The Effects of Endotracheal Tube Size During Bronchoscopy in Simulated Models of Intubated Patients.

OBJECTIVE: The aim is to use a simulation lung model to assess the possibility of performing bronchoscopy through endotracheal tubes (ETT) less than 8.0-mm while appropriately ventilating patients with normal and ARDS lungs in the setting of SARS-CoV-2. METHODS: Five SHERIDAN® ETTs were used to ventilate SimMan® 3G under respiratory compliance levels representing normal and severe ARDS lungs. Baseline measurements of peak pressure, plateau pressure, and auto-positive end expiratory pressure (auto-PEEP) were recorded at four different inspiratory times (Ti). Three different-sized disposable bronchoscopes were inserted, and all measurements were repeated. RESULTS: Normal lung model: Slim bronchoscopes in 6.0-mm ETTs resulted in plateau pressures <30 cm H2 O, and increasing Ti to minimize peak pressure resulted in low auto-PEEP. Regular bronchoscopes in 7.0-mm ETTs had similar results. Large bronchoscopes in 7.5-mm ETTs generated plateau pressures ranging from 28 to 35 cm H2 O with modest auto-PEEP. Severe ARDS lung model: Slim bronchoscopes in 6.0-mm ETTs resulted in plateau pressures of 46 and an auto-PEEP of 5 cm H2 O. Regular bronchoscopes in 7.0-mm ETTs generated similar results. Large bronchoscopes in 8.0-mm ETTs displayed plateau pressures of 44 and an auto-PEEP of 2 cm H2 O. CONCLUSION: To mitigate risk of laryngeal injury, larger ETTs during bronchoscopy should be avoided. Our data show bronchoscopy with any ETT causes auto-PEEP and high plateau pressures, especially in lungs with poor compliance; however, ETT less than 7.5 mm can be used when considering several factors. Our data also suggest similar studies in patients with varying degrees of ARDS would be informative. LEVEL OF EVIDENCE: NA Laryngoscope, 133:147-153, 2023.

Valve-Sparing Root Replacement Versus Bio-Bentall: Inverse Propensity Weighting of 796 Patients.

BACKGROUND: This large cohort, single-center study compared the 10-year survival and freedom from aortic valve reintervention between valve-sparing root replacement (VSRR) and bioprosthetic Bentall (bio-Bentall). METHODS: All patients undergoing elective VSRR or bio-Bentall for aortic root aneurysm between March 2005 through October 2019 were retrospectively reviewed (N = 796; n = 360 for VSRR). Inverse probability of treatment weighting (IPTW) balanced clinical variables between groups. Mean follow-up was 58.0 ± 45.4 months (range, 0-167 months). RESULTS: After IPTW adjustment, 10-year survival did not differ between VSRR (87.0%) and bio-Bentall (92.7%, P = 0.780). Cumulative incidence of aortic valve reintervention was 5.9% for VSRR (95% confidence interval [CI], 2.9%-10.4%) and 10.6% for bio-Bentall (95% CI, 6.2%-16.4%; P = .798). A Fine and Gray competing risk regression model identified age at operation (subdistribution hazard ratio [sHR], 0.97; 95% CI, 0.95-0.99; P = .015), body surface area (sHR, 6.21; 95% CI, 1.97-19.59; P = .002), and bicuspid aortic valve (sHR, 2.15; 95% CI, 1.04-4.44; P = .038) as independently associated with aortic valve reintervention. For patients aged 50 years or younger, the cumulative incidence of aortic valve reintervention was 16.2% for VSRR (95% CI, 7.0%-28.8%) and 17.8% for bio-Bentall (95% CI, 6.9%-32.8%; P = .363). CONCLUSIONS: VSRR and bio-Bentall show similar excellent survival and freedom from aortic reintervention rates up to 10 years; however, a durable valve solution for young patients with bicuspid aortic valve remains a challenge.

Race in Rhinology Clinical Trials: A Decade of Disparity.

OBJECTIVE/HYPOTHESIS: The aim of this study is to assess the ethnic and racial demographics of patients enrolled in prospective chronic rhinosinusitis (CRS) studies relative to the corresponding geographic demographics of the United States (U.S.) census data. STUDY DESIGN: Systematic Review and Population analysis. METHODS: A systematic review was performed to identify CRS clinical trials, conducted in the U.S. and published between 2010 and 2020 in which patients were prospectively enrolled. Pooled racial and ethnicity data were compared to national and corresponding regional census data. RESULTS: Eighty-three studies were included, comprising 12,027 patients. 50.4% were male and the average age was 49.2 years. 8,810 patients underwent a surgical procedure. Of the 12,027 patients, 81.67% were identified as White, 5.35% as Black, 1.27% as Asian, 0.02% as Pacific Islander, 0.12% as American Indian, and 11.57% were classified as Other. The racial and ethnic composition of the pooled study population differs significantly from the national U.S. census data with the underrepresentation of each minority population (P ≤ .0002). Regional sub-analyses yield variable results. In the Northeast and West, there was an underrepresentation of all minority populations. In the South and Midwest, Black enrollment was similar to the U.S. census data, while all other minorities were underrepresented. CONCLUSIONS: The racial and ethnic composition of patients enrolled in prospective CRS clinical trials differs significantly from the demographics of the U.S. POPULATION: The generalizability and external validity of findings derived from studies comprised of demographically mismatched populations has not been established. Future efforts to enroll more representative populations should be emphasized by the research community, funding bodies, and editorial boards. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1722-1728, 2021.

Chronic kidney disease stage stratifies short- and long-term outcomes after aortic root replacement.

OBJECTIVES: Chronic kidney disease (CKD) is prevalent in patients undergoing cardiovascular surgery, and it negatively impacts procedural outcomes; however, its influence on the outcomes of aortic surgery has not been well studied. This study aims to elucidate the importance of CKD on the outcomes of aortic root replacement (ARR). METHODS: Patients who underwent ARR between 2005 and 2019 were retrospectively reviewed (n = 882). Patients were divided into 3 groups based on the Kidney Disease: Improving Global Outcomes criteria: Group 1 [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m2, n = 421); Group 2 (eGFR = 30-59 ml/min/1.73 m2, n = 424); and Group 3 (eGFR < 30 ml/min/1.73 m2, n = 37). To reduce potential confounding, a propensity score matching was also performed between Group 1 and the combined group of Group 2 and Group 3. The primary end point was 10-year survival. Secondary end points were in-hospital mortality and perioperative morbidity. RESULTS: Severe CKD patients presented with more advanced overall chronic and acute illnesses. Kaplan-Meier analysis showed a significant correlation between CKD stage and 10-year survival (log-rank P < 0.001). The number of events for Group 1 was 15, Group 2 was 49 and Group 3 was 11 in 10 years. Group 3 had significantly higher in-hospital mortality (13.5% vs 3.5% in Group 2 vs 0.7% in Group 1, P < 0.001) and stroke (8.1% vs 7.1% vs 1.2%, P < 0.001) as well as introduction to new dialysis (27.0% vs 5.4% vs 1.7%, P < 0.001). eGFR was shown to be an independent predictor of mortality (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99). Comparison between propensity matched groups showed similar postoperative outcomes, and eGFR was still identified as a predictor of mortality (hazard ratio, 0.97; 95% confidence interval, 0.95-0.99). CONCLUSIONS: Higher stage in CKD negatively impacts the long-term survival in patients who are undergoing ARR.

Sex-related difference in outcomes after aortic root replacement.

PURPOSE: Poorer short-term outcomes have been described for females after cardiovascular surgery. We examined the influence of sex on the outcomes after aortic root replacement (ARR). METHODS: Medical records of 848 patients (females, n = 159/848, 19%) who underwent ARR at our center from 2005 to 2018 were retrospectively reviewed. Sex differences of the following outcomes were analyzed: the primary end point (in-hospital mortality or stro111ke), secondary end point (new requirement for permanent pacemaker), and long-term survival (median follow-up 21.4 months [interquartile range,1.3-60.0]). RESULTS: Females were significantly older (61.3 vs 58.7 [male]) with higher rates of pre-existing cerebrovascular disease (14% [22/159] vs 7% [52/689]) and previous valve intervention (20% [32/159] vs 13% [89/689]) but less myocardial infarction [1%(1/159) vs 7%(48/689)]. The surgical indication was different (aneurysm 75% [120/159] vs 87% [602/689], dissection 13% [21/159] vs 6% [41/689]; P < .01]). Females had larger average aneurysm size after controlling for body size (P ≤ .001). There was no sex difference in in-hospital mortality (3% [5/159] vs 2% [16/689]) or stroke (4% [7/159] vs 4% [29/689]). Multivariable logistic regression indicated that female sex was not an independent predictor of combined in-hospital stroke or death (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.28-1.25), confirmed by propensity score analysis. There was no difference in long-term survival (5-year survival, 90.96% vs 93.03%; P = .44). Females had higher incidence of permanent pacemaker requirement [11% (18/159) vs 6% (39/689), P = .03] and female sex was an independent predictor of permanent pacemaker requirement (OR, 2.01; 95% CI, 1.085-3.724; P = .03). CONCLUSIONS: While female patients have different baseline characteristics and indication for ARR, they are not exposed to an increased risk of in-hospital mortality or stroke. However, females experience increased incidence of permanent pacemaker requirement.

Probability of Uneventful Recovery After Elective Aortic Root Replacement for Aortic Aneurysm.

BACKGROUND: Little is known about the chance of patients not experiencing complications (uneventful recovery) after aortic root replacement for aortic aneurysm. The aim of this study was to investigate the probability of uneventful recovery, identify its predictors, and address the association between the uneventful recovery and long-term survival. METHODS: Patients with aortic aneurysm who underwent elective aortic root replacement between 2005 and 2018 were retrospectively reviewed (N = 676). Uneventful recovery was defined as avoidance of all of the following complications during the index hospital stay (selected based on Cox proportional hazards regression for long-term survival): mortality, any stroke, reexploration for bleeding, respiratory failure, acute renal failure, deep sternal infection, and postcardiotomy shock. Permanent pacemaker implantation was included because of its clinical perspectives. Patients were divided into 4 different age groups (group <60 years of age, n = 299; group 60-69 years of age, n = 209; group 70-79 years of age, n = 125; group ≥80 years of age, n = 43), according to a restricted cubic spline analysis on in-hospital mortality and postoperative stroke. RESULTS: Uneventful recovery was 78.1%. The probability of uneventful recovery decreased in a linear fashion as the age increases (82.6% in the group <60 years of age, 79.0% in the group 60-69 years of age, 70.4% in the group 70-79 years of age, 65.1% in the group ≥80 years of age; P = .007). A multivariable logistic regression showed age, left ventricular ejection fraction, previous cardiac surgery, and peripheral artery disease were independent predictors of uneventful recovery. Uneventful recovery resulted in significantly better 5-year survival (log-rank P = .039). CONCLUSIONS: This study provides novel information regarding the probability of uneventful recovery while confirming low in-hospital mortality and stroke rates after elective aortic root replacement for aortic aneurysm. Importantly, uneventful recovery ensures excellent long-term survival.