Simultaneous Heart-Kidney Transplant-Does Hospital Experience With Heart Transplant or Kidney Transplant Have a Greater Impact on Patient Outcomes?

High institutional transplant volume is associated with improved outcomes in isolated heart and kidney transplant. The aim of this study was to assess trends and outcomes of simultaneous heart-kidney transplant (SHKT) nationally, as well as the impact of institutional heart and kidney transplant volume on survival. All adult patients who underwent SHKT between 2005-2019 were identified using the United Network for Organ Sharing (UNOS) database. Annual institutional volumes in single organ transplant were determined. Univariate and multivariable analyses were conducted to assess the impact of demographics, comorbidities, and institutional transplant volumes on 1-year survival. 1564 SHKT were identified, increasing from 54 in 2005 to 221 in 2019. In centers performing SHKT, median annual heart transplant volume was 35.0 (IQR 24.0-56.0) and median annual kidney transplant volume was 166.0 (IQR 89.5-224.0). One-year survival was 88.4%. In multivariable analysis, increasing heart transplant volume, but not kidney transplant volume, was associated with improved 1-year survival. Increasing donor age, dialysis requirement, ischemic times, and bilirubin were also independently associated with reduced 1-year survival. Based on this data, high-volume heart transplant centers may be better equipped with managing SHKT patients than high-volume kidney transplant centers.

Patient Satisfaction Scores After Cardiac Surgery: Should They Be Risk-Adjusted?

The Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) is a survey tool that quantifies patient satisfaction after hospitalization. We sought to interrogate our HCAHPS results in order to identify any association between preoperative health, type of operation, and postoperative outcomes, with patient satisfaction after cardiac surgery. Of 12,572 patients who underwent cardiac surgery between December 2012 and December 2019, 2587 patients (20.6%) completed the HCAHPS survey. Patient satisfaction was quantified using HCAHPS responses, focused on 'top-box' rating in nursing care, physician care, hospital environment, and overall hospital rating, as primary endpoints. Multivariable logistic regression was used to identify those variables associated with top-box scores. Elevated patient risk, as measured by the Society of Thoracic Surgeons (STS) risk score in 2112 patients, was predictive of lower rates of top-box responses in nursing care (OR 0.963, P = 0.003), physician care (OR 0.96, P = 0.002), and overall hospital rating (OR 0.97, P = 0.007). Major postoperative complications were associated with lower patient satisfaction for nursing care (OR 0.67, P = 0.038), physician care (OR 0.59, P = 0.012), and overall hospital rating (OR 0.64, P = 0.035); length of stay ≥ 6 days was associated with increased patient satisfaction for nursing care (OR 1.45, P < 0.001). Increased preoperative risk and postoperative complications are associated with lower rates of top-box patient satisfaction scores after cardiac surgery. When assessing patient satisfaction after cardiac surgery, we suggest that a preoperative risk profile be considered.

Impact of age on outcomes after transcatheter aortic valve implantation.

AIMS: Usage of transcatheter aortic valve implantation (TAVI) for treatment of severe aortic stenosis is increasing across age groups. However, literature on age-specific TAVI outcomes is lacking. The purpose of this study is to assess the risks of procedural complications, mortality, and readmission in patients undergoing TAVI across different age groups. METHODS AND RESULTS: The Nationwide Readmissions Database was used to identify 84 017 patients undergoing TAVI from 2016 to 2018. Patients were stratified into four age groups: younger than 70, 70-79, 80-89, and older than 90. Complications, mortality, and readmission rates were compared between groups in a proportional hazards regression model. Risk of post-procedural stroke, acute kidney injury, and pacemaker or implantable cardioverter defibrillator implantation increased with incremental age grouping. Compared with patients younger than 70, patients aged 70-79 had no significant difference in mortality, whereas patients aged 80-89 and older than 90 had an increased mortality risk [odds ratio (OR) 1.39, confidence interval (CI) 1.14-1.70, P = 0.001 and OR 1.68, CI 1.33-2.12, P < 0.001, respectively]. Patients aged 80-89 and older than 90 had increased overall readmission compared with patients younger than 70 (HR 1.09, CI 1.03-1.14, P = 0.001 and HR 1.33, CI 1.25-1.41, P < 0.001, respectively). Cardiac readmissions followed the same trend. CONCLUSION: Patients aged 80-89 and older than 90 undergoing TAVI have increased risk of readmission, complications, and mortality compared with patients younger than 70.

Factor eight inhibitor bypassing activity for refractory bleeding in coronary artery bypass grafting: A propensity-matched analysis.

Background: Perioperative bleeding and transfusion have been associated with major morbidity and mortality after cardiac surgery. As concerns remain regarding potential graft thrombosis following administration of a prothrombin factor concentrate, the use of factor eight inhibitor bypassing activity (FEIBA) in managing refractory postoperative bleeding has never been evaluated in patients undergoing isolated coronary artery bypass grafting (CABG). Objectives: We aimed to examine the safety of FEIBA in patients undergoing isolated CABG, with respect to 30-day mortality, perioperative outcomes, and thrombotic complications. Methods: A retrospective review was undertaken of all consecutive patients who had undergone isolated on-pump CABG between January 2015 and December 2019 at North Shore University Hospital. Patients requiring intraoperative extracorporeal membrane oxygenator support were excluded. Patients were divided into two groups, dependent upon whether they received FEIBA (n = 63) versus no FEIBA (n = 2493). A 1:5 propensity match analysis was employed, and patients were analyzed with respect to thrombotic complications, reintervention for myocardial ischemia, and short-term clinical outcomes. Results: There was no difference in 30-day mortality between the two cohorts. There was also no significant difference in a composite of thrombotic complications (composed of deep vein thrombosis, pulmonary embolism, and stroke) between the two groups. Similarly, there was no significant difference in the requirement for postoperative reintervention for myocardial ischemia between patients who received FEIBA versus those who did not. Conclusions: Factor eight inhibitor bypassing activity may be safe when used as rescue therapy for refractory bleeding following isolated CABG.

Transcatheter heart valve selection in patients with low ejection fraction and aortic stenosis.

OBJECTIVE: The aim of this study was to compare outcomes of transcatheter heart valve (THV) choice in patients with left ventricular (LV) systolic dysfunction. BACKGROUND: The management congestive heart failure with combined LV systolic dysfunction and severe aortic stenosis (AS) is challenging, yet transcatheter aortic valve replacement (TAVR) has emerged as a suitable treatment option in such patients. Head-to-head comparisons among the balloon-expandable (BEV) and self-expandable (SEV) THV remain limited in this subgroup of patients. METHODS: In this retrospective study, we included patients with severe AS with LV systolic dysfunction (LVEF ≤40%) who underwent TAVR at four high volume centers. Two thousand and twenty-eight consecutive patients were analyzed, of which 335 patients met inclusion criteria. One hundred fourty-six patients (43%) received a SEV, and 189 patients (57%) received a BEV. RESULTS: Baseline characteristics were similar except for a higher proportion of females in the SEV group. The primary composite endpoint of in-hospital mortality, moderate or greater paravalvular (PVL), stroke, conversion to open surgery, aortic valve reintervention, and/or need for permanent pacemaker (PPM) was no different among THV choice. There was more PVL in the SEV group, but higher transaortic gradients in the BEV group. Clinical outcomes and quality of life measures were similar up to 1 year follow-up. CONCLUSION: The choice of THV in patients with severe AS and systolic dysfunction must be weighed on a case-by-case basis.

Deep Versus Moderate Hypothermia in Acute Type A Aortic Dissection: A Propensity-Matched Analysis.

BACKGROUND: The ideal temperature for hypothermic circulatory arrest (HCA) during acute type A aortic dissection (ATAAD) repair has yet to be determined. We examined the clinical impact of different degrees of hypothermia during dissection repair. METHODS: Out of 240 cases of ATAAD between June 2014 and December 2019, 228 patients were divided into two groups according to lowest intraoperative temperature: moderate hypothermic circulatory arrest (MHCA) (20-28°C) versus deep hypothermic circulatory arrest (DHCA) (<20°C). From this, 74 pairs of propensity-matched patients were analysed with respect to operative data and short-term clinical outcomes. Independent predictors of a composite outcome of 30-day mortality and stroke were identified. RESULTS: Mean lowest temperature was 25.5±3.9°C in the MHCA group versus 16.0±2.9°C in DHCA. Overall 30-day mortality of matched cohort was 11.5% (17 deaths), there were no significant different between matched groups. Cardiopulmonary bypass (CPB) times were longer in DHCA (221.0±69.9 vs 190.7±74.5 mins, p=0.01). Antegrade cerebral perfusion (ACP) during HCA predicted a lower composite risk of 30-day mortality and stroke (OR 0.38). Female sex (OR 4.71), lower extremity ischaemia at presentation (OR 3.07), and CPB >235 minutes (OR 2.47), all portended worse postoperative outcomes. CONCLUSIONS: A surgical strategy of MHCA is at least as safe as DHCA during repair of acute type A aortic dissection. ACP during HCA is associated with reduced 30-day mortality and stroke, whereas female sex, lower extremity ischaemia, and longer CPB times are all predictive of poorer short-term outcomes.

Factor eight inhibiting bypass activity for refractory bleeding in acute type A aortic dissection repair: A propensity-matched analysis.

BACKGROUND: Perioperative bleeding and transfusion have been associated with adverse outcomes after cardiac surgery. The use of factor eight inhibiting bypass activity (FEIBA) in managing bleeding after repair of acute Stanford type A aortic dissection (ATAAD) has not previously been evaluated. We report our experience in utilizing FEIBA in ATAAD repair. STUDY DESIGN AND METHODS: A retrospective review was undertaken of all consecutive patients who underwent repair of ATAAD between July 2014 and December 2019. Patients were divided into two groups, dependent upon whether or not they received FEIBA intraoperatively: "FEIBA" (n = 112) versus "no FEIBA" (n = 119). From this, 53 propensity-matched pairs of patients were analyzed with respect to transfusion requirements and short-term clinical outcomes. RESULTS: Thirty-day mortality for the entire cohort was 11.7% (27 deaths), not significantly different between patient groups. Those patients who received FEIBA demonstrated reduced transfusion requirements for all types of blood products in the first 48 h after surgery as compared with the "no FEIBA" cases, including red blood cells, platelets, plasma, and cryoprecipitate (p < .0001). There was no significant difference in major postoperative morbidity between the two groups. The FEIBA cohort did not demonstrate an increased incidence of thrombotic complications (stroke, deep venous thrombosis, pulmonary thromboembolism). DISCUSSION: When used as rescue therapy for refractory bleeding following repair of ATAAD, FEIBA appears to be effective in decreasing postoperative transfusion requirements whilst not negatively impacting clinical outcomes. These findings should prompt further investigation and validation via larger, multi-center, randomized trials.

The Half-Century Mark: Explant of Ball and Cage Valve after 50 Years.

This is a case report of a 69-year-old man with chronic hemolysis and worsening diastolic heart failure, secondary to known periprosthetic leak, who underwent a reoperative mitral valve replacement 50 years following initial implantation of a Starr-Edwards ball and cage valve.

Association between multimodality measures of aortic stenosis severity and quality-of-life improvement outcomes after transcatheter aortic valve replacement.

AIMS: Up to 40% of patients with aortic stenosis (AS) present with discordant grading of AS severity based on common transthoracic echocardiography (TTE) measures. Our aim was to evaluate the utility of TTE and multi-detector computed tomography (MDCT) measures in predicting symptomatic improvement in patients with AS undergoing transcatheter aortic valve replacement (TAVR). METHODS AND RESULTS: A retrospective review of 201 TAVR patients from January 2017 to November 2018 was performed. Pre- and post-intervention quality-of-life was measured using the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Pre-intervention measures including dimensionless index (DI), stroke volume index (SVI), mean transaortic gradient, peak transaortic velocity, indexed aortic valve area (AVA), aortic valve calcium score, and AVA based on hybrid MDCT-Doppler calculations were obtained and correlated with change in KCCQ-12 at 30-day follow-up. Among the 201 patients studied, median KCCQ-12 improved from 54.2 pre-intervention to 85.9 post-intervention. In multivariable analysis, patients with a mean gradient >40 mmHg experienced significantly greater improvement in KCCQ-12 at follow-up than those with mean gradient ≤40 mmHg (28.1 vs. 16.4, P = 0.015). Patients with MDCT-Doppler-calculated AVA of ≤1.2 cm2 had greater improvements in KCCQ-12 scores than those with computed tomography-measured AVA of >1.2 cm2 (23.4 vs. 14.1, P = 0.049) on univariate but not multivariable analysis. No association was detected between DI, SVI, peak velocity, calcium score, or AVA index and change in KCCQ-12. CONCLUSION: Mean transaortic gradient is predictive of improvement in quality-of-life after TAVR. This measure of AS severity may warrant greater relative consideration when selecting the appropriateness of patients for TAVR.

Transfusion in Elective Proximal Aortic Reconstruction: Where Do We Currently Stand?

Aortic procedures are associated with higher risks of bleeding, yet data regarding perioperative transfusion in this patient population are lacking. We evaluated transfusion patterns in patients undergoing proximal aortic surgery to provide a benchmark against which future standards can be assessed. Between June 2014 and July 2017, 247 patients underwent elective aortic reconstruction for aneurysm. Patients with acute aortic syndrome, endocarditis, and/or prior cardiac surgery were excluded. Transfusion data were analyzed by type of operation: ascending aorta replacement ± aortic valve procedure (group 1, n = 122, 49.4%); aortic root replacement with a composite valve-graft conduit ± ascending aorta replacement (group 2, n = 93, 37.7%); valve-sparing aortic root replacement (VSARR) ± ascending aorta replacement (group 3, n = 32, 13.0%). Thirty-day mortality for the entire cohort was 2.02% (5 deaths). Overall, 75 patients (30.4%) did not require any transfusion of blood or other products. Patients in groups 1 and 3 were significantly more likely to avoid transfusion than those in group 2. Mean transfusion volume for any individual patient was modest; those who underwent VSARR (group 3) required less intraoperative red blood cells (RBC) than others. Intraoperative transfusion of RBC was independently associated with an increased risk of death at 30 days. Elective proximal aortic reconstruction can be performed without the need for excessive utilization of blood products. Composite root replacement is associated with a greater need for transfusion than either VSARR or isolated replacement of the ascending aorta.

Paucicellular Fibroma of the Ascending Aorta.

Primary tumors of the aorta are extremely rare. To the best of our knowledge, herein, we present the first case in the literature of a paucicellular fibroma originating from the aortic wall.

Degenerative Pulmonary Valve Insufficiency in a Patient With a Prior Bentall Procedure.

Adult pulmonary valve regurgitation most commonly presents after congenital cardiac surgery, with limited reports of pure degenerative valvular disease. We present a patient who underwent a Bentall procedure for annuloaortic ectasia with severe aortic insufficiency 14 years prior now presenting with degenerative, severe, symptomatic pulmonary valve regurgitation and normal pulmonary pressures. The patient underwent successful valve replacement with a bovine prosthesis. Recovery was unremarkable, and he continues to do well without further cardiac surgical requirements.

The use of innominate artery cannulation for antegrade cerebral perfusion in aortic dissection.

BACKGROUND: Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection. METHODS: A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis. RESULTS: Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%). CONCLUSIONS: This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.

Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome.

OBJECTIVE: The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform. METHODS: We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed. RESULTS: This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS (P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield. CONCLUSIONS: RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.

Acute Type A Aortic Dissection Repair After Hours: Does It Influence Outcomes?

BACKGROUND: Time of day has been associated with adverse outcomes in certain surgical pathologies. Because acute type A aortic dissection typically mandates immediate repair, relatively little attention has been paid to the potential impact of the day-night timing of the operation itself. We sought to determine whether patients with acute dissection treated during typical working hours demonstrated a difference in outcomes compared with those who required surgery after hours. METHODS: We undertook a comprehensive review of our prospectively collected database from July 2014 to October 2018. A total of 164 consecutive patients underwent primary repair of an acute type A dissection. Based on the procedure start time, patients were divided into 2 groups: working hours (7 am to 4 pm, Monday to Friday; n = 60), and after hours (all other times, including weekends and holidays; n = 104). We propensity-matched 58 pairs of patients and analyzed perioperative data and short-term clinical outcomes. RESULTS: Thirty-day mortality for all 164 patients was 10.4% (17 deaths), which was not significantly different between the matched groups (working-hours: 8 deaths [13.8%] versus after hours: 4 deaths [6.9%]; P = .36). Perfusion, cross-clamp, and circulatory arrest times did not differ between groups, nor did the types of aortic repairs performed. Postoperative complications were also comparable, including stroke, reoperation for bleeding, and new-onset renal failure requiring dialysis. CONCLUSIONS: Thirty-day mortality and major morbidity after acute type A dissection repair are independent of when the operation is performed. Expeditious surgical intervention is recommended for all primary acute type A dissection, irrespective of time of day.

Reoperative mitral valve surgery via sternotomy or right thoracotomy: A propensity-matched analysis.

BACKGROUND: There is, as yet, no broad consensus regarding the optimal surgical approach for patients requiring reoperative mitral valve surgery. Consequently, we sought to evaluate the perioperative outcomes for patients undergoing redo mitral surgery via right mini thoracotomy as compared with traditional resternotomy. METHODS: A comprehensive retrospective review of our prospectively collected database was undertaken from January 2011 to December 2017. We propensity matched 90 patients who underwent reoperative mitral valve surgery via right mini thoracotomy with a concurrent cohort of patients who had redo median sternotomy. Intraoperative data and short-term clinical outcomes were analyzed. RESULTS: The 30-day mortality was 3.3% (six deaths) in the entire cohort, not significantly different between redo sternotomy and mini thoracotomy groups. Patients who had their procedure via right mini thoracotomy had reduced intensive care unit (P = .029) and overall hospital (P < .0001) lengths of stay, a diminished requirement for perioperative transfusion (P = .023), and a trend towards faster postoperative extubation. Right thoracotomy patients experienced shorter cardiopulmonary bypass (P = .012) and cardiac arrest (P < .0001) times than did the sternotomy cases. Peripheral cannulation was utilized more frequently in the mini thoracotomy group, as were fibrillatory arrest techniques. CONCLUSION: Reoperative mitral valve surgery via right mini thoracotomy is safe, and is associated with shorter extracorporeal circulation times, reduced transfusion, and faster postoperative recovery.

Should high risk patients with concomitant severe aortic stenosis and mitral valve disease undergo double valve surgery in the TAVR era?

BACKGROUND: Significant mitral regurgitation in patients undergoing transcatheter aortic valve replacement (TAVR) is associated with increased mortality. The aim of this study is to determine if surgical correction of both aortic and mitral valves in high risk patients with concomitant valvular disease would offer patients better outcomes than TAVR alone. METHODS: A retrospective analysis of 43 high-risk patients who underwent concomitant surgical aortic valve replacement and mitral valve surgery from 2008 to 2012 was performed. Immediate and long term survival were assessed. RESULTS: There were 43 high-risk patients with severe aortic stenosis undergoing concomitant surgical aortic valve replacement and mitral valve surgery. The average age was 80 ± 6 years old. Nineteen (44%) patients had prior cardiac surgery, 15 (34.9%) patients had chronic obstructive lung disease, and 39 (91%) patients were in congestive heart failure. The mean Society of Thoracic Surgeons Predicted Risk of Mortality for isolated surgical aortic valve replacement for the cohort was 10.1% ± 6.4%. Five patients (11.6%) died during the index admission and/or within thirty days of surgery. Mortality rate was 25% at six months, 35% at 1 year and 45% at 2 years. There was no correlation between individual preoperative risk factors and mortality. CONCLUSIONS: High-risk patients with severe aortic stenosis and mitral valve disease undergoing concomitant surgical aortic valve replacement and mitral valve surgery may have similar long term survival as that described for such patients undergoing TAVR. Surgical correction of double valvular disease in this patient population may not confer mortality benefit compared to TAVR alone.

Impact of Postoperative Hypothermia on Outcomes in Coronary Artery Bypass Surgery Patients.

OBJECTIVES: To determine the impact of postoperative hypothermia on outcomes in coronary artery bypass graft surgery (CABG) patients. DESIGN: A retrospective study was performed on patients who underwent isolated CABG between 2011 and 2014. SETTING: Single-center study at a university hospital. PARTICIPANTS: All patients who underwent isolated CABG with cardiopulmonary bypass between 2011 and 2014. INTERVENTIONS: Patients underwent isolated CABG on cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Patients were propensity-score matched based on the likelihood of being hypothermic (<36ºC) or normothermic (≥36ºC) on arrival to the cardiac surgery intensive care unit (ICU) from the operating room. Total transfusion requirements, composite in-hospital morbidity and/or mortality endpoint, total hours in the ICU, and length of hospital stay were compared between the 2 groups. Of the 1,030 patients undergoing isolated CABG, 529 (51.3%) were hypothermic on arrival to the ICU. The hypothermic cohort were older, had more females, had lower body mass indices, had lower starting hematocrit values, were cooled to lower temperatures while on cardiopulmonary bypass, and had longer cardiopulmonary bypass runs compared with the normothermic group. Of the 748 patients who were propensity matched, there were no differences in blood and blood product transfusion requirements, mortality and complication rates, time on the ventilator, length of ICU stay, and length of hospital stay between hypothermic and normothermic patients. CONCLUSIONS: Hypothermia at ICU admission after CABG was not associated with increased adverse outcomes, possibly suggesting that complete rewarming before separation from cardiopulmonary bypass may not be essential in all patients.

Bedside Vein Mapping for Conduit Size in Coronary Artery Bypass Surgery.

BACKGROUND AND OBJECTIVES: The greater saphenous vein has been used in coronary artery bypass grafting (CABG) for more than 50 years. Endoscopic vein harvesting has greatly reduced the morbidity associated with obtaining the vein, but the quality of the vein could not be assessed before its was exposed surgically or after the endoscopic procedure had been performed. This study was conducted to evaluate the accuracy of preoperative mapping of the greater saphenous vein at the bedside in assessing suitable conduit size for use in CABG. METHODS: Seventy-two consecutive patients undergoing saphenous vein harvesting for use as a conduit during CABG underwent preoperative ultrasonographic vein mapping on the operating table after the leg was positioned for vein harvesting. Vein diameters at 3 distinct locations were measured by ultrasonography after vein harvesting and preparation. Similar linear regression was used to determine the correlation between measurements by ultrasonography and the true vein size after harvesting. Standard methods of computing 95% lower and upper confidence limits for single predicted values were also used. RESULTS: Two hundred twenty measurements were obtained from 72 patients. Mean vein diameters were 3.4 ± 0.9 and 4.6 ± 0.9 mm as measured by ultrasonography and after vein harvest, respectively. True vein size was an average of 1.2 ± 0.4 mm larger than that measured by ultrasonography. Ultrasonographic determination of vein diameters closely correlated with the true vein diameter (correlation coefficient, 0.91; P < .001), and the measurement obtained predicted the true measurement within 1.6 mm with 95% confidence. CONCLUSION: Bedside ultrasonographic vein mapping provides an accurate noninvasive method for preoperative assessment to determine the suitability of the greater saphenous vein for use as a bypass conduit. It is therefore an important component of preoperative planning before CABG.

Standardizing Robotic Lobectomy: Feasibility and Safety in 128 Consecutive Lobectomies Within a Single Healthcare System.

OBJECTIVE: Single-surgeon cohorts assessing robotically assisted video-assisted thoracic (RA-VATS) lobectomy have reported good outcomes, but there are little data regarding multiple surgeons applying a standard technique in separate hospitals. The purpose of this study was to show how a standardized robotic technique is both safe and reproducible between surgeons and institutions. METHODS: From July 1, 2012, to October 1, 2013, patients undergoing RA-VATS lobectomy for both benign and malignant disease were identified from a prospectively collected database of two thoracic surgeons from different hospitals within the same healthcare system and retrospectively analyzed. Each surgeon employed an identical "rule of 10" completely port-based approach through all 128 cases. The primary end points of the study were in-hospital and 30-day mortality. Secondary end points were differences in morbidity and perioperative outcomes between the two surgeons based on their "rule of 10" technique. RESULTS: A total of 128 cases were performed with 121 lobectomies, 3 bilobectomies, and 4 pneumonectomies for both malignant and benign disease. Each surgeon had 64 cases without a single in-hospital or 30-day mortality. Overall morbidity was 16.4%. Each surgeon had one readmission and take back to operating room (a washout and a mechanical pleurodesis). The most common complication was prolonged air leak (38.1%, 8/21 patients). There was no statistical difference in length of stay, complications, severity of illness, and clinical staging between the two surgeons. There was a significant difference in resected lymph nodes (11.79 vs 14.45, P = 0.0086). Compared with published national meta-analysis on RA-VAT lobectomies, there was a significantly reduced length of stay (4.2 vs 6 days, P = 0.0436) and bleeding (0.8 vs 1.8%, P = 0.0003). Nodal upstaging from cN0 to pN1 was 8% and cN0 to pN2 was 2% for an overall nodal upstaging of 10% for stage I nonsmall cell lung cancer. CONCLUSIONS: By standardizing how a robotic lobectomy is performed, we were able to show that RA-VATS lobectomy is safe and may allow for the expansion of minimally invasive lobectomy to surgeons who otherwise have failed to adopt traditional VATS. When compared with the most recent national meta-analysis, we had reduced morbidity, mortality, bleeding, and length of stay. Robotic nodal upstaging for stage I nonsmall lung cancer was consistent with larger multicenter study. We hope that these results will help lead to the standardization robotic lobectomy and a larger multisurgeon/institutional study that could pave the way for greater adoption of minimally invasive lobectomy.