Cardiac Tamponade Related to a Large Pericardial Mass in a Female with Juvenile Idiopathic Arthritis.

We report the case of a young female with juvenile idiopathic arthritis presenting with cardiac tamponade secondary to an unusual pericardial mass. Pericardial masses are typically incidental findings. In rare circumstances they can cause compressive physiology warranting urgent intervention. She required surgical excision which revealed a pericardial cyst encapsulating a chronic solidified hematoma. Though certain inflammatory disorders are associated with myopericarditis, to our knowledge this is the first reported case of a pericardial mass in a well-controlled young patient. We theorize her immunosuppressant therapy resulted in hemorrhage into a pre-existing pericardial cyst, suggesting the need for further follow-up in those on adalimumab therapy.

Sixth Annual Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs) Report: The Society Of Thoracic Surgeons Pedimacs Annual Report.

BACKGROUND: The Pediatric Interagency Registry for Mechanical Circulatory Support (Pedimacs), supported by The Society of Thoracic Surgeons, provides detailed information on pediatric patients supported with ventricular assist devices (VADs). METHODS: From September 19, 2012, to December 31, 2021, there were 1355 devices in 1109 patients (<19 years) from 42 North American Hospitals. RESULTS: Cardiomyopathy was the most common underlying cause (59%), followed by congenital heart disease (25%) and myocarditis (9%). Regarding device type, implantable continuous (IC) VADs were most common at 40%, followed by paracorporeal pulsatile (PP; 28%) and paracorporeal continuous (PC; 26%). Baseline demographics differed, with the PC cohort being younger, smaller, more complex (ie, congenital heart disease), and sicker at implantation (P < .0001). At 6 months after VAD implantation, a favorable outcome (transplantation, recovery, or alive on device) was achieved in 84% of patients, which was greatest among those on IC VADs (92%) and least for PC VADs (69%). Adverse events were not uncommon, with nongastrointestinal bleeding (incidence of 14%) and neurologic dysfunction (11% [stroke, 4%]), within 2 weeks after implantation being the most prevalent. Stroke and bleeding had negative impacts on overall survival (P = .002 and P < .001, respectively). CONCLUSIONS: This Sixth Pedimacs Report demonstrates the continued evolution of the pediatric field. The complexity of cardiac physiologies and anatomic constraint mandates the need for multiple types of devices used (PC, PP, IC). Detailed analyses of each device type in this report provide valuable information to further advance the care of this challenging and vulnerable population.

Transplantation and Arch Repair in Fontan 3 Years After HeartMate 3: Technical Considerations.

We previously reported the first successful implantation of the HeartMate 3 (Abbott Laboratories) in a Fontan patient. We now report his successful transplantation after 1104 days of support, the longest reported bridge to transplant of a Fontan patient. We describe our operative technique complicated by not only the Fontan anatomy and ventricular assist device but also by a >10-cm ascending and aortic arch aneurysm. Additionally the posttransplant hemodynamics of this patient appeared to demonstrate that effective ventricular assist device support may induce reversal of chronic effects of the failing Fontan circulation, which in this case was the elimination of his aortopulmonary collateral burden.

Impact of Integrated Thoracic Residency on General Surgery Residents' Thoracic Operative Volume.

BACKGROUND: Integrated thoracic surgery (I-6) programs have become popular over traditional general surgery (GS) pathways since their inception in 2007. However the effect of I-6 programs on GS resident training remains unknown. The purpose of this study was to evaluate the effect of I-6 programs on the thoracic operative experience of co-located GS residents. METHODS: Thoracic surgery cases recorded by residents in GS programs co-located with I-6 programs until 2019 were analyzed. Cases were reviewed 5 years before (TSR-5) through 5 years after (TSR-5) the matriculation of the first thoracic resident in the co-located I-6 program. To contextualize the overall trends in the field Accreditation Council for Graduate Medical Education GS resident case logs from 1990 to 2018 were analyzed and total thoracic surgery cases recorded. Statistical analysis was performed with linear regression. RESULTS: Residents in 19 GS programs with co-located I-6 programs showed an increase in total thoracic cases from 3710 to 4451 (Δ/year of +85.05 cases a year; P = .03) balanced by an increase in GS residents from 107 to 126 (Δ/year of +1.45; P = .01) with no significant overall change in the median thoracic operative case volume (31.00 at both thoracic residency before and after 5 years). Nationally from 1990 to 2018 there was no change in the total thoracic operative experience for GS graduates. CONCLUSIONS: The introduction of I-6 programs did not negatively impact thoracic operative experience for residents in co-located GS programs. Adequate training of both I-6 and GS residents at the same institution is feasible.

Risk of Pediatric Cardiac Surgery Increased in Patients Undergoing Tracheal Surgery During the Same Hospitalization.

BACKGROUND: The impact of complex tracheal surgery (TS) on outcomes of children undergoing cardiac surgery has rarely been investigated in large national databases and could impact anticipated outcomes in those patients. METHODS: The Pediatric Health Information System database was reviewed from January 1, 2005 to December 31, 2014, for pediatric (<18 years) patients undergoing select cardiac surgical procedures using International Classification of Disease-9 procedural coding. Patients were divided based upon having TS (excluding tracheostomy) during the same hospitalization. Patients with tracheal and cardiac surgeries (CHS + TS) were propensity matched in a 1 : 2 fashion to patients undergoing isolated cardiac surgeries without TS (CHS) based upon cardiac procedure(s), age at surgery, gender, and discharge year. Hospital mortality and other outcomes were compared between the 2 matched groups. RESULTS: The 283 CHS + TS patients were similar to the 566 CHS patients in gender, race, age, cardiac procedures, and presence of chromosomal abnormalities, all P > .05. Hospital mortality was 13.8% (n = 39) for CHS + TS and 5.8% (n = 33) for CHS patients with an unadjusted 2.58 hazard ratio of death (95% confidence interval: 1.59-4.20; P < .001). CHS + TS was also associated with a greater length of stay (63 days vs 12 days), a higher cost per hospitalization ($322 402 vs $80 273), and more readmissions (64.3% [n = 182] vs 41.8% [n = 243]), all P < .001. CONCLUSIONS: Patients undergoing cardiac and TS in the same hospitalization are at greater risk of in-hospital mortality than patients undergoing similar cardiac surgeries alone and incur higher resource utilization thereafter. The increased risk of mortality is currently underappreciated, but it is important to recognize when discussing expectations with families and providers.

Swipe right for surgical residency: Exploring the unconscious bias in resident selection.

BACKGROUND: Applicants provide a photo with their application through the Electronic Residency Application Service, which may introduce appearance-based bias. We evaluated whether an unconscious appearance bias exists in surgical resident selection. METHODS: After the match, applicant data from the 2018 to 2019 and 2019 to 2020 application cycles were examined. Reviewers were not provided the applicant photo or self-identified race during the second cycle. Photos provided by candidates were then rated by 4 surgical subspecialty residents who had no prior exposure to applications or interview status. Photos were rated on perceived fitness level, visual appearance, and photo professionalism. An overall photo score was then calculated. RESULTS: In the study, 422 applications were reviewed and 164 received interview invitations during the 2018 to 2019 cycle. Alpha Omega Alpha membership (odds ratio, 2.31; 95% confidence interval, 1.18-4.51), overall photo score (odds ratio, 2.29, 95% confidence interval, 1.43-3.66), research (odds ratio, 5.61, 95% confidence interval, 2.84-11.20), age (odds ratio, 0.86, 95% confidence interval, 0.76-0.99), and step 2 (odds ratio, 1.06, 95% confidence interval, 1.03-1.09) were predictors for receiving an interview. For the 2019 to 2020 cycle, 398 applications were reviewed, and 75 applicants received an invitation. Step 2 (odds ratio, 1.07, 95% confidence interval, 1.02-1.12), research (odds ratio, 2.78, 95% confidence interval, 1.40-5.55), age (odds ratio, 0.82, 95% confidence interval, 0.71-0.95), and overall photo score (odds ratio, 2.27; 95% confidence interval, 1.14-4.52) remained predictors despite reviewers being blinded to the photo during this cycle. CONCLUSION: Although objective metrics remain critical in determining interview invitations, overall perceived applicant appearance may influence the selection process. Although visual appearance was associated with receiving an interview, the Electronic Residency Application Service photo does not ultimately affect selection. This may suggest that appearance may influence other objective and subjective aspects of the application.

Transplant Outcomes for Congenital Heart Disease Patients Bridged With a Ventricular Assist Device.

BACKGROUND: Ventricular assist device (VAD) use as a bridge to transplant (BTT) for children with end-stage heart failure and congenital heart disease (CHD), although challenging, has increased, but its effect on posttransplant outcome is unknown. This study describes posttransplant outcomes of CHD patients BTT with a VAD. METHODS: All heart transplant recipients identified in United Network of Organ Sharing database from 2006 to 2015 (n = 21,865) were divided into four groups by those with (+) and without (-) a diagnosis of CHD and with (+) and without (-) VAD support at transplant: +CHD/+VAD, +CHD/-VAD, +VAD/-CHD, and -VAD/-CHD. Posttransplant survival of +CHD/+VAD was compared with +CHD/-VAD, -CHD/+VAD, and -CHD/-VAD in addition to pretransplant characteristics comparison between +CHD/+VAD and +CHD/-VAD. RESULTS: Of 1,871 patients (8.6%) with CHD, 1,348 (72%) were younger than 18 years old, and 143 (7.6%) were BTT with a VAD (+CHD/+VAD). At transplant, +CHD/+VAD compared with +CHD/-VAD were more likely to have worse functional status (<50%: 60% vs 46%, p = 0.004), infections (29% vs 14%, p < 0.001), to be sensitized (47% vs 30%, p < 0.001) and on ventilator support (20% vs 13%, p = 0.029) and dialysis (13% vs 2.5%, p < 0.001). Overall, 1-year (84% vs 87%) and 5-year (72% vs 75%) survival was similar for +CHD/+VAD and +CHD/-VAD (p = 0.694). Survival was also similar when +CHD/+VAD were compared with -CHD/+VAD (n = 7,363; p = 0.529) and -CHD/-VAD (n = 12,613; p = 0.097). CONCLUSIONS: Although more ill pretransplant, CHD patients BTT with a VAD have similar posttransplant survival compared with CHD patients without a VAD and with other non-CHD heart transplant patients. VAD support may mitigate certain risk factors for poor posttransplant outcomes in the challenging CHD cohort.

The 50/50 cc Total Artificial Heart Trial: Extending the Benefits of the Total Artificial Heart to Underserved Populations.

While use of the total artificial heart (TAH) is growing, the use of the device is not uniform across the gender and age spectrum because the vast majority of implants are in adult males. SynCardia has recently developed a smaller 50 cc TAH that was designed to accommodate patients with a body surface area as low as 1.2 m2 (potentially even lower using virtual implantation). Herein, we describe the early use of the 50 cc TAH (10 implants in the US and 18 outside the US). Twenty-eight devices have been implanted worldwide. Nineteen (68%) patients were female, 4 (14%) were 21 years of age or younger, and 2 (7%) had a diagnosis of congenital heart disease (1 Fontan). The smallest patient, by body surface area, was 1.35 m2. Six patients (21%) have been placed on the Freedom Driver, all of whom have survived. Fourteen patients (50%) have had a positive outcome to date. The development of the 50 cc TAH has expanded the population of patients who may benefit from TAH support and thus may help improve outcomes for patients who have had limited biventricular support options to date.