Early to midterm survival of patients with deep sternal wound infection managed with laparoscopically harvested omentum.

OBJECTIVE: The optimal management of deep sternal wound infection (DWSI) remains controversial. Our objective was to evaluate outcomes of patients with DSWI managed with transposition of laparoscopically harvested omentum (LHO). METHODS: Between 2000 and 2020, a total of 38,623 adult patients who underwent full median sternotomy for cardiac surgery were analyzed retrospectively at our institution. DSWI occurred in 455 (1.2%), of whom 364 (93.2%) were managed with pectoralis myocutaneous flap (PMF) and 33 (7.2%) with LHO. Univariate and multivariate analysis models were used to determine predictors of cumulative late mortality and adjusted survival curves were generated. RESULTS: Among patients who received LHO, average age was 65.7 ± 9.7 years and a larger proportion of patients were male. A majority of patients (88%) had coronary bypass surgery, with bilateral internal mammary arteries use in only 21.2%. Mean length of stay (LOS) was 58.90 days and early hospital mortality occurred in 4 patients (12.1%). Patients who received LHO compared to only PMF had larger body mass index and had more heart failure. Furthermore, the hospital LOS was also significantly prolonged in the LHO group (58.9 vs. 27.4 days, p = .002), with a slightly higher in-hospital mortality (12.1% vs. 3.3%, p = .03). Late survival for LHO patients at 5 and 10 years was 71.9% and 44.8%, respectively. CONCLUSION: Use of LHO is a safe and viable alternative to traditional myocutaneous flaps to manage complex DSWI. Early and late survival were favorable in this high-risk population.

Could Blockchain Help With COVID-19 Crisis?

The novel coronavirus that causes the Coronavirus Disease 2019 (COVID-19) has spread all over the world at an unprecedented rate. With growing recognition of the distributed nature of health services, the technology of blockchain has recently reached the impetus of the healthcare domain. This article provides: 1) a panoramic overview of existing solutions and scenarios incorporating blockchain to combat COVID-19 in the healthcare domain along with their benefits and challenges; as well as 2) a framework that will facilitate new research activities on this subject.

Ramping Up the Delivery of Cardiac Surgery During the COVID-19 Pandemic: A Guidance Statement From the Canadian Society of Cardiac Surgeons.

The coronavirus disease 2019 (COVID-19) has had a profound global effect. Its rapid transmissibility has forced whole countries to adopt strict measures to contain its spread. As part of necessary pandemic planning, most Canadian cardiac surgical programs have prioritized and delayed elective procedures in an effort to reduce the burden on the health care system and to mobilize resources in the event of a pandemic surge. While the number of COVID-19 cases continue to increase worldwide, new cases have begun to decline in many jurisdictions. This "flattening of the curve" has inevitably prompted discussions around reopening of the economy, relaxing some public health restrictions, and resuming nonurgent health care delivery. This document provides a template for cardiac surgical programs to begin to ramp-up the delivery of cardiac surgery in a deliberate and graded fashion as the COVID-19 pandemic burden begins to ease that is guided by 3 principles. First, all recommendations from public health authorities regarding COVID-19 containment must continue to be followed to minimize disease spread, ensure patient safety, and protect health care personnel. Second, patients awaiting elective cardiac surgery need to be proactively managed, reprioritizing those with high-risk anatomy or whose clinical status is deteriorating. Finally, case volumes should be steadily increased in a mutually agreed upon fashion and must balance the clinical needs of patients awaiting surgery against the overall requirements of the health care system.

Cardiac Surgery in Canada During the COVID-19 Pandemic: A Guidance Statement From the Canadian Society of Cardiac Surgeons.

On March 11, 2020, the World Health Organization declared that COVID-19 was a pandemic.1 At that time, only 118,000 cases had been reported globally, 90% of which had occurred in 4 countries.1 Since then, the world landscape has changed dramatically. As of March 31, 2020, there are now nearly 800,000 cases, with truly global involvement.2 Countries that were previously unaffected are currently experiencing mounting rates of the novel coronavirus infection with associated increases in COVID-19-related deaths. At present, Canada has more than 8000 cases of COVID-19, with considerable variation in rates of infection among provinces and territories.3 Amid concerns over growing resource constraints, cardiac surgeons from across Canada have been forced to make drastic changes to their clinical practices. From prioritizing and delaying elective cases to altering therapeutic strategies in high-risk patients, cardiac surgeons, along with their heart teams, are having to reconsider how best to manage their patients. It is with this in mind that the Canadian Society of Cardiac Surgeons (CSCS) and its Board of Directors have come together to formulate a series of guiding statements. With strong representation from across the country and the support of the Canadian Cardiovascular Society, the authors have attempted to provide guidance to their colleagues on the subjects of leadership roles that cardiac surgeons may assume during this pandemic: patient assessment and triage, risk reduction, and real-time sharing of expertise and experiences.

Five Maneuvers to Facilitate Faster Robotic Mitral Valve Repair.

Robotically assisted mitral valve reconstruction has become a cornerstone in the management of degenerative mitral valve regurgitation. High-volume centers report exceptional outcomes with minimal morbidity and mortality in select patient populations. As compared to conventional sternotomy, robotically assisted surgery has yielded comparable efficacy and safety, with potential benefits of improved cosmesis and a faster recovery period. Despite the potential benefits of a robotic approach, there has been a reluctance in widespread adoption due to concerns over increased operative and crossclamp times as compared to conventional sternotomy approaches. In light of this specific concern, we have identified opportunities to improve the efficiency of robotic mitral valve repair by application of 5 innovations and surgical strategies.

Impact of visualization on simulation training for vascular anastomosis.

OBJECTIVE: There is mounting evidence supporting the benefit of surgical simulation on the learning of skills independently and in a patient-safe environment. The objective of this study was to examine the effect of visualization of surgical steps via instructional media on performance of an end-to-side microvascular anastomosis. METHODS: Thirty-two first- and second-year surgical trainees from the University of Ottawa received an expert-guided, didactic lecture on vascular anastomosis and performed an end-to-side anastomosis on a procedural model to assess baseline skills. Assessments were performed by 2 blinded, expert observers using validated measurements of skill. Subjects were then proctored to perform anastomoses using the model. Subjects were then randomized to watch an instructional video on performance of vascular anastomosis using visualization as the education strategy. One week later, subjects were again assessed for technical skill on the model. The primary outcome was the score achieved on the Objective Structured Assessment of Technical Skill (OSATS) scale. Secondary outcomes included an anastomosis-specific End-Product Rating Score and time to completion. RESULTS: Compared with residents who received expert-guided simulator training alone, those who used the supplementary multimedia scored significantly greater on OSATS (17.4 ± 2.9 vs 14.2 ± 3.2, P = .0013) and on End-Product Rating Score (11.24 ± 3.0 vs 7.4 ± 4.1, P = .011). However, performance time did not differ between groups (15.7 vs 14.3 minutes, P = .79). CONCLUSIONS: Residents with supplemental instructional media performed an end-to-side anastomosis more proficiently as assessed by OSATS and with a greater quality end-product. This suggests that both didactic simulation training as well as use of visualization multimedia improves learning and performance of vascular anastomosis and should be incorporated into surgical curricula.

The Future of the Academic Cardiothoracic Surgeon: Results of the TSRA/TSDA In-Training Examination Survey.

BACKGROUND: Traditionally cardiothoracic residents spent dedicated research time during general surgery equipping them for a potential academic career. Recent changes in training paradigms, including integrated programs that may not include research time, could affect the development of future academic cardiothoracic surgeons. METHODS: Responses to the 2015 Thoracic Surgery Directors' Association/Thoracic Surgery Residents' Association survey accompanying the in-training examination taken by current cardiothoracic surgery residents were analyzed. Three hundred fifty-four residents were surveyed with a response rate of 100%, although one was excluded from the analysis because of inconsistencies in responses. Statistical analysis included χ(2), Fisher's exact test, and multinomial logistic regression with significance set at a probability value of 0.05. RESULTS: Two hundred sixty-seven of 353 residents (76%) intended on performing research as part of their careers. Integrated residents as opposed to traditional residents (85% versus 69%; p = 0.003), males (78% versus 65%; p = 0.02), those pursuing additional training (85% versus 69%; p = 0.003), and those interested in academic careers (93% versus 33%; p < 0.001) were more likely to pursue research. Differences were also noted in specialty interest, with congenital and heart failure specialties most likely to pursue research careers (92% and 100%, respectively; p < 0.05). Residents intending on research careers were more likely to have had previous research experience, and the most common type of intended research was clinical outcomes (78%). On multinomial logistic regression, previous clinical outcomes research and academic practice were identified as predictors of a research career (odd ratios of 9.7 and 4.1, respectively; each p < 0.05). CONCLUSIONS: The majority of residents plan on pursuing research during their careers. Previous research experience appears to be a key determinant as well as specialty interest.

Gender and Cardiothoracic Surgery Training: Specialty Interests, Satisfaction, and Career Pathways.

BACKGROUND: The cardiothoracic surgical workforce is changing. Although 5% of practicing surgeons are women, 20% of current cardiothoracic surgery residents are women. The purpose of this study was to evaluate the influence of gender on specialty interest, satisfaction, and career pathways of current residents. METHODS: Responses to the mandatory 2015 Thoracic Surgery Residents Association/Thoracic Surgery Directors Association in-training examination survey taken by 354 residents (100% response rate) were evaluated. The influence of gender was assessed with the use of standard univariate analyses. RESULTS: Women accounted for 20% of residents, and the percentage did not vary with postgraduate year or program type (traditional versus integrated). Although no differences were found between the genders related to specialty interest, academic versus private practice career, or pursuit of additional training, women were more likely to pursue additional training in minimally invasive thoracic surgery (10% versus 2.5%, p = 0.001) and less likely to perform research in their careers (65% versus 88%, p = 0.043). Although women were equally satisfied with their career choice, had similar numbers of interviews and job offers, and felt equally prepared for their boards, graduating women felt less prepared technically (77% versus 90%, p = 0.01) and for practicing independently (71% versus 87%, p = 0.01). Women were less likely to be married (26% versus 62%, p < 0.001) and have children (19% versus 49%, p < 0.001). CONCLUSIONS: Although career satisfaction and specialty interest were similar between the genders, women were less likely to intend to perform research during their careers despite similar previous research experience. Women also demonstrated lower rates of marriage and childbearing compared with their male counterparts.

Characterizing the Operative Experience of Cardiac Surgical Trainees: What Are Residents Really Doing in the Operating Room?

BACKGROUND: The present study aimed to describe and compare the operative experience of cardiothoracic surgical residents for basic and advanced cardiac surgical procedures. METHODS: Data were obtained from the 2015 Thoracic Surgery Directors Association Survey administered to all thoracic surgical residents taking the yearly In-Service Training Examination (n = 356). Residents were asked whether they routinely served as the operative surgeon on various cardiac operations and operative tasks. Results were stratified by postgraduate year (PGY), residency type, and primary career interest. RESULTS: The survey response rate was 100%. Considering all training pathways, only 2 of 13 cardiac operations surveyed were routinely performed by graduating chief residents as the operative surgeon: coronary artery bypass grafting (CABG; 92%) and aortic valve replacement (AVR; 88%). Off-pump CABG, minimally invasive mitral valve operation, and transcatheter aortic interventions were infrequently (<30% of the time) performed by graduating residents as the operative surgeon. These results were similar when residents with a career interest in general thoracic surgery were excluded from the analysis. For the operative progression of integrated 6-year (I-6) residents, most began to routinely cannulate for cardiopulmonary bypass, perform proximal coronary anastomoses, and harvest the mammary artery during PGY3. The majority (>50%) of I-6 residents performed CABG as the operative surgeon by PGY4. CONCLUSIONS: There is pronounced heterogeneity in the cardiac operative experience of cardiothoracic surgical residents in the United States, with only CABG and AVR routinely performed by graduating residents as the operative surgeon. This heterogeneity may lead to insufficient training in certain procedures for many graduates.

Is Aortic Valve Repair Reproducible? Analysis of the Learning Curve for Aortic Valve Repair.

BACKGROUND: Aortic valve (AV) preservation and repair, although effective, is performed in a limited number of centres. Lack of wider application might be due to challenges in dissemination of tacit surgical knowledge. We examined the learning curve in 2 centres that initiated dedicated programs in AV repair. METHODS: Prospectively collected data on the first 100 (cohort A) and 150 consecutive patients (cohort B) who underwent AV repair surgery were analyzed. Safety end points included mortality, myocardial infarction or stroke, early AV repeat surgery, re-exploration for bleeding, or pacemaker implantation. Efficiency was assessed according to aortic crossclamp and cardiopulmonary bypass times. Efficacy parameters included residual aortic insufficiency or stenosis. Indices of case complexity included presence of severe aortic insufficiency, nontrileaflet AV, and associated cardiac procedures. Each cohort was divided into 3 equal tertiles (T1, T2, and T3). RESULTS: Early mortality was ≤ 1% in both cohorts. In cohort A, a total of 12 safety events occurred with a significant reduction in incidence over the tertiles (18%, 15%, and 3%, in T1, T2, and T3, respectively; P = 0.05). In cohort B, 20 safety events occurred in 18 patients with a trend toward reduction of incidence over tertiles (20%, 12%, and 8%, in T1, T2, and T3, respectively; P = 0.14). aortic crossclamp and cardiopulmonary bypass times decreased significantly after T2 in cohort A and T1 in cohort B (P < 0.01). Intraoperative procedural efficacy was similar across tertiles in both cohorts. CONCLUSIONS: Procedural safety and efficiency improves with experience whereas efficacy is consistent over time. AV repair is reproducible and appears to have a learning curve of approximately 40-60 cases.

Severe tracheobronchial compression in a patient with Turner's syndrome undergoing repair of a complex aorto-subclavian aneurysm: anesthesia perspectives.

We present a case of severe tracheobronchial compression from a complex aorto-subclavian aneurysm in a patient with Turner's syndrome undergoing open surgical repair. Significant airway compression is a challenging situation and requires careful preoperative preparation, maintenance of spontaneous breathing when possible, and consideration of having an alternative source of oxygenation and circulation established prior to induction of general anesthesia. Cardiopulmonary monitoring is essential for safe general anesthesia and diagnosis of unexpected intraoperative events.

Mapping and ablation of autonomic ganglia in prevention of postoperative atrial fibrillation in coronary surgery: MAAPPAFS atrial fibrillation randomized controlled pilot study.

BACKGROUND: Postoperative atrial fibrillation (POAF) remains common after coronary artery bypass grafting (CABG). Limited efforts to intervene on cardiac autonomic ganglionic plexi (AGP) during surgery show mixed results. In this pilot study, we evaluated the safety and feasibility of map-guided ablation of AGPs during isolated CABG in the prevention of POAF. METHODS: In this pilot study, patients undergoing isolated CABG were randomized into an intervention group (mapping and ablation of AGP [AGP+] group), and a control group (no mapping and ablation [AGP-] group). Using high-frequency stimulation, active AGPs were identified and ablated intraoperatively using radiofrequency. Continuous rhythm monitoring, serum electrolytes, postoperative medications, and postoperative complications were recorded until discharge. RESULTS: Randomization of 47 patients (24 AGP+ and 23 AGP-) resulted in similar baseline characteristics, past medical history, and preoperative medication use. The intervention added a median of 14 minutes to the operative time. The incidence of POAF, mean time in POAF, and median length of stay in hospital were: AGP+ 21% vs AGP- 30%; AGP+ 298 minutes vs AGP- 514 minutes; AGP+ 5 days vs AGP- 6 days; respectively). Postoperative complications, medication use, and daily serum electrolyte profiles were similar in both groups. CONCLUSIONS: This pilot study demonstrated the safety and feasibility of mapping and ablation of AGP during CABG with minimal added operative time. Results further suggest a potentially clinically significant effect on POAF. A multicentre trial is warranted.

Aortic valve preservation and repair in acute Type A aortic dissection.

OBJECTIVES: Repair and preservation of the aortic valve in Type A aortic dissection (AAD) remains controversial. We performed a meta-analysis of outcomes for aortic valve (AV) repair and preservation in AAD focusing on long-term valve-related events. METHODS: Structured searches were performed in Embase (1980-2013) and PubMed (1966-2013) for studies reporting AV repair or preservation in AAD. Early mortality and linearized rates for late mortality and valve-related events were derived. Outcome data were pooled with an inverse-variance-weighted random-effects model. RESULTS: Of 5325 screened articles, 19 observational studies met the eligibility criteria consisting of 2402 patients with a median follow-up of 4.1 [range: 3.1-12.6 years, total 13 733 patient-years (pt-yr)]. The cohort was principally male (median = 68.1%, range: 39-89) with a median age of 59 (range: 55-68) years and Marfan's syndrome was present in 2.5%. AV resuspension was performed in 95% of the patients and the remainder underwent valve-sparing root replacement (reimplantation = 2.5% and remodelling = 2.5%). Pooled early mortality rate was 18.7% [95% confidence interval (95% CI): 12.2-26.2%], and linearized late mortality rate was 4.7%/pt-yr (95% CI: 3.4-6.3). Linearized rate for AV reintervention was 2.1%/pt-yr (95% CI: 1.0-3.6), recurrent aortic insufficiency (>2+) was 0.9%/pt-yr (95% CI: 0.3-2.2) and endocarditis was 0.2%/pt-yr (95% CI: 0.1-0.5). The composite rate of thromboembolism and bleeding was 1.4%/pt-yr (95% CI: 0.7-2.2). CONCLUSIONS: Patients surviving an AAD have a limited long-term survival. Preservation and repair of the aortic valve is associated with a moderate risk of reoperation, but a low risk of thromboembolism, bleeding and endocarditis.

Mitral valve interventions in heart failure.

PURPOSE OF REVIEW: This review describes new developments in mitral valve interventions for patients with heart failure. The review also discusses innovative therapies in the treatment of mitral regurgitation in patients with heart failure and describes novel risk factors of recurrent mitral regurgitation following repair in this population. RECENT FINDINGS: Percutaneous strategies are rapidly emerging as an important adjunct to conventional mitral surgery, specially for patients with functional mitral regurgitation and heart failure. Percutaneous therapies are a well-tolerated alternative to surgery in high-risk patients, but their long-term efficacy is not established. Partial ring annuloplasty and preoperative galectin-3 levels may be associated with recurrent mitral regurgitation after repair. Preclinical work has focused on injectable substances, which may ameliorate adverse left ventricular remodeling and recurrent mitral regurgitation after surgery. SUMMARY: Percutaneous therapies will continue to evolve and serve as an alternative to conventional surgery for patients with mitral regurgitation and heart failure. Determining anatomic and biochemical risk factors associated with recurrent mitral regurgitation after repair is crucial in tailoring therapy to individual patients. Preclinical work regarding infarct stabilization may benefit future patients with heart failure.

Systematic review of aortic valve preservation and repair.

BACKGROUND: Aortic valve repair has emerged as a feasible alternative to replacement in the surgical treatment of selected patients with aortic valve (AV) pathology. In order to provide a synopsis of the current literature, we preformed a systematic review with a focus on valve-related events following AV repair. METHODS: Structured keyword searches of Embase and PubMed were performed in January 2012. A study was eligible for inclusion if it reported early mortality, late mortality, or valve-related morbidity in the adult population. RESULTS: Initial search results identified 3,507 unique studies. After applying inclusion and exclusion criteria, 111 studies remained for full-text review. Of these, 17 studies involving 2,891 patients were included for quantitative assessment. No randomized trials were identified. Tricuspid and bicuspid AV pathologies were present in 65% (range, 21-100%) and 13.5% (range, 5-100%) of the population, respectively. Cusp repair techniques were applied in a median of 46% (range, 5-100%) of patients. The median requirement for early reoperation for post-operative bleeding and early reintervention for primary AV repair failure was 3% (range, 0-10%) and 2% (range, 0-16%), respectively. Pooled early mortality was 2.6% (95% CI: 1.4-4.4%, I(2) =0%). Late mortality and valve-related events were linearized [(number of events/number of patient-years) ×100] (%/pt-yr) for each study. Late operated valve endocarditis was reported at median event rate of 0.23%/pt-yr (range, 0-0.78%/pt-yr), while a composite outcome of neurological events and thromboembolism occurred at a median rate of 0.52%/pt-yr (0-0.95%/pt-yr). Late AV re-intervention requiring AV replacement or re-repair occurred at a rate of 2.4%/pt-yr (range, 0-4.2%/pt-yr). The median 5-year freedom from AV re-intervention and late recurrent aortic insufficiency >2+ estimated from survival curves was 92% (range, 87-98%) and 88% (range, 87-100%), respectively. Pooled late mortality produced summary estimate of 1.3%/pt-yr (95% CI: 0.9-2.1%, I(2) =0%). CONCLUSIONS: The present systematic review confirmed the low operative risk of patients who underwent aortic valve preservation and repair. There is a need for long-term follow-up studies with meticulous reporting of outcomes following AV repair, as well as comparative studies with aortic valve replacement.

Repair of quadricuspid aortic valve associated with ascending aorta dilatation.

Quadricuspid aortic valve is a rare congenital anomaly that may require surgical intervention because of valvular dysfunction. Rarely, it may be associated with enlargement of the ascending aorta. Here, the case is presented of a quadricuspid aortic valve-associated enlargement of the ascending aorta and functional aortic annulus dilatation in a 36-year-old patient. The patient subsequently underwent a successful aortic valve repair and replacement of the ascending aorta.

Reoperation of left heart valve bioprostheses according to age at implantation.

BACKGROUND: Evidence supporting the use of bioprostheses for heart valve replacement in young adults is accumulating. However, reoperation data, which may help guide clinical decision making in young patients, remains poorly defined in the literature. METHODS AND RESULTS: We examined the need for reoperation in 3975 patients who underwent first-time bioprosthetic aortic valve replacement (AVR) (n=3152) or mitral valve replacement (MVR) (n=823). There were 895 patients below the age of 60 years at bioprosthesis implant (AVR, n=636; MVR, n=259). The median interval to reoperation of contemporary, stented aortic bioprostheses was 7.74 years (95% CI 7.28 to 9.97 years) in patients less than 40 years, and 12.93 years (95% CI 11.10 to 15.76 years) in patients between 40 and 60 years of age. Multivariable risk factors associated with reoperation following bioprosthetic AVR include age (hazard ratio [HR] 0.94 per year, 95% CI 0.91 to 0.96, P<0.001) and concomitant coronary artery bypass grafting (HR 0.34, 95% CI 0.11 to 0.99, P=0.04). The median interval to reoperation of contemporary mitral bioprostheses was 8.11 years (95% CI 5.79 to 16.50 years) in patients less than 40 years, and 10.14 years (95% CI 8.64 to 11.14 years) in patients between 40 and 60 years of age. As for AVR, age (HR 0.96 per year, 95% CI 0.95 to 0.98, P<0.001) and concomitant coronary artery bypass grafting (HR 0.55, 95% CI 0.32 to 0.93, P=0.03) were associated with decreased reoperation risk following bioprosthetic MVR. CONCLUSIONS: These data constitute clinically relevant age-specific prognostic information regarding reoperation in young patients, who may wish to select a bioprosthesis at initial left heart valve replacement.

The role of pulmonary embolectomy in the treatment of acute pulmonary embolism: a literature review from 1968 to 2008.

Acute massive or submassive pulmonary embolism (PE) requires prompt diagnosis, risk-stratification and aggressive treatment. Mortality rates can rise up to 70% within the first hour of presentation and are strongly correlated with the degree of right ventricular (RV) dysfunction, cardiac arrest, and consequential congestive heart failure. While anticoagulation is universally employed, there are inadequate data to establish definitive guidelines for the management of massive PE despite the availability of multiple treatment modalities. Medical thrombolytic therapy has not been shown to significantly reduce mortality in patients with massive PE but is still widely employed, whereas surgical and catheter embolectomy are only reserved as last resort treatments for critically ill patients with hemodynamic instability, or for those who are either not candidates for or have failed thrombolysis. Following an extensive review of medical literature, we outline the treatment options for this clinical scenario while focusing on the role of surgical embolectomy. Although traditionally reserved as rescue therapy for cases of failed thrombolysis, surgical embolectomy is a safe procedure with low mortality when performed early and in a selected group of patients. Sufficient evidence exists to extend the criteria for surgical embolectomy from strictly rescue therapy to include hemodynamically stable patients with RV dysfunction. Multidisciplinary approach to this condition coupled with a meticulous surgical technique has significantly lowered the mortality associated with this surgical procedure over the last 10 years.

The use of the Impella LP 2.5 percutaneous microaxial ventricular assist device as hemodynamic support during high-risk abdominal surgery.

Physiologic changes associated with anesthesia and technical aspects of noncardiac surgical procedure expose patients with severely depressed myocardial function to an enormous risk of perioperative complications and morbidity. In cases when these patients require mechanical circulatory support while undergoing emergent or elective operations, perioparative monitoring becomes of paramount importance.