Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

Minimally Invasive Mitral Valve Surgery I: Patient Selection, Evaluation, and Planning.

Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection.

Minimally Invasive Mitral Valve Surgery II: Surgical Technique and Postoperative Management.

Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery.

Minimally Invasive Mitral Valve Surgery III: Training and Robotic-Assisted Approaches.

Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program.

Surgical Resection of a Giant Coronary Aneurysm.

Coronary aneurysms are quite uncommon, and those qualifying as giant aneurysms are even more so. Currently, no standardized treatment protocol exists. We report the case of a 46-year-old man presenting with clinical signs and symptoms of acute myocardial infarction who was found to have a giant coronary aneurysm. The patient was initially evaluated with a computed tomography angiogram, which revealed a 9-cm aneurysm of the left circumflex coronary artery. Surgical resection of the aneurysm, ligation of the proximal circumflex artery, and bypass using the left internal mammary artery to vascularize the proximal circumflex artery was performed.

Right anterior thoracotomy aortic valve replacement is associated with less cost than sternotomy-based approaches: a multi-institution analysis of 'real world' data.

BACKGROUND: Large institutional analyses demonstrating outcomes of right anterior mini-thoracotomy (RAT) for isolated aortic valve replacement (isoAVR) do not exist. In this study, a group of cardiac surgeons who routinely perform minimally invasive isoAVR analyzed a cross-section of US hospital records in order to analyze outcomes of RAT as compared to sternotomy. METHODS: The Premier database was queried from 2007-2011 for clinical and cost data for patients undergoing isoAVR. This de-identified database contains billing, hospital cost, and coding data from >600 US facilities with information from >25 million inpatient discharges. Expert rules were developed to identify patients with RAT and those with any sternal incision (aStern). Propensity matching created groups adjusted for patient differences. The impact of surgical approach on outcomes and costs was modeled using regression analysis and, where indicated, adjusting for hospital size and geographical differences. RESULTS: AVR was performed in 27,051 patients. Analysis identified isoAVR by RAT (n = 1572) and by aStern (n = 3962). Propensity matching created two groups of 921 patients. RAT was more likely performed in southern hospitals (63% vs 36%; p < 0.01), teaching hospitals (66% vs 58%; p < 0.01) and larger hospitals (47% vs 30%; p < 0.01). There was significantly less blood product cost associated with RAT ($1381 vs $1912; p < 0.001). After adjusting for hospital differences, RAT was associated with lower cost than aStern ($38,769 vs $42,656; p < 0.01). CONCLUSIONS: Outcomes analyses can be performed from hospital administrative collective databases. This real world analysis demonstrates comparable outcomes and less cost and ICU time with RAT for AVR.

Update on cardiothoracic surgery resident job opportunities.

BACKGROUND: Concerns regarding ample employment opportunities for graduating cardiothoracic surgery residents may affect perceptions of the field and recruitment into residency programs. We present the results of the Thoracic Surgery Residents Association/Thoracic Surgery Directors Association (TSRA/TSDA) 2008 Resident Survey, and compare them with the 2007 TSRA/TSDA survey and the 2006 interim report of the Society of Thoracic Surgeons Task Force on Job Opportunities. METHODS: In April 2008, the TSRA/TSDA conducted an anonymous survey, linked to the cardiothoracic surgery resident online In-training Exam, with questions germane to resident job seeking and perceptions of the specialty. Results were compared with resident surveys from 2007 and 2006. RESULTS: Response rates for the 2008 and 2007 surveys were 100%, and 54.2% for 2006. Of graduating residents looking for employment, 61.6% had one or more job offers, compared with 64.6% and 83.5% from the 2007 and 2006 surveys, respectively. Of the respondents completing their job search, 24.5% entered private practice and 26.3% academia, compared with 12.1% and 30.1%, respectively, in the 2007 survey. Overall, 57.7% of all respondents had more than $50,000 education-related debt, compared with 54.2% of 2007 respondents. However, 71.5% of all 2008 respondents would recommend cardiothoracic surgery to a potential trainee, compared with 63.7% and 46.0% from 2007 and 2006 survey respondents, respectively. CONCLUSIONS: The 2008 survey suggests that although the majority of respondents found employment on completing residency, the percentage is less than 65%, reinforcing a need for formal networking programs or changes in residency training. Despite continued limited employment opportunities, resident impressions of cardiothoracic surgery have improved from 2006 to 2008.

Absence of correlation between symptoms and rhythm in "symptomatic" atrial fibrillation.

BACKGROUND: Symptoms are widely used as a means of assessment and follow-up of patients with atrial fibrillation. This study assessed the correlation between symptoms and cardiac rhythm in patients being evaluated for operative therapy for atrial fibrillation. METHODS: Seven days of preoperative continuous outpatient home electrocardiographic monitoring was performed on 50 patients with symptomatic atrial fibrillation. Cardiac rhythm was continuously monitored automatically, while patients recorded their symptoms electronically. Correlations were then drawn between symptomatic events and actual rhythm, and between atrial fibrillation episodes and symptoms. RESULTS: Fifty patients (37 men) with symptomatic atrial fibrillation were monitored for a combined 356 days (mean, 7.1 days). Patients were average age of 69 years old. Intermittent atrial fibrillation was reported by 36 patients, and 14 believed their atrial fibrillation was continuous. During monitoring, all patients had periods of both atrial fibrillation and normal sinus rhythm. Of the 552 documented episodes of atrial fibrillation, 467 (85%) were asymptomatic, and 85 (15%) episodes were symptomatic. Patients indicated that they experienced atrial fibrillation symptoms 163 times. Of the 163 symptomatic events, 85 (52%) were actual atrial fibrillation, 64 (42%) were sinus rhythm, and 14 (6%) were other rhythms. The ability of an individual patient to accurately identify atrial fibrillation ranged from 0% to 100%. CONCLUSIONS: Patient-reported symptoms of atrial fibrillation had poor correlation with actual rhythm. The lack of correlation between symptoms and rhythm underscores the importance of continuous home monitoring for accurately quantifying preoperative atrial fibrillation burden and for postoperative follow-up.

Intraoperative epicardial electrophysiologic mapping and isolation of autonomic ganglionic plexi.

BACKGROUND: Autonomic ganglionic plexi (GPs) have been implicated as triggers in lone atrial fibrillation (AF). The purpose of this study was to describe the technique and results of epicardial electrophysiologic mapping and the early effects of GP isolation. METHODS: Intraoperative epicardial electrophysiologic mapping was performed on 41 consecutive patients during a stand-alone minimally invasive operation for AF. A map labeling anatomic locations was developed to describe the findings. Intraoperative high-frequency stimulation (800/minute, 12 to 16 mA, pulse duration 9.9 ms) was performed using a standard quadripolar catheter placed directly on the epicardium. Locations where stimulation resulted in ventricular slowing with doubling of the electrocardiographic R-R interval were defined as active GPs. These areas were mapped and described. After dry bipolar radiofrequency isolation, the sites were again stimulated to assess isolation. RESULTS: Forty-one patients (mean age of 60.2 years, 31 males) underwent operation for AF (28 intermittent AF, 13 chronic). Active GPs were identified in all patients (24 bilateral, 17 unilateral). There was a mean of 5.0 GPs on the right and 2.7 on the left. More than 50% of patients had active GPs along the interatrial groove on the right and along the ligament of Marshall. All sites were inactive after radiofrequency isolation. Six-month follow-up is available for 15 patients, with 14 patients free of AF. CONCLUSIONS: Autonomic GPs can be routinely identified during AF surgery utilizing high-frequency stimulation. The GPs are clustered around the interatrial groove and the ligament of Marshall, and the cardiac response to GP stimulation can be eliminated with bipolar radiofrequency isolation. The addition of GP isolation to bilateral pulmonary vein isolation may increase freedom from AF.

Impact of Preoperative 64-Slice CT Scanning on Mini-Maze Atrial Fibrillation Surgery.

BACKGROUND: : Multidetector computed tomography (MDCT) is emerging as a powerful noninvasive diagnostic tool. The appropriate role of this technique in the preoperative evaluation of cardiovascular disease has yet to be fully defined. Atrial fibrillation is the most common sustained cardiac arrhythmia, and novel minimally invasive surgical techniques have been developed to treat this condition by electrically isolating the pulmonary veins. The ideal methodology to preoperatively evaluate these patients remains debatable. We hypothesized that 64-slice CT could significantly affect perioperative planning. METHODS: : Thirty-six consecutive patients who consented to undergo minimally invasive pulmonary vein isolation at our institution underwent a preoperative 64-slice cardiac CT scan. All cardiac and noncardiac abnormalities were recorded, and modifications to the initial surgical plan were documented. RESULTS: : The mean patient age was 64.4 ± 11.9 years [26 men (72.2%), 17 with known coronary artery disease (47.2%)]. Preoperative CT scanning detected 12 patients with abnormal pulmonary venous anatomy (33.3%), 3 with left atrial thrombus (8.3%), and 17 with significant coronary artery disease (47.2%). Furthermore, 20 studies (55.6%) detected pulmonary abnormalities (including 11 nodules). Preoperative scanning significantly altered surgical planning in 10 cases (27.8%). Alterations in patient treatment included preoperative invasive angiography, conversion of the mini-maze to an open chest procedure, alteration of surgical approach, and postponement/cancellation. CONCLUSIONS: : Sixty-four-slice CT scanning is a safe, rapid, and accurate procedure with important ramifications for surgical planning. This methodology could become an alternative approach to screen preoperative cardiac surgical patients.

The influence of prior abdominal operations on conversion and complication rates in laparoscopic colorectal surgery.

BACKGROUND AND OBJECTIVES: A history of a prior abdominal operation is common among patients presenting for laparoscopic colorectal surgery, and its impact on conversion and complication rates has been insufficiently studied. This study compares the conversion rates of patients with and without a prior abdominal operation (PAO). METHODS: We analyzed 1000 consecutive laparoscopic colorectal resection cases. RESULTS: Complete data on past surgical history were available on 820 of 1000 patients. The overall conversion rate was 14.8% (122/820). A history of PAO was present in 347 patients (42.3%). These patients experienced a higher conversion rate compared with non-PAO patients (68/347, 19.6% versus 54/473, 11.4%; P < 0.001; OR 1.9). Patients with PAO had a significantly higher rate of inadvertent enterotomy (5/347, 1.4% vs. 1/473, 0.2%; P = 0.04; OR 6.9), a higher incidence of postoperative ileus (23/347, 6.6% vs 14/473% 3.0; P = 0.012; OR 2.3), and higher reoperative rates (8/347, 2.3% vs 1/473, 0.2%; P = 0.006; OR 11.1). The incidence of other complications and mortality (total 6/820, 0.7%) was similar regardless of PAO status. CONCLUSION: Having a prior abdominal operation represents a risk factor for conversion in laparoscopic colon and rectal surgery. The incidence of a successfully completed laparoscopic operation, however, remains high in previously operated on patients.

Enoxaparin inhibits fibrin sheath formation and decreases central venous catheter colonization following bacteremic challenge.

OBJECTIVE: Inhibition of fibrin sheath formation by enoxaparin decreases catheter colonization. Fibrin-binding radioactive tracer and catheter weights quantify fibrin reduction. DESIGN: Controlled experimental study of central venous line colonization. SETTING: Animal laboratory. SUBJECTS: Adult male Sprague-Dawley rats. INTERVENTIONS: Central venous lines were introduced into right external jugular veins of 254 animals in three groups: enoxaparin, Fibrimage, and catheter weight. The enoxaparin group (n = 196) received daily enoxaparin injections (n = 97) or catheter implantation only (n = 99); 176 received tail vein injections of Staphylococcus epidermidis on postoperative day (POD) 10. Twenty rats received saline injections as a control. On POD 13, catheters were removed and incubated in broth at 37 degrees C for 48 hrs. Turbid samples were plated. In the Fibrimage group (n = 39), 20 rats receiving enoxaparin were compared with 19 controls without enoxaparin; all received S. epidermidis injections on POD 10. Fibrimage, fibrin-binding radiolabeled tracer, was given 1 hr before catheter removal. In the weight group (n = 19), six rats received enoxaparin; 13 did not. All received injections of S. epidermidis on POD 10. MEASUREMENTS AND MAIN RESULTS: Positive plates underwent analytic profile index testing, ensuring correlation with inoculum. Results were compared using Fisher's exact or chi-square tests. Gamma counts were determined in the Fibrimage group. Catheter tip weights were recorded. Results from the Fibrimage and weight groups were compared using Student's t-test. The enoxaparin group had fewer catheters colonized (17 of 77) vs. no enoxaparin (42 of 99; p < .01). Pericatheter sheaths contained less fibrin compared with controls. Fibrimage group gamma counts were significantly decreased for the enoxaparin subgroup (x = 2244 counts per minute) vs. controls (x = 3767 counts per minute; p < .0002). The weight of catheter tips treated with enoxaparin (x = 39 mg) vs. controls (x = 90 mg) was also significantly decreased (p < .0001). CONCLUSIONS: Enoxaparin decreases the amount of fibrin surrounding central venous catheters. The incidence of catheter colonization decreases when the amount of fibrin within the pericatheter sheath decreases.

Comparing results of residents and attending surgeons to determine whether laparoscopic colectomy is safe.

BACKGROUND: This study was undertaken to compare the technical success and outcomes of laparoscopic colectomy performed by resident surgeons (RS) and attending surgeons (AS). METHODS: A review of 451 consecutive laparoscopic colectomies performed by 2 surgeons either with or without a general surgery resident. Data reviewed included demographics, diagnoses, operative data, and outcomes. Comparison was made between patients operated on by RS under attending surgeon supervision, and patients operated on by AS alone. RESULTS: Of 451 patients, 324 were operated on by RS and 127 by AS. The mean age and preoperative diagnoses were similar between groups. Operative time was significantly longer in the RS group (155 minutes vs. 128 minutes, P < .05). Blood loss was slightly higher in RS groups but was not statistically significant (191 mL vs. 174 mL, P = .31). The incidence of conversion to an open procedure, postoperative complications, and length of stay were similar between groups. CONCLUSIONS: Supervised RS can safely perform laparoscopic colectomy with results similar to AS. RS take longer to perform the procedure than AS.

How do general surgery replacement residents match up with those recruited through the National Resident Matching Program?

BACKGROUND: Although the scope and patterns of attrition of general surgery residents have been reported, no study has examined the residents who replaced them. The purpose of this study was to assess the quality of replacement residents (RRs). METHODS: A questionnaire asked program directors (PDs) about the prevalence, characteristics, and disposition of RRs in general surgery residency programs from 2001 to 2002. RESULTS: PDs from 169 programs (67%) responded, and 109 (64%) of these programs had RRs. Of 244 RRs (7%), 18 (7%) were postgraduate year (PGY)-1 residents; 64 (26%) were PGY-2 residents; 77 (32%) were PGY-3 residents; 52 (21%) were PGY-4 residents; and 33 (14%) were PGY-5 residents. RRs averaged 1.9 years in their programs. One hundred seventy-five (72%) came from outside the current institution, and 142 had (58%) graduated from U.S. medical schools. PDs judged RRs to be superior (20%), comparable (55%), or inferior (25%) to their peers. Neither internal recruitment nor United States medical school graduation predicted performance. Disposition included promotion and graduation (88%), leaving the program voluntarily (5%), repeating the year (4%), and dismissal (3%). Successful RR performance occurred in 71% of RRs. CONCLUSIONS: Typically, RRs were U.S. medical school graduates, were recruited from outside the institution, and have performed satisfactorily.

Management of typical and atypical intestinal malrotation.

BACKGROUND: "Atypical Malrotation" has been increasingly diagnosed at the authors' institution. METHODS: The authors reviewed retrospectively 201 consecutive operations for malrotation over 5 years to anatomically classify, and describe results of operation for, atypical malrotation. The ligament of Treitz (LOT) was classified as high if left of midline and above the 12th thoracic vertebra, low if left of midline and below the 12th thoracic vertebra, and typical if absent or right of midline. RESULTS: A total of 201 patients underwent operation for malrotation, in 176 there were adequate radiologic studies to allow classification of the LOT. Typical malrotation was present in 75 patients, low LOT in 56, and a high LOT in 45. Volvulus was more common in the Typical group compared with the other 2 groups (12 of 75 v 1 of 56 low; 1 of 45 high; P <.05) as were internal hernias (18 of 75 v 6 of 56 low, 1 of 45 high; P <.05). Complications occurred in 13% of typical versus 22% low and 21% of high patients (P =.10). Low and high LOT patients had 13% and 11% incidence of persistent symptoms postoperatively versus 0% of typical patients. CONCLUSION: Atypical malrotation patients are at significantly lower risk of volvulus and internal hernia compared with typical malrotation patients, and operation appears to come with increased morbidity.

Prospective study of the incidence and complications of bacterial contamination of enteral feeding in neonates.

PURPOSE: The goal of this study was to determine incidence of, and complications resulting from, bacterial contamination of enteral feedings in neonates. METHODS: A prospective study of 50 tube-fed neonates was conducted. Infants were bolus fed via an open gravity drained system; demographic and clinical data were gathered. The lumen of the tube was cultured quantitatively after 7 days. All organisms were isolated, identified, frozen, and stored to correlate with clinical cultures. RESULTS: The 50 neonates were fed for a mean of 17.6 days each and represent 125 patient weeks (1 tube per patient per week). A total of 71 of 125 tubes were "contaminated" (>1,000 colony forming units [CFU]/mL), with a mean 908,173 CFU and 3 different bacteria types. Among formula-fed infants, feeding intolerance occurred in 24 of 32 weeks with contaminated tubes versus 0 of 44 weeks with noncontaminated tubes (P <.05). Contamination occurred in 41 of 48 weeks in patients on H2 antagonists versus 32 of 66 weeks in patients with normal gastric acidity (P <.05). Necrotizing enterocolitis developed in 7 patients; all were fed formula contaminated with greater than 100,000 CFU/mL of Gram-negative bacteria. Four required operation; intraoperative cultures found the same organism as cultured previously in the tube in all 4 infants. CONCLUSION: Bacterial contamination of enteral feeding occurs frequently, causes significant feeding intolerance, and may contribute to NEC.

Acidification of formula with citric acid is equally effective and better tolerated than acidification with hydrochloric acid.

OBJECTIVE: To determine whether acidification of formula with citric acid is equally protective against bacterial translocation and gut colonization but better tolerated than acidification with hydrochloric acid in neonatal rabbits. DESIGN: Paired animal model with control. SETTING: Animal laboratory. SUBJECTS: Premature neonatal New Zealand rabbit pups. INTERVENTIONS: A standard neonatal rabbit model in two versions, a bacterial challenge and a no bacterial challenge model, was used to assess bacterial translocation and gut colonization. Two hundred forty-six rabbit pups were delivered by cesarean section 1 day premature and randomly placed into two groups sorted by type of formula acidification (hydrochloric acid or citric acid). Pups were gavage fed pH 3 kitten formula every 12 hrs. Ranitidine hydrochloride at 20 mg x kg(-1) x day(-1) was added to all formula. Bacterial challenge animals were given 1 x 10(6) colony-forming units/mL of Enterobacter cloacae with the third feeding. Animals in the no bacterial challenge group received no bacterial challenge. Animals were killed on day of life 3, and the liver, spleen, mesenteric lymph nodes, and cecum were sequentially harvested and cultured. Organs were qualitatively judged for growth, whereas cecal cultures were quantified as colony-forming units/gram. Stomach biopsies were performed to look for mucosal damage. Long-term tolerance was assessed in 48 pups fed formula acidified to pH 3 with either hydrochloric acid or citric acid and 20 animals fed pH 7 formula without ranitidine. Weight gain and mortality rate were followed for 14 days. MEASUREMENTS AND MAIN RESULTS: Gut colonization and bacterial translocation to liver, spleen, and mesenteric lymph nodes were equivalent between citric acid and hydrochloric acid in both bacterial challenge and no bacterial challenge models. Long term, citric acid animals exceeded hydrochloric acid animals in daily weight gain and survival (p <.05 for both) and equaled pH 7 animals in these measurements. CONCLUSION: Acidification of formula with citric acid is equally protective against bacteria but better tolerated than acidification with hydrochloric acid.

Enteral feeding tubes are a reservoir for nosocomial antibiotic-resistant pathogens.

BACKGROUND: Patients and their surroundings are known reservoirs for nosocomial pathogens. Enteral feeding tubes and formula are not thought of as reservoirs for nosocomial organisms. METHODS: A prospective observation study was conducted comparing methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) cultured from nosocomial infections and MRSA/VRE cultured from enteral feeding tubes used in the same neonatal intensive care unit during the same time period but in different babies. DNA fingerprinting then was used to compare MRSA and VRE cultured from feeding tubes with MRSA/VRE isolates cultured from clinical infections. RESULTS: There were 23 S aureus isolates; 12 of 23 were methicillin resistant (MRSA). There were 4 MRSA infections in patients without feeding tubes. DNA fingerprinting showed that the MRSA species causing each of the clinical infections also was found in the feeding tubes of other babies. There were no vancomycin-resistant Enterococcus infections during the study period. CONCLUSION: Feeding tubes are a reservoir for antibioticresistant pathogens that can be transmitted to other infants.