The 2010 Thoracic Surgery Residents Association workforce survey report: a view from the trenches.

BACKGROUND: Workforce estimates suggest 11% of general surgery residents are considering careers in cardiothoracic (CT) surgery. In an effort to identify areas for programmatic improvement, we examined trends in thoracic surgery residents' perspectives on training and employment. METHODS: Results from the 2010 Thoracic Surgery Residents Association workforce survey were analyzed. The survey was administered to all trainees in North America during the annual in-service exam. Longitudinal trends from 2006 to 2010 are reported. RESULTS: Of 299 respondents, 76% (228 of 299) were US citizens. The most common determinants in choosing CT surgery were types of cases (123 of 299, 41%) and mentorship (95 of 299, 32%). Sixty-five percent (193 of 299) would recommend CT surgery to potential trainees. While 81% (242 of 299) felt they would be adequately trained in their program, 39% (118 of 299) planned additional fellowship training. Only 23% (70 of 299) felt the 80-hour work week had a positive impact on training. Of residents seeking jobs, 68% (62 of 92) received 2 or more job interviews and 70% (69 of 99) more than 1 job offer. Seventeen percent (16 of 92) had no offers. While 45% (51 of 114) reported still searching for employment, 20% (23 of 114) had accepted private practice positions, 25% (29 of 114) academic positions, and 6% (7 of 114) fellowship positions. Education-related debt was greater than $100,000 in 46% (140 of 299) and greater than $200,000 in 17% (52 of 299). From 2007 to 2010, CT residents reporting debt greater than $200,000 rose from 8% to 17%. Accepted fellowship training positions dropped to 6% in 2010 compared with 13% and 15% in 2008 and 2009, respectively. CONCLUSIONS: Diminished CT job opportunities remain a concern. There are concerning trends in debt accrual and perceptions of work-hour restrictions on quality of training. These data justify further investigation into areas of improvement in CT training.

The ventriculo-gallbladder shunt in the treatment of refractory hydrocephalus: a review of the current literature.

The ventriculo-gallbladder (VGB) shunt has been reported on several occasions for the alleviation of ventriculo-peritoneal (VP) -shunt-refractory hydrocephalus. There is little data regarding VGB shunts and a need for delineating appropriate surgical therapy when cerebrospinal fluid drainage to the peritoneum becomes infeasible. We report our experience with VGB shunt placement in three patients with chronic hydrocephalus. All three had a history of prior VP-shunt placements and revisions due to distal obstruction or infection, or contraindications to alternative forms of ventricular drainage. In one patient, the VGB shunt functioned well for 9 years but was revised due to contamination during an unrelated operation. Neither of the other two patients have experienced VGB shunt-related complications. VP shunts are presently regarded as the standard of care for uncomplicated hydrocephalus. When VP shunts fail, the most common alternatives have been ventriculo-atrial and ventriculo-pleural shunts. In five case series involving 59 patients with VGB shunts, the long-term success rate was 62.7 per cent. Infection (10.2%) and obstruction (10.2%) were the most common complications. Based on durability and a low incidence of complications, it is the current consensus that VGB shunts are a viable alternative with good outcomes in the case of failed VP shunts.

Elective hypothermic circulatory arrest to address aortic pathology is safe for the elderly.

BACKGROUND: Due to assumptions of excessive risk, hypothermic circulatory arrest (HCA) has been considered prohibitive in elderly patients. However, as more elderly patients are referred for assessment of difficult aortic valve, ascending aorta, and aortic arch pathology, the risk of HCA in these patients needs to be addressed. We hypothesized that the use of HCA would not increase mortality or complications in elderly patients compared to younger counterparts. METHODS: We retrospectively reviewed the charts of adult patients who underwent elective HCA between January 1995 and June 2007. Of 147 procedures, 45 patients were >or=75 years old. These patients were compared to their younger counterparts in terms of comorbidities, operations, and complications. RESULTS: Comparing patients >or=75 years old to their younger counterparts revealed no significant differences in outcomes including nearly identical rates of confusion (>or=75 15% vs <75 9%, p > 0.5) and stroke (>or=75 11% vs <75 7%, p > 0.2). There was also no difference in 30-day mortality (>or=75 7% vs <75 7%, p = 0.9). Lengths of hospital stays and intensive care unit stays were longer in the older patients, but this was not statistically significant. CONCLUSION: In this study, elderly patients faired well with HCA compared to younger patients. These data suggest that the use of HCA is safe in selected elderly patients. Elderly patients should be considered for indicated procedures of the aortic valve, ascending aorta, and aortic arch regardless of age.

Replacement of the proximal aorta adds no further risk to aortic valve procedures.

BACKGROUND: Aortic valve pathology is often associated with proximal aortic dilatation. Even after valve surgery, the proximal aorta can continue to dilate and thus be at risk for rupture, dissection, or later aortic replacement. We hypothesized that the addition of proximal aortic intervention adds no further risk to aortic valve surgery, which may avoid subsequent proximal aortic procedures or catastrophes. METHODS: Between 1996 and 2004, 430 aortic valve interventions alone and 146 aortic valves with proximal aortic replacements were identified in elective adult patients. The age in the valve-alone patients (68.8 years) was slightly higher than the valve-plus-aorta group (valve/aorta, 60.5 years; p < 0.01), but comorbidities were similar between groups. We compared groups based on hospital mortality and incidence of complications. RESULTS: The 30-day mortality was similar between groups (valve-alone, 3.8% versus valve/aorta, 2.7%; p = 0.5), as were rates for bleeding and operative revision (valve-alone, 6.7% versus valve/aorta, 9.5%; p = 0.5). Pulmonary (valve-alone, 23.0% versus valve/aorta, 11.6%) and renal complications (valve-alone, 8.2% versus valve/aorta, 2.7%) were higher in the valve-alone group (p = 0.02). Logistic regression demonstrated no additional risk of death, neurologic, or cardiac event with replacement of the proximal aorta. CONCLUSIONS: Proximal aortic replacement adds no risk to the patient beyond the aortic valve intervention alone. These findings suggest proximal aortic replacement is safe for patients undergoing valve operations. Patients with a moderately enlarged proximal aorta that may dilate further should also be considered for aortic replacement at the time of valve procedures.

Central cannulation is safe in acute aortic dissection repair.

OBJECTIVE: The site of cannulation for the repair of ascending aortic dissection remains controversial. It is not clear whether cannulation of the dissected vessel is safe or even preferred. We hypothesized that cannulation of the dissected aorta could be done safely with acceptable complication and mortality rates in this high-risk population. METHODS: The charts of repairs of acute ascending aortic dissections (n = 70) from 1996 to 2005 were reviewed. Cannulation was accomplished in 24 patients via the dissected aorta (central) and in 46 patients through cannulation of the femoral or axillary artery (peripheral). All were converted to sidearm cannulation of the graft for reperfusion. Groups were compared on the basis of comorbidities in addition to mortality, complications, hospital stays and final disposition. RESULTS: The groups were comparable on the basis of age and preoperative comorbidities. Similarly, there were no differences in bypass time, crossclamp time, or hypothermic circulatory arrest time between groups. Hospital mortality and postoperative complications, including stroke, were similar between groups, but the peripheral group experienced more cardiac events (peripheral 15% vs central 0%; P < .05) and higher mortality than the central group (peripheral 19.5% vs central 4.2%; P < .05). CONCLUSIONS: Direct cannulation of the dissected aorta was safe compared with peripheral cannulation in these patients. Inasmuch as these data demonstrate that cannulation of the dissected ascending aorta is safe, this technique can be used to tailor the cannulation approach to specific anatomic and patient characteristics that might optimize postoperative outcomes in this disease entity.

Attenuation of lung reperfusion injury by modified ventilation and reperfusion techniques.

BACKGROUND: High ventilation and perfusion pressures after lung transplantation may have deleterious effects. We hypothesized that using combined protective approaches for ventilation and perfusion would be optimal for reducing injury and improving function after ischemia-reperfusion. METHODS: Using an isolated, blood-perfused, rabbit lung model, lungs underwent 120 minutes of reperfusion either immediately (Sham) or after 18 hours of cold ischemia (IR). Groups Sham-P and IR-P underwent protective ventilation and reperfusion, and Groups Sham-C and IR-C underwent conventional ventilation and reperfusion. Protective ventilation involved gradually increasing the flow rate during 5 minutes to 1.8 liters/min, and conventional ventilation entailed immediate initiation of flow at 1.8 liters/min. Protective reperfusion involved gradually increasing perfusion during 5 minutes to 60 ml/min, and conventional reperfusion entailed immediate perfusion at 60 ml/min. Two other groups underwent either protective ventilation with conventional perfusion or vice versa. Airway pressure, pulmonary artery pressure, and arterial blood gases were measured throughout reperfusion. Wet/dry weight, highest oxygenation index, and bronchoalveolar lavage (BAL) protein were also measured. RESULTS: Protective ventilation and perfusion after ischemia (IR-P) resulted in significant improvements in lung function as measured by increased Po(2) and decreased Pco(2), airway pressure, and highest oxygenation index compared with conventional reperfusion (IR-C). Injury was significantly reduced in IR-P lungs as measured by reduced edema (wet/dry weight) and vascular leakage (BAL protein). In most cases, IR-P lungs performed better, with less injury than protective ventilation or perfusion alone. CONCLUSIONS: This protective approach of ventilation and perfusion after ischemia may improve lung function after transplantation, a simple method that could easily be applied clinically.

Early repair of complete atrioventricular septal defect is safe and effective.

BACKGROUND: Surgical repair of complete atrioventricular septal defect (CAVSD) is a well-established procedure performed on young children. Our hypothesis is that with modern techniques, the current risks of CAVSD repair in children aged younger than 3 months and in children older than 3 months are equal. METHODS: This was a retrospective review of 65 infants and children with a mean age of 10.9 months (range, 1 month to 15.5 years) who underwent CAVSD repair from 1990 to 2004. Twenty-six repairs (40%) were done on or before 3 months of age (group A) and 39 repairs (60%) were done after 3 months of age (group B). In all patients, the ventricular septal defect was repaired with an individualized approach according to each patient's specific anatomy: direct suturing without a patch, interposition of a small pericardial patch with a running suture, or both. The atrioventricular commissure was closed with interrupted sutures, and all atrial defects were closed with a pericardial patch. Data were analyzed using the chi2 analysis and the Fisher exact test. RESULTS: Three hospital deaths occurred (<30 days), 2 in group A and 1 in group B (7.7% vs 2.6%, respectively, p = 0.33). One death in group A occurred during another noncardiac surgery. Early reoperation (<1 year of initial surgery) for residual ventricular septal defect or significant mitral regurgitation, or both, occurred in 3 group A patients and in 4 group B patients (11.5% versus 10.3% respectively, p = 0.68). CONCLUSIONS: These results suggest that repair of CAVSD defects in children 3 months of age or younger had similar outcomes compared with those who underwent surgical repair after 3 months of age.