Concomitant Tricuspid Repair in Patients with Degenerative Mitral Regurgitation.

BACKGROUND: Tricuspid regurgitation is common in patients with severe degenerative mitral regurgitation. However, the evidence base is insufficient to inform a decision about whether to perform tricuspid-valve repair during mitral-valve surgery in patients who have moderate tricuspid regurgitation or less-than-moderate regurgitation with annular dilatation. METHODS: We randomly assigned 401 patients who were undergoing mitral-valve surgery for degenerative mitral regurgitation to receive a procedure with or without tricuspid annuloplasty (TA). The primary 2-year end point was a composite of reoperation for tricuspid regurgitation, progression of tricuspid regurgitation by two grades from baseline or the presence of severe tricuspid regurgitation, or death. RESULTS: Patients who underwent mitral-valve surgery plus TA had fewer primary-end-point events than those who underwent mitral-valve surgery alone (3.9% vs. 10.2%) (relative risk, 0.37; 95% confidence interval [CI], 0.16 to 0.86; P = 0.02). Two-year mortality was 3.2% in the surgery-plus-TA group and 4.5% in the surgery-alone group (relative risk, 0.69; 95% CI, 0.25 to 1.88). The 2-year prevalence of progression of tricuspid regurgitation was lower in the surgery-plus-TA group than in the surgery-alone group (0.6% vs. 6.1%; relative risk, 0.09; 95% CI, 0.01 to 0.69). The frequencies of major adverse cardiac and cerebrovascular events, functional status, and quality of life were similar in the two groups at 2 years, although the incidence of permanent pacemaker implantation was higher in the surgery-plus-TA group than in the surgery-alone group (14.1% vs. 2.5%; rate ratio, 5.75; 95% CI, 2.27 to 14.60). CONCLUSIONS: Among patients undergoing mitral-valve surgery, those who also received TA had a lower incidence of a primary-end-point event than those who underwent mitral-valve surgery alone at 2 years, a reduction that was driven by less frequent progression to severe tricuspid regurgitation. Tricuspid repair resulted in more frequent permanent pacemaker implantation. Whether reduced progression of tricuspid regurgitation results in long-term clinical benefit can be determined only with longer follow-up. (Funded by the National Heart, Lung, and Blood Institute and the German Center for Cardiovascular Research; ClinicalTrials.gov number, NCT02675244.).

Transcatheter heart valve explant with infective endocarditis-associated prosthesis failure and outcomes: the EXPLANT-TAVR international registry.

BACKGROUND AND AIMS: Surgical explantation of transcatheter heart valves (THVs) is rapidly increasing, but there are limited data on patients with THV-associated infective endocarditis (IE). This study aims to assess the outcomes of patients undergoing THV explant for IE. METHODS: All patients who underwent THV explant between 2011 and 2022 from 44 sites in the EXPLANT-TAVR registry were identified. Patients with IE as the reason for THV explant were compared to those with other mechanisms of bioprosthetic valve dysfunction (BVD). RESULTS: A total of 372 patients from the EXPLANT-TAVR registry were included. Among them, 184 (49.5%) patients underwent THV explant due to IE and 188 (50.5%) patients due to BVD. At the index transcatheter aortic valve replacement, patients undergoing THV explant for IE were older (74.3 ± 8.6 vs. 71 ± 10.6 years) and had a lower Society of Thoracic Surgeons risk score [2.6% (1.8-5.0) vs. 3.3% (2.1-5.6), P = .029] compared to patients with BVD. Compared to BVD, IE patients had longer intensive care unit and hospital stays (P < .05) and higher stroke rates at 30 days (8.6% vs. 2.9%, P = .032) and 1 year (16.2% vs. 5.2%, P = .010). Adjusted in-hospital, 30-day, and 1-year mortality was 12.1%, 16.1%, and 33.8%, respectively, for the entire cohort, with no significant differences between groups. Although mortality was numerically higher in IE patients 3 years postsurgery (29.6% for BVD vs. 43.9% for IE), Kaplan-Meier analysis showed no significant differences between groups (P = .16). CONCLUSIONS: In the EXPLANT-TAVR registry, patients undergoing THV explant for IE had higher 30-day and 1-year stroke rates and longer intensive care unit and hospital stays. Moreover, patients undergoing THV explant for IE had a higher 3-year mortality rate, which did not reach statistical significance given the relatively small sample size of this unique cohort and the reduced number of events.

Trends of Medicare Reimbursement Rates for Gender-Affirming Surgery Procedures.

BACKGROUND: Awareness of Medicare reimbursement is important for gender-affirming surgeons who treat transgender patients with Medicare. In 2014, Medicare began to provide coverage for medically necessary transition-related surgery. The purpose of this study was to analyze trends in Medicare reimbursement rates for gender-affirming surgery procedures from 2014 to 2022. METHODS: The Medicare Physician Fee Schedule Look-Up Tool provided by the Centers for Medicare and Medicaid Services was used, and the Current Procedural Terminology codes for 43 gender-affirming surgery services were obtained. Monetary units, conversion factors, relative value units (RVUs) for work, facility, and malpractice costs for 30 transmasculine and 13 transfeminine procedures were analyzed. Descriptive statistics were performed to account for inflation and to determine the relative differences between 2014 and 2022. RESULTS: For all gender-affirming surgery procedures covered by Medicare, the average relative difference of monetary units decreased by 2.99% between 2014 and 2022. On average, there was a 3.97% decrease of work-based RVU charges for transmasculine procedures and a 1.73% decrease of work-based RVU charges for transfeminine procedures. After adjusting for inflation, the average relative difference of monetary units for all gender-affirming surgery procedures decreased by 23.42% between 2014 and 2022. CONCLUSIONS: Reimbursement rates for gender-affirming surgery procedures covered under Medicare have decreased over the observed period, and trends in reimbursement rates have not kept up with consumer price index inflation. Gender-affirming surgeons should be conscious of these changes in reimbursement rates and advocate for fairer compensation to promote medical care among an underserved population.

Acute Infarcts on Brain MRI Following Aortic Arch Repair With Circulatory Arrest: Insights From the ACE CardioLink-3 Randomized Trial.

BACKGROUND: to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging on brain magnetic resonance imaging after aortic arch surgery. METHODS: This preplanned secondary analysis of the randomized, controlled ACE (Aortic Surgery Cerebral Protection Evaluation) CardioLink-3 trial compared the safety and efficacy of innominate versus axillary artery cannulation during elective proximal aortic arch surgery. Participants underwent pre and postoperative magnetic resonance imaging. New ischemic lesions were defined as lesions visible on postoperative, but not preoperative diffusion weighted imaging. RESULTS: Of the 111 trial participants, 102 had complete magnetic resonance imaging data. A total of 391 new ischemic lesions were observed on diffusion-weighted imaging in 71 (70%) patients. The average number of lesions in patients with ischemic lesion were 5.5±4.9 with comparable numbers in the right (2.9±2.0) and left (3.0±2.3) hemispheres (P=0.49). Half the new lesions were in the middle cerebral artery territory; 63% of the cohort had ischemic lesions in the anterior circulation, 49% in the posterior circulation, 42% in both, and 20% in watershed areas. A probability mask of all diffusion-weighted imaging lesions revealed that the cerebellum was commonly involved. More severe white matter hyperintensity on preoperative magnetic resonance imaging (odds ratio, 1.80 [95% CI, 1.10-2.95]; P=0.02) and lower nadir nasopharyngeal temperature during surgery (odds ratio per 1°C decrease, 1.15 [95% CI, 1.00-1.32]; P=0.05) were associated with the presentation of new ischemic lesion; older age (risk ratio per 1-year increase, 1.02 [95% CI, 1.00-1.04]; P=0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06 [95% CI, 1.00-1.14]; P=0.06) were associated with greater number of lesions. CONCLUSIONS: In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and predominantly involved the middle cerebral artery territory or cerebellum. Underlying small vessel disease, lower temperature nadir during surgery, and advanced age were risk factors for perioperative ischemic lesions. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02554032.

The Top 100 Cited Articles in the Microsurgical Treatment for Lymphedema.

BACKGROUND: Evidence-based medicine uses the current best evidence for decisions about patient care. Lymphedema is a chronic debilitating medical condition caused by a dysfunctional lymphatic system. This study analyzes the most cited articles, including the levels of evidence, for the surgical treatment of lymphedema. METHODS: The Web of Science Sci-Expanded Index was utilized to search for surgical treatment of lymphedema. Articles were examined by three independent reviewers and the top 100 articles were determined. The corresponding author, citation count, publication year, topic, study design, level of evidence, journal, country, and institution were analyzed. RESULTS: Since 1970, the top 100 articles have been cited 7,300 times. The average citation count was 68 and standard deviation was 55. The majority was case series (71), followed by retrospective cohort (8), prospective cohort (7), retrospective case-control (5), and randomized controlled trials (2). Based on the "Level of Evidence Pyramid," 71 articles were level IV, 13 articles were level III, and 9 articles were level II. On the Grading of Recommendations Assessment, Development, and Evaluation Scale, there were 71 articles with "very low," 20 articles with "low," and 2 articles with "moderate" quality of evidence. CONCLUSION: The top 100 cited articles were mostly case series and lacked high levels of evidence. Most studies are retrospective case series with short-term outcomes. However, low level evidence for new surgical procedures is to be expected. Current trends suggest the treatment and understanding of lymphedema will continue to improve.

Rationale and design of a randomized trial evaluating an external support device for saphenous vein coronary grafts.

BACKGROUND: Coronary artery bypass grafting (CABG) is the most common revascularization approach for the treatment of multi-vessel coronary artery disease. While the internal mammary artery is nearly universally used to bypass the left anterior descending coronary artery, autologous saphenous vein grafts (SVGs) are still the most frequently used conduits to grafts the remaining coronary artery targets. Long-term failure of these grafts, however, continues to limit the benefits of surgery. METHODS: The Cardiothoracic Surgical Trials Network trial of the safety and effectiveness of a Venous External Support (VEST) device is a randomized, multicenter, within-patient trial comparing VEST-supported versus unsupported saphenous vein grafts in patients undergoing CABG. Key inclusion criteria are the need for CABG with a planned internal mammary artery to the left anterior descending and two or more saphenous vein grafts to other coronary arteries. The primary efficacy endpoint of the trial is SVG intimal hyperplasia (plaque + media) area assessed by intravascular ultrasound at 12 months post randomization. Occluded grafts are accounted for in the analysis of the primary endpoint. Secondary confirmatory endpoints are lumen diameter uniformity and graft failure (>50% stenosis) assessed by coronary angiography at 12 months. The safety endpoints are the occurrence of major adverse cardiac and cerebrovascular events and hospitalization within 5 years from randomization. CONCLUSIONS: The results of the VEST trial will determine whether the VEST device can safely limit SVG intimal hyperplasia in patients undergoing CABG as treatment for coronary atherosclerotic disease.

Valve-sparing aortic root replacement: a primer for cardiologists.

PURPOSE OF REVIEW: The purpose of this article is to review the contemporary evidence supporting valve-sparing aortic root replacement as the best option for patients with aortic root aneurysms and preservable aortic valves as well as to review the technical variations and modern adjuncts of these operations that impact both short and long-term durability. RECENT FINDINGS: In patients with an aortic root aneurysm, with or without aortic valve regurgitation, valve-sparing aortic root replacement provide excellent clinical outcomes and stable valve function over several decades. Successful execution of this operation depends on careful patient selection and a thorough understanding of the anatomical and physiological relationships between the various components of the aortic root. Echocardiography remains the mainstay of imaging to determine the feasibility of valve-sparing root replacement. SUMMARY: Valve-sparing aortic root replacement is an excellent alternative to composite valve graft replacement in nonelderly patients with aortic root aneurysms. Dedicated aortic root surgeons perform several technical variations of valve-sparing procedures aimed at matching the specific aortic root disorder with the optimal operation.

Transcatheter Aortic Valve Implantation with ACURATE neo: Results from the PROGRESS PVL Registry.

Objectives: The PROGRESS PVL registry evaluated transcatheter aortic valve implantation (TAVI) in patients treated with ACURATE neo, a supra-annular self-expanding bioprosthetic aortic valve. Background: While clinical outcomes with TAVI are comparable with those achieved with surgery, residual aortic regurgitation (AR) and paravalvular leak (PVL) are common complications. The ACURATE neo valve has a pericardial sealing skirt designed to minimize PVL. Methods: The primary endpoint was the rate of total AR over time, as assessed by a core echocardiographic laboratory. The study enrolled 500 patients (mean age: 81.8 ± 5.1 years; 61% female; mean baseline STS score: 6.0 ± 4.5%) from 22 centers in Europe and Canada; 498 patients were treated with ACURATE neo. Results: The rate of ≥ moderate AR was 4.6% at discharge and 3.1% at 12 months; the rate of ≥ moderate PVL was 4.6% at discharge and 2.6% at 12 months. Paired analyses showed significant improvement in overall PVL between discharge and 12 months (P < 0.001); 64.6% of patients had no change in PVL grade, 24.9% improved, and 10.5% worsened. Patients also exhibited significant improvement in transvalvular gradient (P < 0.001) and effective orifice area (P=0.01). The mortality rate was 2.2% at 30 days and 11.3% at 12 months. The permanent pacemaker implantation (PPI) rate was 10.2% at 30 days and 12.2% at 12 months. Conclusions: Results from PROGRESS PVL support the sustained safety and performance of TAVI with the ACURATE neo valve, showing excellent valve hemodynamics, good clinical outcomes, and significant interindividual improvement in PVL from discharge to 12-month follow-up.

Malperfusion syndrome in acute type A aortic dissection: Thinking beyond the proximal repair.

BACKGROUND AND OBJECTIVE: Malperfusion syndrome (MPS) is associated with the highest mortality and major morbidity risk in patients with acute Type A aortic dissection (TAAD). The timing of the open proximal aortic repair in the presence of MPS remains debatable given variability in clinical presentation and different local treatment algorithms. This paper provides an up to date and comprehensive overview of published outcomes and available techniques for addressing malperfusion in the setting of acute TAAD. METHODS: We have reviewed published data from the major aortic dissection registries including the International Registry of Acute Aortic Dissection, the German Registry for Acute Aortic Dissection In Type A, and the Nordic Consortium for Acute Type A Aortic Dissection, as well as the most up to date literature involving malperfusion in the setting of acute TAAD. This data highlights unique strategies that have been adopted at aortic centers internationally to address malperfusion in this setting pre-, intra-, and postoperatively, which are summarized here and may be of great clinical benefit to other centers treating this disease with more traditional methods. RESULTS: The review of the available data has definitively shown an increased mortality up to 43% and morbidity in patients presenting with MPS in the setting of acute TAAD. More specifically, preoperative MPS has been shown to be an independent predictor of mortality with mesenteric malperfusion associated with the worst mortality outcomes from 70% to 100%. Addressing MPS pre or intraoperatively is associated with significantly reduced mortality outcomes down to 4%-13%. CONCLUSION: Adapting a dynamic and easily accessible diagnostic method for the comprehensive assessment of different forms of malperfusion (dynamic/static) and incorporating it within the surgical plan is the first step toward early diagnosis and prevention of malperfusion related complications.

Ross procedure for acute infective endocarditis.

Surgical treatment of infective endocarditis remains a challenge, with concerns of optimal prosthesis selection and risks of recurrent infection remaining paramount. The pulmonary autograft has unique features which may make it the ideal aortic valve substitute, especially in infectious endocarditis. We describe strategic considerations and technical details in performing a Ross procedure in a young patient with acute aortic valve endocarditis.

Prophylactic LVAD for high-risk patients undergoing cardiac surgery.

BACKGROUND: Postcardiotomy cardiogenic shock (PCS) is associated with poor prognosis. Medical therapy with afterload reduction, contractility optimization and systemic vasopressors often fails, and mechanical support is required. The aim of this study was to propose a strategy of prophylactic left ventricular assist device (LVAD) for high-risk patients undergoing cardiac surgery. METHODS: Between 2013 and 2019, 12 consecutive patients at high risk for PCS underwent cardiac surgery (valve surgery and/or coronary artery bypass grafting) with preplanned, prophylactic implantation of LVAD (CentriMag or Rotaflow). We reviewed patient characteristics and outcomes. RESULTS: Eight patients underwent a valve corrective surgery and seven patients underwent coronary artery bypass grafting. Eleven of 12 patients had successful LVAD insertion, support and wean, and survival to hospital discharge. Left ventricular function was stable perioperatively and improved at follow-up. Patients required low doses of inotropic support and no patients required extracorporeal membranous oxygenation. Major complications included, prolonged mechanical ventilation (n = 7), intra-aortic balloon pump (n = 1), temporary dialysis (n = 2), stroke (n = 1), bleeding requiring reoperation (n = 3), infection requiring mediastinal washout (n = 1). At a mean follow-up of, 660 ± 460.6 days all patients had either NYHA Class 1 (n = 6) or 2 (n = 4). There were two late mortalities (after 1 year). CONCLUSIONS: Prophylactic LVAD is a viable technique in select cardiac surgery patients who are high-risk for postcardiotomy shock. Further prospective study is warranted.

Complexity of Online Facial Feminization Surgery Material Exceeds Patient Health Literacy.

The increase in healthcare coverage for transgender populations has made facial feminization surgeries (FFS) more accessible. Majority of patients interested in surgery regularly check online medical information to help understand surgical procedures, risks, and recovery. National health organizations recommend that patient information material should be written at a sixth-grade-reading level, but online material often surpasses patient health literacy. This study evaluates the readability of online FFS resources. An Internet search of the top 100 Web sites was conducted using the keywords "facial feminization surgery." Web sites were analyzed for relevant patient information articles on FFS and categorized into health care and nonhealth care groups. Readability examinations were performed for written text using the Automated Readability Index, Coleman-Liau Index, Flesch-Kincaid Grade Level, Gunning Fog Index, and Simple Measure of Gobbledygook Index. Statistical analysis was performed using 2-tailed z tests, with statistical significance set at P≤0.05. A total of 100 articles from 100 Web sites were examined. The average readability for all online FFS resources was at a 12th-grade-writing level. Articles from health care organizations were at a 13th-grade-reading level and nonhealth care organization articles were at a 12th-grade-reading level (P<0.01). Online patient information for FFS is more complex than nationally recommended writing levels, which may interfere with patient decision making and outcomes. Patient resources for FFS should be written at a lower reading level to promote patient education, satisfaction, and compliance.

Randomized, Controlled Trial Comparing Mitral Valve Repair With Leaflet Resection Versus Leaflet Preservation on Functional Mitral Stenosis: The CAMRA CardioLink-2 Study.

BACKGROUND: Equipoise exists between the use of leaflet resection and preservation for surgical repair of mitral regurgitation caused by prolapse. We therefore performed a randomized, controlled trial comparing these 2 techniques, particularly in regard to functional mitral stenosis. METHODS: One hundred four patients with degenerative mitral regurgitation surgically amenable to either leaflet resection or preservation were randomized at 7 specialized cardiac surgical centers. Exclusion criteria included anterior leaflet or commissural prolapse, as well as a mixed cause for mitral valve disease. Using previous data, we determined that a sample size of 88 subjects would provide 90% power to detect a 5-mm Hg difference in mean mitral valve gradient at peak exercise, assuming an SD of 6.7 mm with a 2-sided test with α=5% and 10% patient attrition. The primary end point was the mean mitral gradient at peak exercise 12 months after repair. RESULTS: Patient age, proportion who were female, and Society of Thoracic Surgeons risk score were 63.9±10.4 years, 19%, and 1.4±2.8% for those who were assigned to leaflet resection (n=54), and 66.3±10.8 years, 16%, and 1.9±2.6% for those who underwent leaflet preservation (n=50). There were no perioperative deaths or conversions to replacement. At 12 months, moderate mitral regurgitation was observed in 3 subjects in the leaflet resection group and 2 in the leaflet preservation group. The mean transmitral gradient at 12 months during peak exercise was 9.1±5.2 mm Hg after leaflet resection and 8.3±3.3 mm Hg after leaflet preservation (P=0.43). The participants had similar resting peak (8.3±4.4 mm Hg versus 8.4±2.6 mm Hg; P=0.96) and mean resting (3.2±1.9 mm Hg versus 3.1±1.1 mm Hg; P=0.67) mitral gradients after leaflet resection and leaflet preservation, respectively. The 6-minute walking distance was 451±147 m for those in the leaflet resection versus 481±95 m for the leaflet preservation group (P=0.27). CONCLUSIONS: In this adequately powered randomized trial, repair of mitral prolapse with either leaflet resection or leaflet preservation was associated with similar transmitral gradients at peak exercise at 12 months postoperatively. These data do not support the hypothesis that a strategy of leaflet resection (versus preservation) is associated with a risk of functional mitral stenosis. Registration: URL: https://www.clinicaltrials.gov; Unique identifier NCT02552771.

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.

Variability in research productivity among Canadian surgical specialties.

Background: Academic productivity, as measured by number and impact of publications, is central to the career advancement and promotion of academic surgeons. We compared research productivity metrics among specialties and sought factors associated with increased productivity. Methods: Academic surgeons were identified through departmental webpages and their scholarly metrics were collected through Scopus in a standardized fashion. We collected total number of documents, h-index, and average number of publications per year in the preceding 5 years. We explored whether presence of a training program, graduate degree, academic rank and size of the clinical group affected productivity metrics. Linear regression was used for multivariable analysis. Results: We collected data on 2172 surgeons from 15 separate academic centres across Canada. Wide variability existed in metrics among specialties, with cardiac and neurosurgery being the most productive, and vascular surgery and plastic surgery being the least productive. The average number of publications was 71, and the average h-index was 18.7. The average h-index for cardiac surgery was 25.7 compared with 8.3 for vascular surgery (p < 0.001). Our multivariable model identified academic rank, surgical specialty, graduate degree, presence of a training program, and larger clinical group as being associated with increased academic productivity. Conclusion: There is variability in research productivity among Canadian surgical specialties. Cardiac surgery and neurosurgery are productive, whereas vascular surgery and plastic surgery are less productive than other surgical disciplines. Obtaining a research-oriented graduate degree, being part of a larger clinical group, and presence of a training program were all associated with higher productivity, even after adjusting for academic rank and specialty.

Contexte: La productivité universitaire, évaluée selon le nombre de publications et leurs retombées, est déterminante pour la carrière et l'avancement des professeurs de chirurgie. Nous avons comparé des indicateurs de la productivité en recherche de diverses spécialités et cherché les facteurs liés à une productivité accrue. Méthodes: Nous avons identifié les professeurs de chirurgie dans les pages Web de départements, et recueilli dans Scopus, de manière normalisée, les données : nombre total de documents, indice h et nombre moyen de publications par année dans les 5 dernières années. Nous avons cherché à savoir si l'existence d'un programme de formation, le diplôme d'études supérieures, le rang professoral et la taille du groupe clinique avaient une incidence sur les indicateurs de productivité. L'analyse multivariable a été faite au moyen d'une régression linéaire. Résultats: Nous avons recueilli des données sur 2172 chirurgiens de 15 différents centres universitaires du Canada. Les indicateurs variaient grandement selon la spécialité. La productivité la plus élevée était associée à la chirurgie cardiaque et à la neurochirurgie, et la productivité la moins élevée, à la chirurgie vasculaire et à la chirurgie plastique. Le nombre moyen de publications était de 71 et l'indice h moyen, de 18,7. L'indice h moyen pour la chirurgie cardiaque était de 25,7, comparativement à 8,3 pour la chirurgie vasculaire (p < 0,001). Notre modèle multivariable a montré que le rang professoral, la spécialité chirurgicale, le diplôme d'études supérieures, l'existence d'un programme de formation et un grand groupe clinique sont liés à une productivité universitaire accrue. Conclusion: La productivité en recherche varie en fonction de la spécialité chirurgicale au Canada. La chirurgie cardiaque et la neurochirurgie sont productives, tandis que la chirurgie vasculaire et la chirurgie plastique le sont moins que d'autres spécialités. L'obtention d'un diplôme d'études supérieures axées sur la recherche, l'appartenance à un grand groupe clinique et l'existence d'un programme de formation étaient toutes associées à une productivité supérieure, même après correction pour tenir compte du rang professoral et de la spécialité.

Sex-Related Differences in Patients Undergoing Thoracic Aortic Surgery.

BACKGROUND: Contemporary outcomes after surgical management of thoracic aortic disease have improved; however, the impact of sex-related differences is poorly understood. METHODS: A total of 1653 patients (498 [30.1%] female) underwent thoracic aortic surgery with hypothermic circulatory arrest between 2002 and 2017 in 10 institutions of the Canadian Thoracic Aortic Collaborative. Outcomes of interest were in-hospital death, stroke, and a modified Society of Thoracic Surgeons-defined composite for mortality or major morbidity (stroke, renal failure, deep sternal wound infection, reoperation, prolonged ventilation). Multivariable logistic regression was used to determine independent predictors of these outcomes. RESULTS: Women were older (mean±SD, 66±13 years versus 61±13 years; P<0.001), with more hypertension and renal failure, but had less coronary disease, less previous cardiac surgery, and higher ejection fraction than men. Rates of aortic dissection were similar between women and men. Rates of hemiarch, and total arch repair were similar between the sexes; however, women underwent less aortic root reconstruction including aortic root replacement, Ross, or valve-sparing root operations (29% versus 45%; P<0.001). Men experienced longer cross-clamp and cardiopulmonary bypass times, but similar durations of circulatory arrest, methods of cerebral perfusion, and nadir temperatures. Women experienced a higher rate of mortality (11% versus 7.4%; P=0.02), stroke (8.8% versus 5.5%; P=0.01), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (31% versus 27%; P=0.04). On multivariable analyses, female sex was an independent predictor of mortality (odds ratio, 1.81; P<0.001), stroke (odds ratio, 1.90; P<0.001), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (odds ratio, 1.40; P<0.001). CONCLUSIONS: Women experience worse outcomes after thoracic aortic surgery with hypothermic circulatory arrest. Further investigation is required to better delineate which measures may reduce sex-related outcome differences after complex aortic surgery.

An Epidemiological Analysis of Pediatric Dog Bite Injuries Over a Decade.

BACKGROUND: An estimated 800,000 dog bites require medical attention every year. The purpose of this study is to review the characteristics of dog bite injuries in children and examine temporal trends. METHODS: The Kids' Inpatient Database was used to identify pediatric patients with dog bite injuries over a 10-y period. Demographic data, primary payer, injury characteristics, length of hospitalization, and treatments were recorded. Statistical analysis was performed in SAS 9.3 (SAS Institute Inc, Cary, NC). RESULTS: A total of 6308 patients were identified. Average age at time of injury was 6.4 ± 4.3 y. Children under age 5 y were the most affected subgroup (39.3% in 2000 versus 44.7% in 2009, P < 0.001). Most bites were to the head/neck and significantly increased from 53.9% in 2000 to 60.1% in 2009. Cellulitis complicated many injuries (33.7% in 2000 versus 44.8% in 2009, P < 0.001). Overall, 50% of patients underwent a procedure; 31% had an invasive surgical procedure; and 5.1% of patients required skin grafts or flaps. CONCLUSIONS: Dog bites are a common cause of pediatric injuries and are a significant burden on families and the health care system. Evaluating the characteristics of these injuries can guide educational efforts.

Minimally invasive periareolar approach to repair sinus venosus atrial septal defect with partial anomalous pulmonary venous connection.

BACKGROUND AND AIM: Atrial septal defects with anomalous venous connections are commonly repaired via sternotomy, requiring careful baffle reconstruction to redirect pulmonary venous return and ensure a durable result. The cosmetically appealing periareolar incision may provide an esthetically superior alternative to the anterolateral minithoracotomy incision used in minimally invasive cardiac surgery. METHODS: We describe a patient with a sinus venosus atrial septal defect and partial anomalous pulmonary venous connection who underwent successful minimally invasive, endoscopic repair with apical vein translocation and autologous pericardial baffle reconstruction through a periareolar approach. RESULTS: Post-operative echocardiography demonstrated excellent results with no residual shunt and a widely patent baffle and preserved biventricular function. At 1-year post-op, our patient has had a greatly improved quality of life and an excellent cosmetic result with normal nipple-areolar sensation. CONCLUSIONS: We believe that periareolar approaches should be considered for all adult patients with simple and complex atrial septal defects.

Nicotinamide Phosphoribosyltransferase in Smooth Muscle Cells Maintains Genome Integrity, Resists Aortic Medial Degeneration, and Is Suppressed in Human Thoracic Aortic Aneurysm Disease.

RATIONALE: The thoracic aortic wall can degenerate over time with catastrophic consequences. Vascular smooth muscle cells (SMCs) can resist and repair artery damage, but their capacities decline with age and stress. Recently, cellular production of nicotinamide adenine dinucleotide (NAD+) via nicotinamide phosphoribosyltransferase (Nampt) has emerged as a mediator of cell vitality. However, a role for Nampt in aortic SMCs in vivo is unknown. OBJECTIVES: To determine whether a Nampt-NAD+ control system exists within the aortic media and is required for aortic health. METHODS AND RESULTS: Ascending aortas from patients with dilated aortopathy were immunostained for NAMPT, revealing an inverse relationship between SMC NAMPT content and aortic diameter. To determine whether a Nampt-NAD+ control system in SMCs impacts aortic integrity, mice with Nampt-deficient SMCs were generated. SMC-Nampt knockout mice were viable but with mildly dilated aortas that had a 43% reduction in NAD+ in the media. Infusion of angiotensin II led to aortic medial hemorrhage and dissection. SMCs were not apoptotic but displayed senescence associated-ß-galactosidase activity and upregulated p16, indicating premature senescence. Furthermore, there was evidence for oxidized DNA lesions, double-strand DNA strand breaks, and pronounced susceptibility to single-strand breakage. This was linked to suppressed poly(ADP-ribose) polymerase-1 activity and was reversible on resupplying NAD+ with nicotinamide riboside. Remarkably, we discovered unrepaired DNA strand breaks in SMCs within the human ascending aorta, which were specifically enriched in SMCs with low NAMPT. NAMPT promoter analysis revealed CpG hypermethylation within the dilated human thoracic aorta and in SMCs cultured from these tissues, which inversely correlated with NAMPT expression. CONCLUSIONS: The aortic media depends on an intrinsic NAD+ fueling system to protect against DNA damage and premature SMC senescence, with relevance to human thoracic aortopathy.

Left ventricular remodeling after mini-mitral repair-does the complexity of mitral disease matter?

OBJECTIVES: Degenerative mitral valve (MV) regurgitation (MR) is associated with left ventricular (LV) dilatation. Surgical treatment of MR has been shown to favorably affect LV remodeling. We prospectively compared the long-term echocardiographic outcomes of LV remodeling following mini-mitral repair for simple versus complex MV disease. METHODS: We prospectively followed up 203 consecutive patients who underwent mini-MV repair for severe degenerative MR over a 9-year period. Simple disease (n = 122 patients: posterior leaflet prolapse) was compared to complex disease (n = 81 patients: anterior, bilateral or commissural prolapse). Baseline demographics were similar between simple and complex groups (age: 63 ± 13 years vs 60 ± 15 years; p = .2; sex: 71% male vs 72% male, p = 1; preoperative MR grade ≥ 3+: 100%; n = 122; vs 100%; n = 81; p = 1), respectively. RESULTS: Preoperative left ventricular ejection fraction (LVEF) was significantly lower in the complex group as compared to the simple group (57.2% simple vs 56.0% complex; p = .04). Preoperative LV end-systolic diameter (LVESD: 35 mm simple vs 36 mm complex, p < .05) and LV end-diastolic diameter (LVEDD: 50 mm simple vs 51 mm complex; p < .05), as well as LV mass index (99.5 g/m2 vs 102.4 g/m2 ; p = .06) were larger in the complex group. Despite different baseline characteristics of LV function and geometry, both groups had similar remodeling of LV after MV repair. CONCLUSIONS: Patients with complex MV disease are referred late for surgical repair, causing LV function and dimensions to never fully recover. This suggests that earlier referral (before LV changes and potentially before symptoms) may be the preferred approach in those with complex disease.