Outcomes of minimally invasive isolated tricuspid valve repair and replacement through right mini-thoracotomy.

Objective: Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR). Methods: We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery. Results: Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease. Conclusions: A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.

Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis.

OBJECTIVES: Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures. METHODS: We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed. RESULTS: Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay. CONCLUSIONS: In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Authorship Trends and Disparities in Cardiothoracic Surgery.

BACKGROUND: Previous investigations have revealed significant gender disparities in the academic arenas of cardiothoracic surgery. However, the status of gender representation in cardiothoracic publications has not been well described. This study aimed to evaluate authorship trends by gender in two high-impact cardiothoracic surgical journals. METHODS: In this bibliometric analysis, PubMed was searched for articles published in The Annals of Thoracic Surgery and the Journal of Thoracic and Cardiovascular Surgery from 2010 to 2021. The web-based application Genderize.io was used to classify names of first and last authors as men vs women. The Cochran-Armitage trend test and multivariable logistic regression were used to evaluate authorship per year and the association of first and last author gender, respectively. RESULTS: Among 14,443 articles, 16.7% had women first authors and 8.1% had women last authors. The proportion of articles written by women authors increased, rising from 12.6% to 21.1% (P < .0001) for first and 5.4% to 11.5% (P < .0001) for last authors. Papers written with women as first author were associated with 2.0 higher odds of having a woman as last author (95% CI, 1.7-2.3; P < .0001). The mean number of last author publications was higher for men than for women (2.4 vs 1.7, P < .0001). CONCLUSIONS: Over the past decade, despite a welcomed increase in women authorship in high-impact journals in cardiothoracic surgery, women represent a small proportion of published authors. Women first authors are more likely to publish with women last authors, demonstrating the impact of same-gender collaborations while emphasizing a need for cross-gender mentorship.

Demographics of Current and Aspiring Integrated Six-year Cardiothoracic Surgery Trainees.

BACKGROUND: The integrated 6-year thoracic surgery (I-6) residency model was developed in part to promote early interest in cardiothoracic surgery in diverse trainees. To determine gaps in and opportunities for recruitment of women and minority groups in the pipeline for I-6 residency, we quantified rates of progression at each training level and trends over time. METHODS: We obtained 2015 to 2019 medical student, I-6 applicant, and I-6 resident gender and race/ethnicity demographic data from the American Association of Medical Colleges and Electronic Residency Application Service public databases and Accreditation Council for Graduate Medical Education Data Resource Books. We performed χ2, Fisher exact, and Cochran-Armitage tests for trend to compare 2015 and 2019. RESULTS: Our cross-sectional analysis found increased representation of women and all non-White races/ethnicities, except Native American, at each training level from 2015 to 2019 (P < .001 for all). The greatest trends in increases were seen in the proportions of women (28% vs 22%, P = .46) and Asian/Pacific Islander (25% vs 15%, P = .08) applicants. There was also an increase in the proportions of women (28% vs 24%, P = .024) and White (61% vs 58%, P = .007) I-6 residents, with a trend for Asian/Pacific Islanders (20% vs 17%, P = .08). The proportions of Hispanic (5%) and Black/African American (2%) I-6 residents in 2019 remained low. CONCLUSIONS: I-6 residency matriculation is not representative of medical student demographics and spotlights a need to foster early interest in cardiothoracic surgery among all groups underrepresented in medicine while ensuring that we mitigate bias in residency recruitment.

Endovascular therapy for patients with heritable thoracic aortic disease.

BACKGROUND: Patients with genetic or heritable aortic conditions and thoracic aortic aneurysm syndrome often develop cardiovascular abnormalities originating at the aortic root and affecting the entire thoracoabdominal aorta. Although thoracic endovascular aortic repair (TEVAR) is usually avoided in these patients, TEVAR may be worthwhile for those at high risk for surgical complications and in certain emergency circumstances. We explored indications for TEVAR in patients with suspected or confirmed genetic or heritable aortic conditions and investigated early and mid-term outcomes. METHODS: Our institutional aortic surgery database was queried for patients with suspected or confirmed Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, Turner syndrome, neurofibromatosis, or familial aortic aneurysm and dissection who underwent TEVAR between February 1, 2002 and October 31, 2020. We extracted operative details and in-hospital, follow-up, and survival data. RESULTS: Thirty-seven patients who underwent 40 endovascular interventions met the inclusion criteria; 25 previously underwent ascending aorta or aortic root surgery, and 21 previously underwent open thoracoabdominal surgery. Postoperative complications included respiratory failure (24.3%), cardiac complications (16.2%), renal failure (13.5%), tracheostomy (8.1%), and spinal cord ischemia (paraplegia/paraparesis) (8.1%). Follow-up ranged from 1.3 to 8.5 years (median: 3.6 years), with 15 deaths overall (three early/in-hospital). Thirteen patients (35.1%) had 22 repeat interventions (open and endovascular) post-TEVAR; five had the endograft removed. CONCLUSIONS: Despite consensus that thoracic aneurysms in patients with genetic or heritable aortic conditions should be treated with conventional open surgery, the outcomes from our study suggest that TEVAR might be suitable in emergency settings or for patients in this population who are not candidates for open surgery, who are at high risk for reintervention, or who have a previously implanted Dacron graft. Nonetheless, lifelong surveillance is important for these patients after TEVAR to monitor for new dissection at distal or proximal landing zones, as repeat interventions are frequent.

Demographic Landscape of Cardiothoracic Surgeons and Residents at United States Training Programs.

BACKGROUND: Recruiting and promoting women and racial/ethnic minorities could help enhance diversity and inclusion in the academic cardiothoracic (CT) surgery workforce. However, the demographics of trainees and faculty at US training programs have not yet been studied. METHODS: Traditional, integrated (I-6), and fast-track (4+3) programs listed in the Accreditation Council for Graduate Medical Education (ACGME) public database were analyzed. Demographics of trainees and surgeons, including gender, race/ethnicity, subspecialty, and academic appointment (if applicable), were obtained from ACGME Data Resource Books, institutional websites, and public profiles. Chi-square and Cochran-Armitage trend tests were performed. RESULTS: In July 2020, 78 institutions had at least 1 CT surgery training program; 40 (51%) had only a traditional program, 20 (26%) traditional and I-6, 6 (8%) all 3 types of program, and 4 (5%) only I-6. The proportion of female trainees increased significantly from 2011 to 2019 (19% vs 24%, P < .001), with female I-6 trainees outnumbering female traditional trainees since 2018. Significant increases by race/ethnicity were observed overall and by program type, notably for Asian and Hispanic individuals in I-6 programs and Black individuals in traditional programs. Finally, of the 1175 CT surgeons identified, 633 (54%) were adult cardiac surgeons, 360 (37%) assistant professors, 116 (10%) women, and 33 (3%) Black. CONCLUSIONS: The demographic landscape of CT surgery trainees and faculty across multiple training pathways reflects increasing representation by gender and race/ethnicity. However, we must continue to work toward equitable representation in the workforce to benefit the diverse patients we treat.

Impact of Psychiatric Comorbidities on Surgical Outcomes for Non-Small Cell Lung Cancer.

BACKGROUND: Psychiatric comorbidities (PCs) have been associated with poor surgical outcomes in several malignancies. However, the impact of PCs on surgical outcomes for non-small cell lung cancer (NSCLC) remains largely unknown. METHODS: NSCLC patients who underwent pulmonary resection at a single institution between 2006 and 2017 were included. Presence of preoperative PCs was identified by documented diagnostic codes. Demographic, histopathologic, perioperative, and survival data were analyzed. Categorical variables were compared using the χ2 or Fisher exact test. Overall and disease-free survival was analyzed using Kaplan-Meier method. Univariable and multivariable logistic regression analyses were performed for 30-day readmission. RESULTS: Among 2907 patients, PCs were present preoperatively in 180 (6%), including anxiety, 130 (72%); depression, 52 (29%); adjustment disorder, 28 (16%); alcohol abuse, 16 (9%); sleep disorder, 8 (4%); and schizophrenia, 3 (2%). Patients with PCs were younger, with fewer cardiovascular complications. There were no differences in length of stay. However, PCs led to increased 30-day readmission (12% vs 6%, P = .004). Reasons for readmission did not differ between groups (P = .679). Multivariable analysis showed PCs independently predicted 30-day readmission (odds ratio, 2.00; P = .005). Importantly, there were no differences in 30- or 90-day mortality (P = .495 and P = .748, respectively), overall survival (P = .439), or disease-free survival (P = .924). CONCLUSIONS: NSCLC patients with and without PCs experienced similar perioperative and long-term outcomes, suggesting that individuals should not be denied surgical care on the basis of such comorbidities. However, further research should seek to identify reasons for increased risk of readmission for patients with PCs and validate these findings in other settings.