Comparison of Male and Female Surgeons' Experiences With Gender Across 5 Qualitative/Quantitative Domains.

Importance: A growing body of literature has been developed with the goal of attempting to understand the experiences of female surgeons. While it has helped to address inequities and promote important programmatic improvements, work remains to be done. Objective: To explore how practicing male and female surgeons' experiences with gender compare across 5 qualitative/quantitative domains: career aspirations, gender-based discrimination, mentor-mentee relationships, perceived barriers, and recommendations for change. Design, Setting, and Participants: This national concurrent mixed-methods survey of Fellows of the American College of Surgeons (FACS) compared differences between male and female FACS. Differences between female FACS and female members of the Association of Women Surgeons (AWS) were also explored. A randomly selected 3:1 sample of US-based male and female FACS was surveyed between January and June 2020. Female AWS members were surveyed in May 2020. Exposure: Self-reported gender. Main Outcomes and Measures: Self-reported experiences with career aspirations (quantitative), gender-based discrimination (quantitative), mentor-mentee relationships (quantitative), perceived barriers (qualitative), and recommendations for change (qualitative). Results: A total of 2860 male FACS (response rate: 38.1% [2860 of 7500]) and 1070 female FACS (response rate: 42.8% [1070 of 2500]) were included, in addition to 536 female AWS members. Demographic characteristics were similar between randomly selected male and female FACS, with the notable exception that female FACS were less likely to be married (720 [67.3%] vs 2561 [89.5%]; nonresponse-weighted P < .001) and have children (660 [61.7%] vs 2600 [90.9%]; P < .001). Compared with female FACS, female AWS members were more likely to be younger and hold additional graduate degrees (320 [59.7%] were married; 238 [44.4%] had children). FACS of both genders acknowledged positive and negative aspects of dealing with gender in a professional setting, including shared experiences of gender-based harassment, discrimination, and blame. Female FACS were less likely to have had gender-concordant mentors. They were more likely to emphasize the importance of gender when determining career aspirations and prioritizing future mentor-mentee relationships. Moving forward, female FACS emphasized the importance of avoiding competition among female surgeons. They encouraged male surgeons to acknowledge gender bias and admit their potential role. Male FACS encouraged male and female surgeons to treat everyone the same. Conclusions and Relevance: Experiences with gender are not limited to supportive female surgeons. The results of this study emphasize the importance of recognizing the voices of all stakeholders involved when striving to promote workforce diversity and the related need to develop quality improvement/surgical education initiatives that enhance inclusion through open, honest discourse.

Spotlighting Research During COVID-19: Introduction of an International Online Multi-Round Research Competition for Trainees.

PROBLEM: The coronavirus pandemic led to the cancellation of many academic events. While some transitioned to virtual formats, others disappeared, offering fewer opportunities for trainees to share research. Facing this challenge, the Association of Women Surgeons developed a novel approach. Designed to promote greater global inclusion, increase audience engagement and opportunities for networking and feedback from practicing surgeons, they restructured their annual trainee research symposium as a virtual, multi-round competition. APPROACH: Submission to the research competition was open to trainees at any level. The competition comprised four rounds: (1) visual abstracts (all welcomed), (2) three-minute "Quickshot" presentation (32 advance), (3) eight-minute oral presentations (16 advance), and (4) final question-and-answer style defense (final 4 compete). Progression through the first three rounds was determined by public voting. Winners were determined by live voting during the final session. OUTCOMES: A total of 73 visual abstracts were accepted for presentation. Fifty-six percent (n = 41) of first authors were medical students, 36% residents (n = 26), and 7% fellows (n = 6). Five were from international first authors (7%). Abstracts represented research topics including basic science (n = 6, 8%)), clinical outcomes (n = 38, 52%), and education (n = 29, 40%). Social media impressions exceeded a total of 30,000 views. NEXT STEPS: This virtual, multi-round research competition served as a blueprint for a novel approach to research dissemination. The format enabled expanded US national and international engagement with trainees in all stages of their career. Future research symposia should consider the impact of popularity bias, timing, and voting strategies during the event planning period to optimize success.

Two different geometric orientations for aortic neoroot creation in bicuspid aortic valve repair with root reimplantation.

OBJECTIVE: Bicuspid aortic valve (BAV) represents 2 cusps oriented along a spectrum of equal (180°/180°) or unequal (150°/210°) leaflet surface area distribution along the aortic annular plane. We have taken the approach of respecting the native geometric orientation of the repaired BAV leaflets when creating the aortic neoroot during valve-sparing root reimplantation (VSRR) procedures. We investigated midterm outcomes with this 2-prong approach for VSRR in BAV syndrome. METHODS: Of 72 patients in a prospectively maintained BAV repair database, 68 met inclusion criteria: 36 patients had 180°/180° neoroot geometry, and 32 patients had 150°/210° orientation. A multivariate ordinal logistic mixed effects model was performed to study parameters associated with recurrent AI greater than 2+. RESULTS: Preoperative parameters were similar between 180°/180° and 150°/210° groups, except for greater incidence of AI 4+ in the latter (50.0% [n = 16] vs 8.3% [n = 3]; P < .001). Postoperatively, stroke, renal failure, reoperation for bleeding, and pacemaker rates were 0 in the entire cohort. In-hospital/30-day mortality in the entire cohort was 1.5% (n = 1). Multivariate ordinal logistic mixed effects model showed that preoperative AI greater than 3+ (odds ratio, 0.4; P = .46) and geometric orientation of the aortic neoroot (odds ratio, 3.8; P = .25) were not significantly associated with recurrence of AI greater than 2+. CONCLUSIONS: Respecting BAV geometry for VSRR neoroot creation yields excellent midterm outcomes and may minimize conjoint cusp leaflet stress that may occur in "forcing" a 150°/210° type I BAV into a 180°/180° neoroot.

Functional Outcomes of Type I Bicuspid Aortic Valve Repair With Annular Stabilization: Subcommissural Annuloplasty Versus External Subannular Aortic Ring.

BACKGROUND: In bicuspid aortic valve patients with nonaneurysmal root (<45 mm) and severe aortic insufficiency (AI), external subannular aortic ring (ESAR) is being increasingly utilized for annular stabilization, compared with traditional subcommissural annuloplasty (SCA). To this date, there is no comparative study assessing functional equivalence or superiority of ESAR over SCA. METHODS: From 2003 to 2017, 139 patients underwent type I bicuspid aortic valve repair, of which 50 patients underwent concomitant SCA and 24 underwent ESAR. Cases with suboptimal echocardiographic imaging were excluded, resulting in 38 patients in the SCA group and 20 patients in ESAR group. Intraoperative transesophageal echocardiography before and after procedure were retrospectively analyzed for 11 parameters in the functional aortic root complex. RESULTS: ESAR patients had larger preoperative annulus (28.3 ± 3.2 mm versus 29.8 ± 3.7 mm, p = 0.1) and left ventricular (LV) outflow tract (28.1 ± 3.5 mm versus 29.8 ± 4.0 mm, p = 0.1) diameters, with greater leaflet prolapse (3.4 ± 1.3 mm versus 4.3 ± 1.3, p = 0.02). In both groups, 100% freedom from AI greater than 1+ was achieved, with significant reduction of vena contracta (-3.0 ± 0.6 mm, p < 0.001; -3.2 ± 0.4 mm, p < 0.001) and level of eccentricity of AI jet (AI angle change: -24.3 ± 6.5 degrees, p = 0.002; -22.3 ± 7.2 degrees, p = 0.01). Reduction in LV dimensions (-7.1 ± 1.2 mm, p < 0.001; -8.9 ± 1.9 mm, p < 0.001), annulus (-3.4 ± 0.4 mm, p < 0.001; -5.1 ± 2.7 mm, p < 0.001), LV outflow tract (-2.3 ± 0.4 mm, p < 0.001; -4.4 ± 0.5 mm, p < 0.001), and degree of leaflet prolapse (-1.6 ± 0.4 mm, p = 0.005; -2.1 ± 0.4 mm, p = 0.001) was achieved in both groups. Comparison of postprocedure outcomes showed improved mean transvalvular gradients in ESAR (11.2 ± 5.7 mm Hg versus 7.1 ± 2.5 mm Hg, p = 0.003), with similar freedom from AI. CONCLUSIONS: In addition to providing equivalent and excellent freedom from AI, ESAR also renders a more robust annular reduction than SCA, along with improved transvalvular gradients.

Predicting Distal Aortic Remodeling After Endovascular Repair for Chronic DeBakey III Aortic Dissection.

BACKGROUND: Chronic DeBakey III aortic dissection is typically managed with open aortic reconstruction. Thoracic endovascular aortic grafting (TEVAR) has been attempted in patients with chronic DeBakey III with improved outcomes over medical management, however with frequent failures. This study investigates factors associated with positive aortic remodeling from a large aortic center. METHODS: Three-dimensional reconstructions (M2S, West Lebanon, NH) of computed tomography angiography scans of 48 patients who underwent TEVAR from 2005 to 2015 were analyzed. The dissection was characterized, and measurements were obtained from preoperative and postoperative scans at four time points. Standard univariate Wilcoxon rank sum and Fisher's exact tests were used to analyze continuous and ordinal/nominal data, respectively. Multivariable logistic regression was performed. RESULTS: In a multivariate logistic model, having fewer than two visceral vessels off the true lumen was a negative predictor of total thrombosis (odd ratio [OR] 0.01, 95% confidence interval [CI]: <0.01 to 0.84, p = 0.04). In a logistic model that predicted total thrombosis in zones 3 and 4, maximum diameter 2 cm above the celiac axis was a significant negative predictor (OR 0.75, 95% CI: 0.57 to 0.99, p = 0.05). In a model that predicted failure of the maximum overall diameter of the descending aorta to regress within 1 year after TEVAR, maximum overall diameter preoperatively (OR 1.19, 95% CI: 1.02 to 1.29, p = 0.03) and tear location on the greater curve (OR 18.1, 95% CI: 1.3 to 243, p = 0.03) were significant positive predictors. CONCLUSIONS: TEVAR is feasible in chronic dissection but is limited by complex dissection-related anatomy. Increasing number of visceral vessels off the false lumen, maximum preoperative aortic size, and location of the primary tear on the greater curve were associated with poorer remodeling.

Concomitant Endografting of a Type B Aortic Dissection During Transfemoral Aortic Valve Replacement.

An 87-year-old woman with severe aortic stenosis underwent a transfemoral transcatheter aortic valve replacement (TAVR). Intraoperative transesophageal echocardiography demonstrated a well-seated valve with no paravalvular leak; however, a new acute type B aortic dissection was identified. Endografts were delivered through the TAVR sheath and deployed, effectively treating the dissection. The patient did well postoperatively, with imaging at 2 years demonstrating a well-functioning aortic valve and no migration or endoleak of the thoracic endografts. To our knowledge, this is the first report of successful concomitant thoracic endografting during TAVR for the treatment of iatrogenic aortic dissection in this setting.