Consistent improvements in short- and long-term survival following heart transplantation over the past three decades.

BACKGROUND: Despite noted improvements in short-term survival outcomes following orthotopic heart transplantation (OHT), review of the relevant literature suggests little improvement in long-term outcomes for patients surviving beyond 1 year. METHODS: All OHT cases performed between 1989 and 2019 within the United Network for Organ Sharing (UNOS) database were reviewed. Adults who underwent isolated OHT were included in a 1-year survival analysis. Those who survived at least 1 year post-transplant were included in a long-term survival analysis. Demographic factors were assessed using Students' t test and chi-square analysis. Survival trends and risk factors were assessed using the Kaplan-Meier and the Cox regression analysis, respectively. RESULTS: A total of 53 265 and 46 372 recipients were included in the short-term and long-term cohorts, respectively. In an adjusted analysis, the reference implant era 2014-2019 had significantly better short-term survival outcomes when compared with earlier implant eras: 1989-1993 (HR: 2.92), 1994-1998 (HR: 1.53), 1999-2003 (HR: 1.27), 2004-2008 (HR: 1.11), and 2009-2013 (HR: 1.02). The same trend was recognized for long-term outcomes: 1989-1993 (HR: 1.87), 1994-1998 (HR: 1.27), 1999-2003 (HR: 1.09), and 2004-2008 (HR: 1.03). CONCLUSIONS: Despite increases in multiple traditional risk factors, both short-term and long-term survival outcomes have consistently improved over the past 30 years, suggesting other factors are contributing to improved outcomes in recent eras.

Allograft discard risk index for heart transplantation.

BACKGROUND: The numberof patients awaiting heart transplantation (HTx) substantially exceeds the number of donor hearts transplanted each year, yet nearly 65% of eligible donor hearts are discarded rather than transplanted. METHODS: Deceased organ donors listed within the UNOS Deceased Donor Database between 2010 and 2020 were reviewed. Those greater than 10 years old and consented for heart donation were included and randomly separated into training (n = 48 435) and validation (n = 24 217) cohorts. A discard risk index (DSRI) was created using the results of univariable and multivariable analyses. Discard data were assessed at DSRI value deciles, and stratum-specific likelihood ratio (SSLR) analysis and Kaplan-Meier survival function were used for mortality data. RESULTS: Factors associated with higher DSRI values included donor age > 45, LVEF, HBV-core antibodies, hypertension, and diabetes. The DSRI C-statistic was .906 in the training cohort and .904 in the validation cohort. The DSRI did not reliably predict 30-day or 1-year mortality after transplantation (C-statistic .539 and .532, respectively). CONCLUSIONS: The factors leading to heart allograft discard are not correlated to the same degree with post-transplant outcomes. This suggests that optimizing utilization of certain allografts with slightly higher risk of discard could increase the heart donor pool with limited impact on posttransplant mortality.

A Systematic Review of Wellness in Plastic Surgery Training.

BACKGROUND: Physician and resident wellness has been increasingly emphasized as a means of improving patient outcomes and preventing physician burnout. Few studies have been performed with a focus on wellness in plastic surgery training. OBJECTIVES: The aim of this study was to systematically review what literature exists on the topic of wellness in plastic surgery training and critically appraise it. METHODS: A PubMed search was performed to identify journal articles related to wellness in plastic surgery residency. Seventeen studies (6 cohort and 11 cross-sectional) met inclusion criteria and were appraised with the Newcastle-Ottawa Quality Assessment Scale (NOQAS) to determine the quality of the studies based on selection, comparability, and outcome metrics. RESULTS: Critical assessment showed that the studies were highly variable in focus. Overall, the quality of the data was low, with an average NOQAS score of 4.1. Only 2 studies focused on plastic surgery residents, examining work hours and social wellness, respectively; they were awarded NOQAS scores of 3 and 4 out of 10. CONCLUSIONS: The results of this systematic review suggest that little research has been devoted to wellness in surgery training, especially in regard to plastic surgery residents, and what research that has been performed is of relatively low quality. The available research suggests a relatively high prevalence of burnout among plastic surgery residents. Evidence suggests some organization-level interventions to improve trainee wellness. Because outcomes-based data on the effects of such interventions are particularly lacking, further investigation is warranted.

Optimal positioning of self-expanding valves before deployment decreases paravalvular regurgitation following transcatheter aortic valve replacement.

OBJECTIVES: To evaluate the association between measurements performed during Medtronic CoreValve (MCV) deployment and paravalvular leak (PVL). BACKGROUND: The MCV can be recaptured and repositioned, allowing the TAVR operator to implant at a more favorable position. The association between angiographic measurements of MCV position while the valve is recapturable and PVL post deployment has not been investigated. METHODS: 493 patients undergoing TAVR with MCV (January 2011-July 2017) were included. PVL was defined as intraprocedural aortic regurgitation that was judged clinically to require balloon postdilation. Depth of the valve at the left coronary cusp (LCC) and noncoronary cusp (NCC) were measured when the valve was 80% deployed. An optimal cutoff value for the ratio LCC/NCC for PVL was identified in 40 patients. Using this cutoff value, the association between LCC/NCC and PVL was then validated in 453 patients. RESULTS: The median LCC/NCC was 1.51 (interquartile range 1.06-1.89).The optimal cutoff value for LCC/NCC was 1.48 (93% sensitivity, 77% specificity, AUC0.85). In the validation group 112 (24.7%) patients had PVL. For LCC/NCC ≥ 1.48, the incidence of PVL was lower compared to LCC/NCC < 1.48 (9.58% vs. 41.78%, P < 0.0001). LCC/NCC of 1.48 had a sensitivity of 79.5% and specificity of 63.6% for PVL (AUC0.72). In a multivariate model, LCC/NCC < 1.48 independently predicted PVL (OR = 6.67, 95% CI 3.96-11.23, P < 0.0001). CONCLUSION: Positioning the MCV such that the LCC/NCC is ≥1.48 may result in less PVL.

Endovascular iliac rescue technique for complete arterial avulsion after transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) has emerged as an alternative therapy to open aortic valve repair for high-risk patients with aortic stenosis, but larger delivery sheath size is associated with vascular complications. We report 2 cases in which a minimally invasive technique was used for the hybrid repair of confirmed or suspected large-bore sheath traumatic avulsion (i.e., "iliac on a stick") after TAVR. We believe our hybrid approach to rescuing the iliac artery in suspected or confirmed complete artery avulsion could improve outcomes for patients who require TAVR.

Twenty-year survival following lung transplantation.

Background: Lung transplantation median survival has seen improvements due to recognition of short-term survival factors but continues to trail behind other solid organs due to limited understanding of long-term survivorship. Given the creation of the United Network for Organ Sharing (UNOS) database in 1986, it was difficult to accrue data on long-term survivors until recently. This study characterizes factors impacting lung transplant survival beyond 20 years, conditional to 1-year survival. Methods: Lung transplant recipients listed in UNOS from 1987 to 2002 who survived to 1 post-transplant year were reviewed. Kaplan-Meier and adjusted Cox regression analyses were performed at 20 and 10 years to identify risk factors associated with long-term outcomes independent of their short-term effects. Results: A total of 6,172 recipients were analyzed, including 472 (7.6%) recipients who lived 20+ years. Factors associated with increased likelihood of 20-year survival were female-to-female gender match, recipient age 25-44, waitlist time >1 year, human leukocyte antigen (HLA) mismatch level 3, and donor cause of death: head trauma. Factors associated with decreased 20-year survival included recipient age ≥55, chronic obstructive pulmonary disease/emphysema (COPD/E) diagnosis, donor smoking history >20 pack-years, unilateral transplant, blood groups O&AB, recipient glomerular filtration rate (GFR) <10 mL/min, and donor GFR 20-29 mL/min. Conclusions: This is the first study identifying factors associated with multiple-decade survival following lung transplant in the United States. Despite its challenges, long-term survival is possible and more likely in younger females in good waitlist condition without COPD/E who receive a bilateral allograft from a non-smoking, gender-matched donor of minimal HLA mismatch. Further analysis of the molecular and immunologic implications of these conditions are warranted.

Correlation between Relative Value Units and Operative Time for Flap-Based Reconstruction Procedures.

BACKGROUND: Procedures performed by plastic surgeons tend to generate lower work relative value units (RVUs) compared to other surgical specialties despite their major contributions to hospital revenue. The authors aimed to compare work RVUs allocated to all free flap and pedicled flap reconstruction procedures based on their associated median operative times and discuss implications of these compensation disparities. METHODS: A retrospective analysis of deidentified patient data from the American College of Surgeons National Surgical Quality Improvement Program was performed, and relevant CPT codes for flap-based reconstruction were identified from 2011 to 2018. RVU data were assessed using the 2020 National Physician Fee Schedule Relative Value File. The work RVU per unit time was calculated using the median operative time for each procedure. RESULTS: A total of 3991 procedures were included in analysis. With increased operative time and surgical complexity, work RVU per minute trended downward. Free-fascial flaps with microvascular anastomosis generated the highest work RVUs per minute among all free flaps (0.114 work RVU/minute). Free-muscle/myocutaneous flap reconstruction generated the least work RVUs per minute (0.0877 work RVU/minute) among all flap reconstruction procedures. CONCLUSIONS: Longer operative procedures for flap-based reconstruction were designated with higher work RVU. Surgeons were reimbursed less per operative unit time for these surgical procedures, however. Specifically, free flaps resulted in reduced compensation in work RVUs per minute compared to pedicled flaps, except in breast reconstruction. More challenging operations have surprisingly resulted in lower compensation, demonstrating the inequalities in reimbursement within and between surgical specialties. Plastic surgeons should be aware of these discrepancies to appropriately advocate for themselves.

Surgical Treatment of Atrioesophageal Fistula: A Systematic Review.

BACKGROUND: Atrioesophageal fistula is a rare and morbid complication of ablation therapy for atrial fibrillation. Surgery provides increased survival; however, which surgical approach provides the best outcome is unclear. METHODS: We performed a retrospective analysis of cases in the literature and at our institution. We characterized patients by presenting symptoms, diagnostic method, surgical therapy with different approaches, and survival. RESULTS: In total, 219 patients were found, with 216 patients identified from 122 papers in the literature and 3 patients from our institutional database (2000-2022). The most common presenting symptoms included fever/chill (71.8%) and neurologic deficiency (62.9%). The overall survival for this cohort was 47%. Patients who had an operation had significantly improved survival compared with those who did not have an operation (71.9.3% vs 11%, P < .001). Patients who survived after surgical intervention typically underwent right thoracotomy (45.1%), patch repair of the left atrium (61.1%), and primary repair of the esophagus (68.3%) on cardiopulmonary bypass (84.8%) with a flap between the 2 organs (84.6%). Patients who had cardiopulmonary bypass had increased survival (39 of 45 [86.7%]) compared with those who did not have cardiopulmonary bypass (7 of 17 [41.2%], P < .001). CONCLUSIONS: Patients with atrioesophageal fistula should undergo surgical intervention. A patch repair of the left atrium and primary repair of the esophagus with a flap between the organs during cardiopulmonary bypass is the most common successful repair. Cardiopulmonary bypass may allow better débridement and repair of the left atrium, which may provide a survival advantage in the treatment of this rare disease.

Distal Aortic Malperfusion Exacerbated by Antegrade Stent-Graft Placement During Hybrid Repair of Acute DeBakey Type I Aortic Dissection.

We present the case of an acute DeBakey type I aortic dissection with malperfusion. The patient underwent valve resuspension, ascending aortic and partial arch replacement, debranching of the innominate artery, and placement of a small-diameter stent within the left common carotid artery, after which antegrade deployment of a stent-graft into the proximal descending thoracic aorta was performed to expand the true lumen. Distal malperfusion was exacerbated by the stent-graft's traversal into the false lumen, necessitating further endovascular repair to reestablish flow to the distal aorta. Mitigation before stent-graft placement (for example, inserting a wire within the true lumen under fluoroscopic guidance to ensure stent-graft placement in the true lumen) and prompt corrective procedures are paramount, given the grim consequences of prolonged distal ischemia.

Trends in Survival for Pediatric Transplantation.

OBJECTIVES: Progress in pediatric transplantation measured in the context of waitlist and posttransplant survival is well documented but falls short of providing a complete perspective for children and their families. An intent-to-treat analysis, in which we measure survival from listing to death regardless of whether a transplant is received, provides a more comprehensive perspective through which progress can be examined. METHODS: Univariable and multivariable Cox regression was used to analyze factors impacting intent-to-treat survival in 12 984 children listed for heart transplant, 17 519 children listed for liver transplant, and 16 699 children listed for kidney transplant. The Kaplan-Meier method and log-rank test were used to assess change in waitlist, posttransplant, and intent-to-treat survival. Wait times and transplant rates were compared by using χ2 tests. RESULTS: Intent-to-treat survival steadily improved from 1987 to 2017 in children listed for heart (hazard ratio [HR] 0.96, 95% confidence interval [CI] 0.96-0.97), liver (HR 0.95, 95% CI 0.94-0.97), and kidney (HR 0.97, 95% CI 0.95-0.99) transplant. Waitlist and posttransplant survival also improved steadily for all 3 organs. For heart transplant, the percentage of patients transplanted within 1 year significantly increased from 1987 to 2017 (60.8% vs 68.7%); however, no significant increase was observed in liver (68.9% vs 72.5%) or kidney (59.2% vs 62.7%) transplant. CONCLUSIONS: Intent-to-treat survival, which is more representative of the patient perspective than individual metrics alone, steadily improved for heart, liver, and kidney transplant over the study period. Further efforts to maximize the donor pool, improve posttransplant outcomes, and optimize patient care while on the waitlist may contribute to future progress.

Lobectomy for pulmonary vein occlusion secondary to radiofrequency ablation.

Pulmonary vein stenosis, a recognized complication of transcatheter radiofrequency ablation in the left atrium, is often asymptomatic. Significant stenosis is commonly treated with percutaneous balloon dilation with or without stenting. We encountered a case of complete pulmonary vein occlusion that caused lobar thrombosis, pleuritic pain, and persistent cough. Imaging studies revealed virtually no perfusion to the affected lobe. A lobectomy was performed, resolving the persistent cough and pain. Pulmonary vein occlusion should be suspected in patients who present with pulmonary symptoms after having undergone ablative procedures for atrial fibrillation. This condition may necessitate surgical intervention if interventions such as balloon dilation or stenting are not possible or are ineffective.

Surgery for Tumors of the Heart.

Most surgeons will encounter only a handful of primary cardiac tumors outside of myxomas. Approximately 3 quarters of primary cardiac tumors are benign and 1 quarter is malignant. In most cases, cardiac tumors are silent but when symptoms do occur, they are primarily determined by tumor size and anatomical location, not by histopathology. The diagnosis and preoperative imaging relies heavily on multimodal imaging including echocardiography, computed tomography, magnetic resonance imaging, and coronary angiography. Surgical resection is the most common treatment for most simple primary cardiac tumors and for some complex benign tumors. Surgical resection of primary cardiac tumors frequently involves the need for complex cardiac reconstruction, particularly when malignant. Secondary tumors to the heart are 30 times more frequent than primary cardiac tumors, and their incidence is increasing, largely as a result of advances in cancer diagnosis and therapy. Surgical resection is feasible in only a small fraction of highly-selected patients with secondary tumors to the heart. For complex benign tumors-such as paraganglioma or large fibromas-and all primary and secondary malignant tumors, a multidisciplinary cardiac tumor team review in experienced centers of excellence is recommended.

Transcatheter Aortic Valve-in-Valve Procedure in Patients with Bioprosthetic Structural Valve Deterioration.

Surgical aortic valve replacement is the gold standard procedure to treat patients with severe, symptomatic aortic valve stenosis or insufficiency. Bioprosthetic valves are used for surgical aortic valve replacement with a much greater prevalence than mechanical valves. However, bioprosthetic valves may fail over time because of structural valve deterioration; this often requires intervention due to severe bioprosthetic valve stenosis or regurgitation or a combination of both. In select patients, transcatheter aortic valve replacement is an alternative to surgical aortic valve replacement. Transcatheter valve-in-valve (ViV) replacement is performed by implanting a transcatheter heart valve within a failing bioprosthetic valve. The transcatheter ViV operation is a less invasive procedure compared with reoperative surgical aortic valve replacement, but it has been associated with specific complications and requires extensive preoperative work-up and planning by the heart team. Data from experimental studies and analyses of results from clinical procedures have led to strategies to improve outcomes of these procedures. The type, size, and implant position of the transcatheter valve can be optimized for individual patients with knowledge of detailed dimensions of the surgical valve and radiographic and echocardiographic measurements of the patient's anatomy. Understanding the complexities of the ViV procedure can lead surgeons to make choices during the original surgical valve implantation that can make a future ViV operation more technically feasible years before it is required.

Early Trifecta valve failure: Report of a cluster of cases from a tertiary care referral center.

BACKGROUND: The Trifecta valve (St Jude Medical, Inc, St Paul, Minn) was approved for commercial use by the US Food and Drug Administration in 2011. Several isolated cases have been reported since then, describing early structural valve deterioration. We report a case series of 8 Trifecta valve failures, describing patients' clinical substrate and management, and the pathologic characteristics of the explanted valves. METHODS: Trifecta valve failure occurred in 7 patients (8 valves) receiving 19-mm (n = 2), 21-mm (n = 3), 23-mm (n = 1), and 25-mm (n = 2) valves. The mean duration of valve durability was 32 ± 21 months, and the most common lesion was prosthetic regurgitation. The mean Society of Thoracic Surgeons risk score for perioperative mortality at the time of reintervention was 9.75% ± 8.1%. Heart failure exacerbation was the most common presenting symptom. RESULTS: Five patients underwent surgical aortic valve replacement, 2 patients received valve-in-valve transcatheter aortic valve replacement, and 1 patient died of cardiogenic shock before reintervention. The most common pathologic finding in the explanted valves was a tan-yellow fibrofatty circumferential pannus adherent to the inflow portion of the Trifecta valve. CONCLUSIONS: Our findings provide further insights into the pathologic mechanisms leading to early Trifecta valve failure. In addition to tear of the noncoronary cusp of the Trifecta prosthesis described as the most common mechanism in the literature for its failure, circumferential pannus formation composed of fibrofatty tissue in the inflow portion and leaflet calcification concentrated around the posts in the outflow portion are important mechanisms contributing toward early Trifecta valve failure.

Transcatheter Aortic Valve Replacement for Perceval Sutureless Aortic Valve Failure.

As experience with Perceval aortic prosthesis and valve-in-valve TAVR grows, it will be crucial to meticulously document short- and long-term follow-up for establishment of real-world safety and durability of these new technologies.

The transition from open to endoscopic saphenous vein harvesting and its clinical impact: The Texas Heart Institute experience.

Open saphenous vein harvesting can be associated with wound complications, incision pain, prolonged convalescence, and poor cosmetic results. Endoscopic vein harvesting has been widely used for prevention of these problems. We compared outcomes of open and endoscopic vein harvesting for coronary artery bypass grafting at the Texas Heart Institute. We retrospectively analyzed data from 1,573 consecutive coronary artery bypass procedures performed at our institution during a 20-month period. Each procedure included saphenectomy by endoscopic vein harvesting (n = 588) performed by physician assistants, or by traditional open vein harvesting (n = 985) performed by physicians or physician assistants. The primary outcome variable was the incidence of postoperative leg infections. Both groups were similar in terms of preoperative risk factors. After surgery, leg wound infections were significantly less frequent in the endoscopic vein harvesting group (3/588, 0.5%) than in the open vein harvesting group (27/985, 2.7%; P < 0.002). The most common organism involved in leg infections was Staphylococcus (20/30, 66%): S. aureus was present in 14 of 30 infections (47%). Open vein harvesting was the only significant independent risk factor for leg infection. We conclude that endoscopic vein harvesting reduces leg wound infections, is safe and reliable, and should be the standard of care when venous conduits are required for coronary artery bypass grafting and vascular procedures. Although the transition from open to endoscopic vein harvesting can be challenging in institutions, it can be successful if operators receive adequate training in endoscopic technique and are supported by surgeons and staff.

Use of an Intravascular Warming Catheter during Off-Pump Coronary Artery Bypass Surgery in a Patient with Severe Cold Hemagglutinin Disease.

Cold hemagglutinin disease with broad thermal amplitude and high titers presents challenges in treating cardiac-surgery patients. Careful planning is needed to prevent the activation of cold agglutinins and the agglutination of red blood cells as the patient's temperature drops during surgery. We describe our approach to mitigating cold agglutinin formation in a 77-year-old man with severe cold hemagglutinin disease who underwent off-pump coronary artery bypass surgery without the use of preoperative plasmapheresis. This experience shows that the use of an intravascular warming catheter can maintain normothermia and prevent the activation and subsequent formation of cold agglutinins. To our knowledge, this is the first reported use of this technique in a patient with cold hemagglutinin disease. The chief feature in this approach is the use of optimal thermal maintenance-rather than the more usual decrease in cold-agglutinin content by means of therapeutic plasma exchange.

Will drug-eluting stents replace coronary artery bypass surgery?

Although coronary artery bypass grafting (CABG) remains the treatment of choice for certain types of coronary artery disease (CAD), percutaneous coronary intervention (PCI)--particularly coronary angioplasty with stenting--has become the most popular nonmedical treatment approach to CAD. Some have speculated that, with the advent of drug-eluting stents (DESs), PCI will replace CABG entirely. However, the complete disappearance of CABG is both unlikely and unwarranted, for several reasons. Published randomized trials of CABG, PCI, and medical approaches to CAD compared only highly selected subgroups of patients because of strict exclusion criteria that often favored the PCI cohorts. Therefore, their results do not constitute sufficient evidence for the superiority of PCI over CABG in all CAD patients requiring revascularization. As PCI indications broaden to include more complex lesions and more high-risk patients, outcomes will not remain as favorable. In addition, although PCI is less invasive than surgery, CABG offers more complete revascularization and better freedom from repeat revascularization. Furthermore, no long-term patency data on DESs yet exist, whereas excellent 10- and 20-year patency rates have been reported for the left internal mammary artery-to-left anterior descending artery graft used in most CABG procedures. While PCI has been changing, CABG has not been stagnant; recently, advances in many aspects of the CABG procedure have improved short- and long-term outcomes in CABG patients. Both CABG and PCI technologies will continue to advance, not necessarily exclusive of one another, but no data yet exist to suggest that DESs will render CABG obsolete any time soon.

Early detection of a cavopulmonary tumor embolus with the use of transesophageal echocardiography.

Pulmonary tumor embolization from renal cell carcinoma is associated with severe cardiopulmonary morbidity and high perioperative mortality rates. We report the case of a 71-year-old woman who presented with right-sided abdominal pain. Magnetic resonance images revealed a mass originating from the upper pole of the right kidney and extending into the infrahepatic portion of the inferior vena cava. Transesophageal echocardiography was continuously used to monitor the mass during intended radical nephrectomy and tumor resection. When the right kidney was mobilized, intracaval thrombus detached and migrated to the patient's right atrium, causing severe hemodynamic instability. After emergent sternotomy and during the initiation of cardiopulmonary bypass, the mass was no longer echocardiographically detectable in the heart; it was soon removed completely from the left pulmonary artery. The mass was a renal cell carcinoma. We recommend the use of transesophageal echocardiography as an efficient diagnostic tool in the early detection of pulmonary tumor embolization during the resection of renal cell carcinoma that involves the inferior vena cava.