ATAA based on demographic and clinical characteristics. This algorithm may guide the targeted screening of an undiagnosed ATAA.

Research productivity of radiation therapy physics faculty in the United States.

PURPOSE: Research productivity metrics are important for decisions regarding hiring, retention, and promotion in academic medicine, and these metrics can vary widely among different disciplines. This article examines productivity metrics for radiation therapy physicists (RTP) in the United States. METHODS AND MATERIALS: Database searches were performed for RTP faculty at US institutions that have RTP residencies accredited by the Commission on Accreditation of Medical Physics Education Programs (CAMPEP). Demographics, academic rank, number of publications, academic career length, Hirsch index (h-index), m-quotient, and history of National Institutes of Health (NIH) funding as a principal investigator (PI) were collected for each RTP. Logistic regression was performed to determine the probability of academic rank as a function of h-index and m-quotient. Statistical tests used included the Wilcoxon ranked sum test and the Pearson χ2 test. RESULTS: A total of 1038 faculty and staff were identified at 78 institutions with CAMPEP-accredited residencies. The average RTP academic career duration is 13.5 years, with 46.7 total publications, h-index of 10.7, and m-quotient of 0.66. Additionally, 10.5% of RTP have a history of NIH funding as a PI. Large disparities were found in academic productivity of doctoral-prepared physicists compared to those with a terminal master's degree. For differences in junior and senior faculty, statistical tests yielded significance in career duration, number of publications, h-index, and m-quotient. Gender disparities were identified in the overall distribution of RTP consistent with the membership of the American Association of Physicists in Medicine. Further gender disparities were found in the number of doctoral-prepared RTP and physicists in senior faculty roles. CONCLUSIONS: This manuscript provides objective benchmark data regarding research productivity of academic RTP. These data may be of interest to faculty preparing for promotion, and also to institutional leadership.

The impact of trainees' working hour regulations on outcome in CABG and valve surgery in the State of New York.

BACKGROUND AND AIM: In 2011, the Accreditation Council for Graduate Medical Education (ACGME) restricted the first-year residents' duty-hour to less than 16-hour shifts, decreased the maximum shift duration for senior residents, and increased minimum time off after on-call duties. Whether these changes may have impacted the outcomes in cardiac surgery remains unclear. METHODS: We performed a difference-in-difference analysis of the New York State Cardiac Surgery Reporting System data in 2004-2006 (before the duty-hour policies change) and 2014-2016 (after the change). We evaluated differences in 30-day risk-adjusted mortality rates (RAMR) in coronary artery bypass grafting (CABG) and valve surgeries, stratifying data by hospital type: teaching hospitals (TH) versus nonteaching hospitals (NTH). NTH served as the control not affected by the duty-hour policies. RESULTS: (1) The overall surgical volume for CABG surgery has decreased over time (37,645-24,991), while the volume for valve surgery remained similar (20,969-21,532); (2) TH had better short-term outcomes for CABG procedures during 2014-2016 (median RAMR: 1.01% vs. 1.55% in TH vs. NTH, respectively; p = .025) as well as for valve procedures during both 2004-2006 (5.16% vs. 7.49%, p = .020) and 2014-2016 (2.59% vs. 4.09%, p = .033); (3) at difference-in-difference analysis, trainees' duty-hour regulations were not associated with worsening short-term outcomes in both CABG (p = .296) and valve (p = .651) procedures performed in TH. CONCLUSION: The introduction of the 2011 trainees' duty-hour regulations was not associated with worse short-term outcomes for CABG and valve surgery performed in the State of NY by TH.

Progression of aortic stenosis in patients with bicuspid aortic valve.

BACKGROUND: Bicuspid aortic valve is the most common congenital heart defect and predisposes patients to developing aortic stenosis more frequently and at a younger age than the general population. However, the influence of bicuspid aortic valve on the rate of progression of aortic stenosis remains unclear. METHODS: In 236 patients (177 tricuspid aortic valve and 59 bicuspid aortic valve) matched by initial severity of mild or moderate aortic stenosis, we retrospectively analyzed baseline echocardiogram at diagnosis with latest available follow-up echocardiogram. Baseline comorbidities, annualized progression rate of hemodynamic parameters, and hazard of aortic valve replacement were compared between valve phenotypes. RESULTS: Median echocardiographic follow-up was 2.6 (interquartile range [IQR] 1.6-4.2) years. Patients with tricuspid aortic stenosis were significantly older with more frequent comorbid hypertension and congestive heart failure. Median annualized progression rate of mean gradient was 2.3 (IQR 0.6-5.0) mmHg/year versus 1.5 (IQR 0.5-4.1) mmHg/year (p = .5), and that of peak velocity was 0.14 (IQR 0-0.31) m/s/year versus 0.10 (IQR 0.04-0.26) m/s/year (p = .7) for tricuspid versus bicuspid aortic valve, respectively. On multivariate analyses, bicuspid aortic valve was not significantly associated with more rapid progression of aortic stenosis. In a stepwise Cox proportional hazards model adjusted for baseline mean gradient, bicuspid aortic valve was associated with increased hazard of aortic valve replacement (hazard ratio: 1.7, 95% confidence interval [1.0-3.0], p = .049). CONCLUSION: Bicuspid aortic valve may not significantly predispose patients to more rapid progression of mild or moderate aortic stenosis. Guidelines for echocardiographic surveillance of aortic stenosis need not be influenced by valve phenotype.

Telemedicine in the era of coronavirus 19: Implications for postoperative care in cardiac surgery.

BACKGROUND: The Coronavirus 19 (COVID-19) pandemic forced an unprecedented shift of postoperative care for cardiac surgery patients to telemedicine. How patients and surgeons perceive telemedicine is unknown. We examined patient and provider satisfaction with postoperative telehealth visits following cardiac surgery. METHODS: Between April 2020 and September 2020, patients who underwent open cardiac surgery and had a postoperative appointment via telemedicine were administered a patient satisfaction survey over the phone. Time of survey administration ranged from 1 to 4 weeks following their appointment. Surgeons also completed a satisfaction survey following each telemedicine appointment they conducted. RESULTS: Fifty patients were surveyed. Of these, 36 (72%) had a postoperative appointment over the telephone, and 14 (28%) had a postoperative appointment via video-chat. Overall, patients expressed satisfaction with the care that they received via our two telemedicine modalities (mean Likert scale agreement 4.8, SD 0.5). Despite this, 46% of patients said they would prefer their next postoperative appointment to be via telemedicine even if there was not a stay-at-home order in place. All surgeons surveyed reported (agree/strongly agree) that they would prefer to see their postoperative patients using telemedicine. CONCLUSIONS: These findings highlight acceptability of continuing telemedicine use in the postoperative care of cardiac surgery patients.

AngioVac suction embolectomy using a roller pump: Operative technique.

AngioVac suction embolectomy is recommended by the manufacturer to be performed with a centrifugal pump due to safety considerations. However, roller head pumps are significantly cheaper to use, and thus may be more readily available during shortages and in resource-poor settings. We present the technique of Angiovac suction embolectomy being successfully performed with a roller pump to evacuate a clot-in-transit in the inferior vena cava and right atrium, along with discussion of important safety caveats.

Survival of Patients With Mild Secondary Mitral Regurgitation With and Without Mild Tricuspid Regurgitation.

BACKGROUND: Mild secondary mitral regurgitation (SMR) is considered clinically benign when left-ventricular ejection fraction (LVEF) is preserved, but evidence on survival associated with mild SMR in normal LVEF is limited. METHODS: We conducted a retrospective cohort study of patients who underwent echocardiography in a health care network between 2013 and 2018. We compared the survival of 4 groups: no valvular abnormalities (group 1), trace SMR with trace or mild tricuspid regurgitation (TR) (group 2), mild SMR with trace or no TR (group 3), and mild SMR with mild TR (group 4). A Cox proportional hazard model evaluated hazard of death in groups 2 to 4 compared with group 1, adjusting for demographics, comorbidities, and LVEF. The same comparisons were repeated in a subgroup of patients with preserved LVEF. RESULTS: Among the 16,372 patients of mean age 61 (51 to 71) years and 48% women, there were 8132 (49.7%) group 1 patients, 1902 (11.6%) group 2 patients, 3017 (18.4%) group 3 patients, and 3321 (20.3%) group 4 patients. Compared with group 1, group 4 had significantly increased adjusted hazard of death (hazard ratio [HR], 1.21; 95% confidence interval [CI], 1.12-1.31; P < 0.001), whereas groups 2 and 3 did not show a significantly different hazard of death. In those with preserved LVEF, the hazard was also significantly higher in group 4, compared with group 1 (HR, 1.14; 95% CI, 1.03-1.26; P = 0.013). CONCLUSIONS: Mild SMR with mild TR, irrespective of LVEF, was associated with worse survival compared with patients without any valvular abnormalities. Patients with mild SMR may require closer monitoring, even with normal LVEF.

The relationship between cardiac surgeon experience and average patient risk profile: CA and NY statewide analysis.

BACKGROUND: It is unknown how high and low-risk cases are distributed among cardiac surgeons of different experience levels. The purpose of this study was to determine if high and low-risk coronary artery bypass grafting (CABG) cases are distributed among surgeons in such a way that would optimize outcomes in light of recent studies that show mid-career surgeons may obtain better patient outcomes on more complex cases. METHODS: We performed a cross-sectional study using aggregated New York (NY) and California (CA) statewide surgeon-level outcome data, including 336 cardiac surgeons who performed 43,604 CABGs. The surgeon observed and expected mortality rates (OMR and EMR) were collected and the number of years-in-practice was determined by searching for surgeon training history on online registries. Loess and linear regression models were used to characterize the relationship between surgeon EMR and surgeon years-in-practice. RESULTS: The median number of surgeon years-in-practice was 20 (interquartile range [IQR] 11-28) with a median annual case volume of 46 (IQR 19, 70.25). The median surgeon observed to expected mortality (O:E) ratio was 0.87 (IQR 0.19-1.4). Median EMR for CA surgeons was 2.42% and 1.44% for NY surgeons. Linear regression models showed EMR was similar across years in practice. Regression models also showed surgeon O:E ratios were similar across years-in-practice. CONCLUSION: High and low-risk CABG cases are relatively equally distributed among surgeons of differing experience levels. This equal distribution of high and low-risk cases does not reflect a triaging of more complex cases to more experienced surgeons, which prior research shows may optimize patient outcomes.