Early onset of deep sternal wound infection after cardiac surgery is associated with decreased survival: A propensity weighted analysis.

OBJECTIVES: To compare outcomes after the development of early (≤30 days) versus delayed (>30 days) deep sternal wound infection (DSWI) after cardiac surgery. METHODS: Between 2005 and 2016, 64 patients were treated surgically for DSWI following cardiac surgery. Thirty-three developed early DSWI, while 31 developed late DSWI. The mean follow-up was 34.1 ± 32.3 months. RESULTS: Survival for the entire cohort at 1, 3, and 5 years was 93.9%, 85.1%, and 80.8%, respectively. DSWI diagnosed early and attempted medical management was strongly associated with overall mortality (hazard ratio [HR], 25.0 and 9.9; 95% confidence intervals [CIs], 1.18-52.8 and 1.28-76.5; p-value .04 and .04, respectively). Survival was 88.1%, 77.0%, 70.6% and 100%, 94.0% and 94.0% at 1, 3, and 5 years in the early and late DSWI groups, respectively (log-rank = 0.074). Those diagnosed early were more likely to have a positive wound culture (odds ratio [OR], 0.06; 95% CI, 0.01-0.69; p = .024) and diagnosed late were more likely to be female (OR, 8.75; 95% CI, 2.0-38.4; p = .004) and require an urgent DSWI procedure (OR, 9.25; 95% CI, 1.86-45.9; p = .007). Both early diagnosis of DSWI and initial attempted medial management were strongly associated with mortality (HR, 7.48; 95% CI, 1.38-40.4; p = .019 and HR, 7.76; 95% CI, 1.67-35.9; p = .009, respectively). CONCLUSIONS: Early aggressive surgical therapy for DSWI after cardiac surgery results in excellent outcomes. Those diagnosed with DSWI early and who have failed initial medical management have increased mortality.

Long-term outcomes with the pulmonary autograft inclusion technique in adults with bicuspid aortic valves undergoing the Ross procedure.

OBJECTIVE: To compare outcomes with wrapped (pulmonary autograft inclusion) versus unwrapped techniques in adults with bicuspid aortic valves undergoing the Ross procedure. METHODS: Between 1992 and 2019, 129 adults with bicuspid aortic valves (aged ≥18 years) underwent the Ross procedure by a single surgeon. Patients were divided into those without autograft inclusion (unwrapped, n = 71) and those with autograft inclusion (wrapped, n = 58). Median follow-up was 10.3 years (interquartile range, 3.0-16.8 years). Need for autograft reintervention was analyzed using competing risks. RESULTS: Pre- and intraoperative characteristics as well as 30-day morbidity or mortality did not differ between cohorts. Survival at 1, 5, and 10 years, respectively, was 97.2%, 97.2%, and 95.6% in the unwrapped cohort and 100%, 100%, and 100% in the wrapped cohort (P = .15). Autograft valve failure occurred in 25 (35.2%) of the unwrapped and 3 (5.2%) of the wrapped patients. Competing risks analysis demonstrated the wrapped cohort to have a lower need for autograft reintervention (subhazard ratio, 0.28, 95% confidence interval, 0.08-0.91; P = .035). The cumulative incidence of autograft reintervention (death as a competing outcome) at 1, 5, and 10 years, respectively, was 10.2%, 14.9%, and 26.8% in the unwrapped cohort and 4.0%, 4.0%, and 4.0% in the wrapped cohort. CONCLUSIONS: In adults with bicuspid aortic valves, the Ross procedure with pulmonary autograft inclusion stabilizes the aortic root preventing dilatation and reduces the need for reoperation. The autograft inclusion technique allows the Ross procedure to be performed in this population with excellent long-term outcomes.

Breast implants and minimally invasive cardiac surgery: a case series.

INTRODUCTION: The number of women affected by valvular heart disease and the number of women with breast implants are both on the rise. Minimally invasive heart surgery using a limited thoracotomy offers many potential benefits including reduction in blood loss, shorter hospital stay, faster recovery time, decreased pain, and improved cosmesis. Minimally invasive heart surgery often requires access to the second, third, or fourth intercostal space of the anterior chest wall. The presence of a breast implant may interfere with the surgeon's ability to gain adequate exposure for entry to the appropriate intercostal space. We present a case series of 5 women with breast implants who successfully underwent minimally invasive cardiac valve surgery. METHODS: A retrospective review was conducted of all patients with breast implants who underwent minimally invasive cardiac valve surgery at the University of Southern California University Hospital. In each patient, an inframammary incision was performed, facilitating removal of the implant, performance of the cardiac operation, and reimplantation of the implant. RESULTS: Five women with breast implants who underwent minimally invasive cardiac valve surgery were identified; of these, 4 (80%) patients underwent repair of the mitral valve for mitral regurgitation, whereas 1 (20%) underwent an aortic valve replacement for aortic stenosis. Two patients underwent a concomitant maze procedure for atrial fibrillation during the same operation. The median follow-up time was 7.4 months, and the follow-up period ranged from 2 to 12 months. There were no significant postoperative complications such as infection, hematoma, or need for reoperation. CONCLUSIONS: Our series of 5 patients demonstrates that minimally invasive heart surgery performed through an inframammary incision can be safely performed in those with breast implants.

Surgical Resection of a Symptomatic Ascending Aortic Mural Thrombus.

Aortic mural thrombus (AMT) is a rare disease with an unclear optimal treatment strategy. AMT in the ascending aorta is particularly uncommon and is associated with the additional risk of embolization to the brain. Resection of an ascending AMT is particularly challenging given the high risk of thrombus dislodgment during aortic cannulation and cross-clamp application. This case demonstrates successful surgical resection of a symptomatic ascending AMT without the use of hypothermic circulatory arrest, with complete excision of the thrombus and replacement of the abnormal aorta using graft material.

Lack of Awareness of Reimbursement and Compensation Models Among Cardiothoracic Surgery Trainees.

BACKGROUND: The objective of this study was to identify trainee knowledge gaps in reimbursement and compensation, determine the perceived importance of understanding these topics, and to explore if the Thoracic Surgery Curriculum needs additional educational material. METHODS: The Thoracic Surgical Residents Association Executive Committee selected the research proposal and distributed an anonymous electronic survey to 531 Accreditation Council for Graduate Medical Education cardiothoracic surgery trainees. Standard descriptive statistics and regression analyses were performed. RESULTS: One hundred fourteen responses were collected (response rate, 21.5%). Most trainees understood little to none about how attending surgeons are reimbursed (n = 74, 69%). Most trainees reported knowing little or nothing about pay-for-performance compensation (n = 73, 67%), bundled care (n = 82, 75%), or value-based reimbursement (n = 84, 77%). Approximately 20% of trainees were accurate in estimating surgeon reimbursement for 3 common cardiothoracic surgery procedures to within 20% of the true reimbursement value, whereas approximately 30% were accurate to within 50% of the true reimbursement value. No respondent characteristics were found to be associated with a more or less accurate reimbursement response. Additionally 81% of trainees (n = 87) responded that by the conclusion of training, understanding surgeon reimbursement is very important or extremely important and 90% of trainees (n = 95) either somewhat agreed or strongly agreed with including these topics in the Thoracic Surgical Curriculum. CONCLUSIONS: Despite acknowledging the importance of understanding physician compensation and reimbursement, cardiothoracic surgery trainees do not understand how the current models work. This study exemplifies the need for a succinct curriculum in this domain for trainees nationwide.

Thoracic aortic stent-grafting for acute, complicated, type B aortic dissections.

BACKGROUND: To report a single-center experience of aortic stent-grafting for the treatment of acute, complicated, type B aortic dissections. METHODS: A retrospective review was conducted of the data obtained from all patients who underwent endovascular stent-grafting for acute, type B aortic dissection between 2006 and 2009. The primary and secondary endpoints were 30-day mortality and morbidity rates, respectively. RESULTS: In all, 104 thoracic endovascular aortic aneurysm repairs were performed during the study period. Nine (8.6%) patients (six men; mean age: 65 years) underwent thoracic endovascular aortic aneurysm repair for acute, complicated, type B aortic dissections. Seven (78%) patients had uncontrolled hypertension on presentation. Visceral branch vessel involvement of the dissection was limited to the celiac axis origin in one patient with no evidence of visceral malperfusion. The indication for repair was aortic rupture in five patients, renal malperfusion in two, and persistent pain in the remaining two. Average time taken from presentation to surgery was 5.5 days. Two patients presenting with aortic ruptures had retrograde extension of the dissection that required replacement of the aortic valve and ascending aorta. The mean length of thoracic aorta covered was 21 cm. Complete coverage of the left subclavian artery was required in three patients and partial coverage in two. On completion angiogram, two type I endoleaks were detected, one of which was resolved by postoperative day 5. The 30-day mortality rate was 22%. One mortality was secondary to aortic rupture. The other mortality was due to multiorgan system failure. Seven patients (78%) had one or more major complications. There were no strokes or paraplegia. CONCLUSION: The association of morbidity and mortality with endovascular stent-grafting for acute, complicated, type B aortic dissections is significant, which most likely reflects the lethal nature of the disease. The precise role of endovascular treatment in these patients remains to be defined.

The Ross procedure utilizing the pulmonary autograft inclusion technique in adults.

A retrospective cohort study was conducted in which 129 adult patients with bicuspid aortic valves underwent the Ross procedure with either a standard root inclusion technique or a modified technique whereby the pulmonary autograft is wrapped in a vascular conduit. Primary outcomes were survival and the need for pulmonary autograft reintervention. Competing risk analysis demonstrated the wrapped technique reduced pulmonary autograft reintervention.

Perimembranous ventricular septal defect and Gerbode defect.

A 27-year-old male presented with a known history of congenital ventricular septal defect (VSD). A Gerbode-type defect was discovered intraoperatively that was originally misinterpreted as pulmonary hypertension. The case report will review the Gerbode defect and the transesophageal echocardiography findings. It is important, in patients with history of perimembranous VSD, to consider Gerbode-type defect when the tricuspid regurgitation jet velocity is high.

The Development of a Novel Perfused Cadaver Model With Dynamic Vital Sign Regulation and Real-World Scenarios to Teach Surgical Skills and Error Management.

The landscape of graduate medical education has changed dramatically over the past decade and the traditional apprenticeship model has undergone scrutiny and modifications. The mandate of the 80-hour work-week, the introduction of integrated residency programs, increased global awareness about patient safety along with financial constraints have spurred changes in graduate educational practices. In addition, new technologies, more complex procedures, and a host of external constraints have changed where and how we teach technical and procedural skills. Simulation-based training has been embraced by the surgical community and has quickly become an essential component of most residency programs as a method to add efficacy to the traditional learning model. The purpose of this paper is twofold: (1) to describe the development of a perfused cadaver model with dynamic vital sign regulation, and (2) to assess the impact of a curriculum using this model and real world scenarios to teach surgical skills and error management. By providing a realistic training environment our aim is to enhance the acquisition of surgical skills and provide a more thorough assessment of resident performance. Twenty-six learners participated in the scenarios. Qualitative data showed that participants felt that the simulation model was realistic, and that participating in the scenarios helped them gain new knowledge, learn new surgical techniques and increase their confidence performing the skill in a clinical setting. Identifying the importance of both technical and nontechnical skills in surgical education has hastened the need for more realistic simulators and environments in which they are placed. Team members should be able to interact in ways that allow for a global display of their skills thus helping to provide a more comprehensive assessment by faculty and learners.

Resection of Metastatic Hepatocellular Carcinoma in the Ventricular Septum Causing Left Ventricular Outflow Tract Obstruction.

Isolated cardiac involvement of recurrent metastatic hepatocellular carcinoma (HCC) is extremely rare. We report a patient with left ventricular outflow tract (LVOT) obstruction due to isolated recurrent HCC involving the interventricular septum (IVS). A ventriculotomy with resection of the tumor and patch repair of the IVS was performed with successful relief of LVOT obstruction. The patient was discharged home 6 days later symptom-free.

Optimal Approach for Repair of Left Atrial-Esophageal Fistula Complicating Radiofrequency Ablation.

Left atrial-esophageal fistula after endovascular radiofrequency ablation for cardiac arrhythmias is a life-threatening complication. Immediate surgical repair offers the best chance for survival. The optimal surgical technique is unknown. We describe our recommended surgical approach.

Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection.

BACKGROUND: Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair. METHODS: Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality. RESULTS: Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p < 0.01). CONCLUSIONS: A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.

Type B Aortic Arch Interruption in an Adult.

The presentation and treatment of a patient with a type B interrupted aortic arch with an isolated left subclavian artery is described.

A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients.

OBJECTIVES: Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy. METHODS: Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed. RESULTS: Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups. CONCLUSION: Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted.

Pressurized Cadaver Model in Cardiothoracic Surgical Simulation.

Simulation is increasingly recognized as an integral aspect of thoracic surgery education. A number of simulators have been introduced to teach component cardiothoracic skills; however, no good model exists for numerous essential skills including redo sternotomy and internal mammary artery takedown. These procedures are often relegated to thoracic surgery residents but have significant negative implications if performed incorrectly. Fresh tissue dissection is recognized as the gold standard for surgical simulation, but the lack of circulating blood volume limits surgical realism. Our aim is to describe the technique of the pressurized cadaver for use in cardiothoracic surgical procedures, focusing on internal mammary artery takedown.

Age-Related Outcomes of the Ross Procedure Over 20 Years.

BACKGROUND: The Ross procedure is an alternative for patients with aortic valve disease not amenable to repair. Long-term follow-up after a Ross has demonstrated the need for autograft (left ventricular outflow tract [LVOT]) and homograft (right ventricular outflow tract [RVOT]) reinterventions. We assessed the age-stratified outcomes of the LVOT and RVOT after the Ross procedure performed by a single surgeon during a 20-year period. METHODS: We retrospectively reviewed 305 consecutive patients aged 4 days to 70 years, stratified by age younger than than 1 (n = 41), 1 to 10 (n = 85), 10 to 20 (n = 84), 20 to 40 (n = 59), and older than 40 years (n = 36). Median follow-up was 8.2 years (interquartile range, 1 month to 19.2 years). Primary end points were survival and freedom from reintervention on the LVOT and RVOT. Outcomes were compared by Kaplan-Meier analysis. RESULTS: A total of 173 patients (57%) had prior intervention on their aortic valve, 95 (31%) had isolated regurgitation, 91 (30%) had stenosis, and 119 (39%) had mixed pathology. There were 92 concomitant procedures (43 congenital lesions, 18 aorta, 9 mitral valve). In-hospital morbidity was 11.5% (35 of 305); mortality was 3.6% (11 of 305) and highest in infants. Need for an emergency operation (p < 0.05) predicted mortality in infants. The LVOT reintervention rate was lowest in infants compared with older patients (p < 0.05); conversely, age was directly related to RVOT reintervention (p < 0.01). Autograft encasement in a Hemashield (Atrium, Hudson, NH) tube in patients aged older than 10 years improved 5-year freedom from reintervention on the LVOT from 81% to 91% (p < 0.001). At last follow-up, aortic insufficiency was mild or less in 290 (95%) patients, and heart function was normal in 285 (93%). CONCLUSIONS: The Ross procedure is a safe, effective, and anti-coagulation-free alternative for aortic valve replacement across all age groups. Long-term survival and preservation of heart function are highly favorable. Surgical mortality is related to salvage procedures in infants. When feasible, autograft durability can be improved by using a Hemashield graft for support.

Gamification in thoracic surgical education: Using competition to fuel performance.

OBJECTIVES: In an effort to stimulate residents and trainers to increase their use of simulation training and the Thoracic Surgery Curriculum, a gamification strategy was developed in a friendly but competitive environment. METHODS: "Top Gun." Low-fidelity simulators distributed annually were used for the technical competition. Baseline and final video assessments were performed, and 5 finalists were invited to compete in a live setting from 2013 to 2015. "Jeopardy." A screening examination was devised to test knowledge contained in the Thoracic Surgery Curriculum. The top 6 2-member teams were invited to compete in a live setting structured around the popular game show Jeopardy. RESULTS: "Top Gun." Over 3 years, there were 43 baseline and 34 final submissions. In all areas of assessment, there was demonstrable improvement. There was increasing evidence of simulation as seen by practice and ritualistic behavior. "Jeopardy." Sixty-eight individuals completed the screening examination, and 30 teams were formed. The largest representation came from the second-year residents in traditional programs. Contestants reported an average in-training examination percentile of 72.9. Finalists reported increased use of the Thoracic Surgery Curriculum by an average of 10 hours per week in preparation. The live competition was friendly, engaging, and spirited. CONCLUSIONS: This gamification approach focused on technical and cognitive skills, has been successfully implemented, and has encouraged the use of simulators and the Thoracic Surgery Curriculum. This framework may capitalize on the competitive nature of our trainees and can provide recognition of their achievements.