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1.  First nationwide survey of US integrated 6-year cardiothoracic surgical residency program directors 
Objective
The recently implemented integrated 6-year (I-6) format represents a significant change in cardiothoracic surgical residency training. We report the results of the first nationwide survey assessing I-6 program directors' impressions of this new format.
Methods
A 28-question web-based survey was distributed to program directors of all 24 Accreditation Council for Graduate Medical Education-accredited I-6 training programs in November 2013. The response rate was a robust 67%.
Results
Compared with graduates of traditional residencies, most I-6 program directors with enrolled residents believed that their graduates will be better trained (67%), be better prepared for new technological advances (67%), and have superior comprehension of cardiothoracic disease processes (83%). Just as with traditional program graduates, most respondents believed their I-6 graduates would be able to independently perform routine adult cardiac and general thoracic operations (75%) and were equivocal on whether additional specialty training (eg, minimally invasive, heart failure, aortic) was necessary. Most respondents did not believe that less general surgical training disadvantaged I-6 residents in terms of their career (83%); 67% of respondents would have chosen the I-6 format for themselves if given the choice. The greater challenges in training less mature and experienced trainees and vulnerability to attrition were noted as disadvantages of the I-6 format. Most respondents believed that I-6 programs represent a natural evolution toward improved residency training rather than a response to declining interest among medical school graduates.
Conclusions
High satisfaction rates with the I-6 format were prevalent among I-6 program directors. However, concerns with respect to training relatively less experienced, mature trainees were evident.
doi:10.1016/j.jtcvs.2014.04.004
PMCID: PMC4336151  PMID: 24820188
2.  Hypothermia and operative mortality during on-pump coronary artery bypass grafting 
Objective
Controversy surrounds the effect of hypothermia on operative mortality during cardiac surgery. The present study accessed a large clinical database of coronary artery bypass graft operations to address the issue.
Methods
A retrospective review of the Society of Thoracic Surgeons Adult Cardiac Surgery Database identified patients treated with isolated, nonemergency, on-pump coronary artery bypass grafting from July 2011 to December 2012. The patients were divided into 3 groups according to their lowest core temperature during the procedure: moderate hypothermia (≤34°C), mild hypothermia (>34°C but ≤36°C), and normothermia (>36°C). The primary endpoint of the study was operative mortality, defined according to the Database criteria.
Results
During the study period, 142,541 patients were available for analysis; 94,777 (66.5%) received moderate hypothermia, 42,750 (30.3%) mild hypothermia, and 5014 (3.5%) normothermia. Operative mortality occurred in 1394 patients (1.5%) in the moderate hypothermia, 534 (1.3%) in the mild hypothermia, and 105 (2.1%) in the normothermia group. Multivariate analysis identified hypothermia (both mild [odds ratio, 0.66; 95% confidence interval, 0.54–0.81; P<.0001] and moderate [odds ratio, 0.73; 95% confidence interval, 0.60–0.89; P =.0015]) was protective against operative mortality compared with normothermia. No incremental benefit was noted between the different hypothermia grades (P = .0827).
Conclusions
Most patients receive hypothermia during on-pump coronary artery bypass grafting. Hypothermia is protective against operative mortality compared with normothermia in such patients. Moderate hypothermia does not provide additional survival benefit.
doi:10.1016/j.jtcvs.2014.05.091
PMCID: PMC4336164  PMID: 25125205
3.  Antegrade versus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest: Does it matter? A propensity-matched analysis 
Objective
The choice of cerebral perfusion strategy for aortic arch surgery has been debated, and the superiority of antegrade (ACP) or retrograde (RCP) cerebral perfusion has not been shown. We examined the early and late outcomes for ACP versus RCP in proximal (hemi-) arch replacement using deep hypothermic circulatory arrest (DHCA).
Methods
A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective hemiarch replacement at a single referral institution from June 2005 to February 2013. Total arch cases were excluded to limit the analysis to shorter DHCA times and a more uniform patient population for whom clinical equipoise regarding ACP versus RCP exists. A total of 440 procedures were identified, with 360 (82%) using ACP and 80 (18%) using RCP. The endpoints included 30-day/in-hospital and late outcomes. A propensity score with 1:1 matching of 40 pre- and intraoperative variables was used to adjust for differences between the 2 groups.
Results
All 80 RCP patients were propensity matched to a cohort of 80 similar ACP patients. The pre- and intra-operative characteristics were not significantly different between the 2 groups after matching. No differences were found in 30-day/in-hospital mortality or morbidity outcomes. The only significant difference between the 2 groups was a shorter mean operative time in the RCP cohort (P = .01). No significant differences were noted in late survival (P = .90).
Conclusions
In proximal arch operations using DHCA, equivalent early and late outcomes can be achieved with RCP and ACP, although the mean operative time is significantly less with RCP, likely owing to avoidance of axillary cannulation. Questions remain regarding comparative outcomes with straight DHCA and lesser degrees of hypothermia.
doi:10.1016/j.jtcvs.2014.04.014
PMCID: PMC4336168  PMID: 24908350
4.  Differential prognostic significance of extralobar and intralobar nodal metastases in patients with surgically resected stage II non–small cell lung cancer 
Objectives
We sought to determine the prognostic significance of extralobar nodal metastases versus intralobar nodal metastases in patients with lung cancer and pathologic stage N1 disease.
Methods
A retrospective review of a prospectively maintained lung resection database identified 230 patients with pathologic stage II, N1 non–small cell lung cancer from 1997 to 2011. The surgical pathology reports were reviewed to identify the involved N1 stations. The outcome variables included recurrence and death. Univariate and multivariate analyses were performed using the R statistical software package.
Results
A total of 122 patients had extralobar nodal metastases (level 10 or 11); 108 patients were identified with intralobar nodal disease (levels 12–14). The median follow-up was 111 months. The baseline characteristics were similar in both groups. No significant differences were noted in the surgical approach, anatomic resections performed, or adjuvant therapy rates between the 2 groups. Overall, 80 patients developed recurrence during follow-up: 33 (30%) of 108 in the intralobar and 47 (38%) of 122 in the extralobar cohort. The median overall survival was 46.9 months for the intralobar cohort and 24.4 months for the extralobar cohort (P<.001). In a multivariate Cox proportional hazard model that included the presence of extralobar nodal disease, age, tumor size, tumor histologic type, and number of positive lymph nodes, extralobar nodal disease independently predicted both recurrence-free and overall survival (hazard ratio, 1.96; 95% confidence interval, 1.36–2.81; P = .001).
Conclusions
In patients who underwent surgical resection for stage II non–small cell lung cancer, the presence of extralobar nodal metastases at level 10 or 11 predicted significantly poorer outcomes than did nodal metastases at stations 12 to 14. This finding has prognostic importance and implications for adjuvant therapy and surveillance strategies for patients within the heterogeneous stage II (N1) category.
doi:10.1016/j.jtcvs.2013.12.015
PMCID: PMC4336169  PMID: 24507984
5.  Frailty and risk in proximal aortic surgery 
Objectives
Although frailty has recently been examined in various populations as a predictor of morbidity and mortality, its effect on thoracic aortic surgery outcomes has not been studied. The objective of the present study was to evaluate the role of frailty in predicting postoperative morbidity and mortality in patients undergoing proximal aortic replacement surgery.
Methods
A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective proximal aortic operations (root, ascending aorta, and/or arch) at a single-referral institution from June 2005 to December 2012. A total of 581 patients underwent proximal aortic surgery, of whom 574 (98.8%) were included in the present analysis; 7 were excluded because of incomplete data. Frailty was evaluated using an index consisting of age > 70 years, body mass index < 18.5 kg/m2, anemia, history of stroke, hypoalbuminemia, and total psoas volume in the bottom quartile of the population. One point was given for each criterion met to determine a frailty score of 0 to 6. Frailty was defined as a score of ≥ 2. Risk models for length of stay > 14 days, discharge to other than home, 30-day composite major morbidity, 30-day composite major morbidity/mortality, and 30-day and 1-year mortality were calculated using multivariate regression modeling.
Results
Of the 574 patients, 148 (25.7%) were defined as frail (frailty score ≥ 2). The unadjusted 30-day/in-hospital and long-term outcomes were significantly worse for the frail versus nonfrail patients in all but 1 of the outcomes analyzed; no difference was found in the 30-day readmission rates between the 2 groups. In the multivariate model, a frailty score of ≥ 2 was associated with discharge to other than home and 30-day and 1-year mortality.
Conclusions
Frailty, as defined using a 6-component frailty index, can serve as an independent predictor of discharge disposition and early and late mortality risk in patients undergoing proximal aortic surgery. These frailty markers, all of which are easily assessed preoperatively, could provide valuable information for patient counseling and risk stratification before proximal aortic replacement.
doi:10.1016/j.jtcvs.2013.09.011
PMCID: PMC4336171  PMID: 24183336
6.  Mechanical preconditioning enables electrophysiologic coupling of skeletal myoblast cells to myocardium 
Objective
The effect of mechanical preconditioning on skeletal myoblasts in engineered tissue constructs was investigated to resolve issues associated with conduction block between skeletal myoblast cells and cardiomyocytes.
Methods
Murine skeletal myoblasts were used to generate engineered tissue constructs with or without application of mechanical strain. After in vitro myotube formation, engineered tissue constructs were co-cultured for 6 days with viable embryonic heart slices. With the use of sharp electrodes, electrical coupling between engineered tissue constructs and embryonic heart slices was assessed in the presence or absence of pharmacologic agents.
Results
The isolation and expansion procedure for skeletal myoblasts resulted in high yields of homogeneously desmin-positive (97.1% ± 0.1%) cells. Mechanical strain was exerted on myotubes within engineered tissue constructs during gelation of the matrix, generating preconditioned engineered tissue constructs. Electrical coupling between preconditioned engineered tissue constructs and embryonic heart slices was observed; however, no coupling was apparent when engineered tissue constructs were not subjected to mechanical strain. Coupling of cells from engineered tissue constructs to cells in embryonic heart slices showed slower conduction velocities than myocardial cells with the embryonic heart slices (preconditioned engineered tissue constructs vs embryonic heart slices: 0.04 ± 0.02 ms vs 0.10 ± 0.05 ms, P = .011), lower stimulation frequencies (preconditioned engineered tissue constructs vs maximum embryonic heart slices: 4.82 ± 1.42 Hz vs 10.58 ± 1.56 Hz; P = .0009), and higher sensitivities to the gap junction inhibitor (preconditioned engineered tissue constructs vs embryonic heart slices: 0.22 ± 0.07 mmol/L vs 0.93 ± 0.15 mmol/L; P = .0004).
Conclusions
We have generated skeletal myoblast–based transplantable grafts that electrically couple to myocardium.
doi:10.1016/j.jtcvs.2012.07.036
PMCID: PMC4334564  PMID: 22980065
7.  Meta-analysis of minimally invasive coronary artery bypass versus drug-eluting stents for isolated left anterior descending coronary artery disease 
Objective
To compare the outcomes between minimally invasive coronary artery bypass (MINI-CAB) and drug-eluting stent (DES) implantation for isolated left anterior descending artery disease.
Methods
Randomized and observational comparative publications were identified using MEDLINE and Google Scholar databases (January 2003 to December 2013). Studies without outcomes data, without DES use, or using conventional bypass surgery were excluded. The outcomes of interest were cardiac death, myocardial infarction, target vessel revascularization, and periprocedural stroke. Data were compared using the Mantel-Haenszel methods and are presented as odds ratios (ORs), 95%confidence intervals (CIs), and number needed to treat.
Results
From 230 publications, we identified 4 studies (2 randomized and 2 observational) with 941 patients (478 had undergone MINI-CAB and 463 DES implantation). The incidence of target vessel revascularization at maximum follow-up (range, 6–60 months) was significantly lower in the MINI-CAB group (OR, 0.16; 95%CI, 0.08–0.30; P < .0001; number needed to treat, 13). The incidence of cardiac mortality and MI was similar between the MINI-CAB and DES groups during follow-up (OR, 1.05; 95% CI, 0.44–2.47; and OR, 0.83; 95% CI, 0.43–1.58, respectively). In addition, a similar incidence of periprocedural death (OR, 0.85; 95% CI, 0.21–3.47; P = .82), myocardial infarction (OR, 0.98; 95% CI, 0.38–2.58; P = .97), and stroke (OR, 1.36; 95% CI, 0.28–6.70; P = .70) was observed between the 2 treatment modalities.
Conclusions
Given the available evidence, MINI-CAB will result in lower target vessel revascularization rates but otherwise similar clinical outcomes compared with DESs in patients with left anterior descending artery disease.
doi:10.1016/j.jtcvs.2014.03.028
PMCID: PMC4322677  PMID: 24755335
8.  Insurance status predicts acuity of thoracic aortic operations 
Objective
Nonelective case status is the strongest predictor of mortality for thoracic aortic operations. We hypothesized that underinsured patients were more likely to require nonelective thoracic aortic surgery because of reduced access to preventative cardiovascular care and elective surgical services.
Methods
Between June 2005 and August 2011, 826 patients were admitted to a single aortic referral center and underwent 1 or more thoracic aortic operations. Patients with private insurance or Medicare (insured group, n = 736; 89%) were compared with those with Medicaid or no insurance (underinsured group, n = 90; 11%).
Results
The proportion of patients requiring nonelective surgery was higher for underinsured than insured patients (56% vs 26%, P < .0001). Multivariable analysis revealed underinsurance to be the strongest independent predictor of nonelective case status (odds ratio [OR], 2.67; P < .0001). Preoperative use of lipid-lowering medications (OR, 0.63; P < .009) or a history of aortic surgery (OR, 0.48; P < .001) was associated with a decreased risk of nonelective operation. However, after adjustment for differences in preoperative characteristics and case status, underinsurance did not confer an increased risk of procedural morbidity or mortality (adjusted OR, 0.94; P = .83) or late death (adjusted hazard ratio, 0.83, P = .58) when compared with insured patients.
Conclusions
Underinsured patients were at the greatest risk of requiring nonelective thoracic aortic operation, possibly because of decreased use of lipid-lowering therapies and aortic surveillance. These data imply that greater access to preventative cardiovascular care may reduce the need for nonelective thoracic aortic surgery and lead to improved survival from thoracic aortic disease.
doi:10.1016/j.jtcvs.2014.03.013
PMCID: PMC4322755  PMID: 24725770
9.  Sex differences in early outcomes after lung cancer resection: Analysis of the Society of Thoracic Surgeons’ General Thoracic Database 
Objectives
Women with lung cancer have superior long-term survival outcomes compared to men, independent of stage. The etiology of this disparity is unknown. For patients undergoing lung cancer resection, these survival differences could be due, in part, to relatively better perioperative outcomes for women. This study was undertaken to determine differences in perioperative outcomes after lung cancer surgery based on sex.
Methods
The STS General Thoracic Database was queried for all patients undergoing resection of lung cancer between 2002 and 2010. Postoperative complications were analyzed with respect to sex. Univariable analysis was performed, then multivariable modeling to determine significant risk factors for postoperative morbidity and mortality.
Results
A total of 34,188 patients (16,643 men and 17,545 women) were considered. Univariable analysis demonstrated statistically significant differences in postoperative complications favoring women in all categories of postoperative complications. Women also had lower in-hospital and 30-day mortality (O.R. 0.56, 95% CI 0.44-0.71; p<0.001).
Multivariable analysis demonstrated that several pre-operative conditions independently predicted 30-day mortality: male sex, increasing age, lower diffusion capacity, renal insufficiency, preoperative radiation therapy, cancer stage, extent of resection and thoracotomy as surgical approach.
Coronary artery disease was an independent predictor of mortality in women but not men. Thoracotomy as surgical approach and preoperative radiation therapy were predictive of mortality for men but not women. Post-operative prolonged air leak and empyema predicted mortality in men but not women.
Conclusions
Women have lower postoperative morbidity and mortality after lung cancer surgery. Some risk factors are sex-specific with regard to mortality. Further study is warranted to determine the etiology of these differences and to determine their effect on survival.
doi:10.1016/j.jtcvs.2014.03.012
PMCID: PMC4314218  PMID: 24726742
10.  [No title available] 
PMCID: PMC3716843  PMID: 23477689
11.  [No title available] 
PMCID: PMC3926808  PMID: 24246548
12.  [No title available] 
PMCID: PMC3947119  PMID: 24210830
13.  [No title available] 
PMCID: PMC3947125  PMID: 24267781
14.  THE EFFECT OF PRE-OPERATIVE NUTRITIONAL STATUS ON POST-OPERATIVE OUTCOMES IN CHILDREN UNDERGOING SURGERY FOR CONGENITAL HEART DEFECTS IN SAN FRANCISCO (UCSF) AND GUATEMALA CITY (UNICAR) 
The Journal of thoracic and cardiovascular surgery  2013;147(1):10.1016/j.jtcvs.2013.03.023.
Objective
To determine the association between preoperative nutritional status and postoperative outcomes in children undergoing surgery for congenital heart defects (CHD).
Methods
Seventy-one patients with CHD were enrolled in a prospective, two-center cohort study. We adjusted for baseline risk differences using a standardized risk adjustment score for surgery for CHD. We assigned a World Health Organization Z-score for each subjects’ preoperative triceps skinfold measurement, an assessment of total body fat mass. We obtained preoperative plasma concentrations of markers of nutritional status (prealbumin, albumin) and myocardial stress (B-type natriuretic peptide, BNP). Associations between indices of preoperative nutritional status and clinical outcomes were sought.
Results
Subjects had a median (IQR) age of 10.2 (33) months. In the UCSF cohort, duration of mechanical ventilation (median 19 hours, IQR 29), length of ICU stay (median 5 days, IQR 5), duration of any continuous inotropic infusion (median 66 hours, IQR 72) and preoperative BNP levels (median 30 pg/mL, IQR 75) were associated with a lower preoperative triceps skinfold Z-score (p<0.05). Longer duration of any continuous inotropic infusion and higher preoperative BNP levels were also associated with lower preoperative prealbumin (12.1 ± 0.5 mg/dL) and albumin (3.2 ± 0.1) (p<0.05).
Conclusions
Lower total body fat mass and acute and chronic malnourishment are associated with worse clinical outcomes in children undergoing surgery for CHD at UCSF, a resource-abundant institution. There is an inverse correlation between total body fat mass and BNP levels. Duration of inotropic support and BNP increase concomitantly as measures of nutritional status decrease, supporting the hypothesis that malnourishment is associated with decreased myocardial function.
doi:10.1016/j.jtcvs.2013.03.023
PMCID: PMC3787941  PMID: 23583172
15.  Endovascular Coil Embolization of Segmental Arteries Prevents Paraplegia After Subsequent TAAA Repair – An Experimental Model 
Objective
To test a strategy for minimizing ischemic spinal cord injury (SCI) following extensive thoracoabdominal aneurysm (TAAA) repair, we occluded a small number of segmental arteries (SAs) endovascularly one week before simulated aneurysm repair in an experimental model.
Methods
30 juvenile Yorkshire pigs (25.2±1.7kg) were randomized into three groups. All SAs—intercostal and lumbar—were sacrificed by a combination of surgical ligation of the lumbar SAs and occlusion of intercostal SAs with thoracic endovascular stent grafting (TEVAR). 7–10 days before this simulated TAAA replacement, SAs in the lower thoracic/upper lumbar region were occluded using embolization coils: 1.5±0.5 SAs in Group 1 (T13/L1), and 4.5±0.5 in Group 2 (T11-L3). No SAs were coiled in the controls. Hind limb function was evaluated blindly from daily videotapes using a modified Tarlov score: 0=paraplegia; 9=full recovery. After sacrifice, each segment of spinal cord was graded histologically using the 9-point Kleinman score: 0=normal, 8=complete necrosis.
Results
Hind limb function remained normal after coil embolization. After simulated TAAA repair, paraplegia occurred in 6/10 control pigs, but only 2/10 pigs in Group 1: no pigs in Group 2 had SCI. Tarlov scores were significantly better in Group 2 (Control vs 1 p=0.06; Control vs 2 p= 0.0002; 1 vs 2 p=0.05). A dramatic reduction in histologic damage—most prominently in the coiled region—was seen when SAs were embolized before simulated TAAA repair.
Conclusions
Endovascular coiling of 2–4 SAs prevents paraplegia in an experimental model of extensive hybrid TAAA repair, and helps protect the spinal cord from ischemic histopathological injury. A clinical trial in a selected patient population at high risk for postoperative SCI may be appropriate.
doi:10.1016/j.jtcvs.2013.09.022
PMCID: PMC3918675  PMID: 24220154
16.  Duration and magnitude of blood pressure below cerebral autoregulation threshold during cardiopulmonary bypass is associated with major morbidity and operative mortality 
The Journal of thoracic and cardiovascular surgery  2013;147(1):10.1016/j.jtcvs.2013.07.069.
Objectives
Optimizing blood pressure using near-infrared spectroscopy monitoring has been suggested to ensure organ perfusion during cardiac surgery. Near-infrared spectroscopy is a reliable surrogate for cerebral blood flow in clinical cerebral autoregulation monitoring and might provide an earlier warning of malperfusion than indicators of cerebral ischemia. We hypothesized that blood pressure below the limits of cerebral autoregulation during cardiopulmonary bypass would be associated with major morbidity and operative mortality after cardiac surgery.
Methods
Autoregulation was monitored during cardiopulmonary bypass in 450 patients undergoing coronary artery bypass grafting and/or valve surgery. A continuous, moving Pearson’s correlation coefficient was calculated between the arterial pressure and low-frequency near-infrared spectroscopy signals and displayed continuously during surgery using a laptop computer. The area under the curve of the product of the duration and magnitude of blood pressure below the limits of autoregulation was compared between patients with and without major morbidity (eg, stroke, renal failure, mechanical lung ventilation >48 hours, inotrope use >24 hours, or intra-aortic balloon pump insertion) or operative mortality.
Results
Of the 450 patients, 83 experienced major morbidity or operative mortality. The area under the curve of the product of the duration and magnitude of blood pressure below the limits of autoregulation was independently associated with major morbidity or operative mortality after cardiac surgery (odds ratio, 1.36; 95% confidence interval, 1.08–1.71; P = .008).
Conclusions
Blood pressure management during cardiopulmonary bypass using physiologic endpoints such as cerebral autoregulation monitoring might provide a method of optimizing organ perfusion and improving patient outcomes from cardiac surgery.
doi:10.1016/j.jtcvs.2013.07.069
PMCID: PMC3865134  PMID: 24075467
18.  A composite outcome for neonatal cardiac surgery research 
Objective
The objective of this study was to determine whether a composite outcome, derived of objective signs of inadequate cardiac output, would be associated with other important measures of outcomes and therefore be an appropriate end point for clinical trials in neonatal cardiac surgery.
Methods
Neonates (n = 76) undergoing cardiac operations requiring cardiopulmonary bypass were prospectively enrolled. Patients were defined to have met the composite outcome if they had any of the following events before hospital discharge: death, the use of mechanical circulatory support, cardiac arrest requiring chest compressions, hepatic injury (2 times the upper limit of normal for aspartate aminotransferase or alanine aminotransferase), renal injury (creatinine >1.5 mg/dL), or lactic acidosis (an increasing lactate >5 mmol/L in the postoperative period). Associations between the composite outcome and the duration of mechanical ventilation, intensive care unit stay, hospital stay, and total hospital charges were determined.
Results
The median age at the time of surgery was 7 days, and the median weight was 3.2 kg. The composite outcome was met in 39% of patients (30/76). Patients who met the composite outcome compared with those who did not had a longer duration of mechanical ventilation (4.9 vs 2.9 days, P<.01), intensive care unit stay (8.8 vs 5.7 days, P<.01), hospital stay (23 vs 12 days, P<.01), and increased hospital charges ($258,000 vs $170,000, P<.01). In linear regression analysis, controlling for surgical complexity, these differences remained significant (R2 = 0.29–0.42, P<.01).
Conclusions
The composite outcome is highly associated with important early operative outcomes and may serve as a useful end point for future clinical research in neonates undergoing cardiac operations.
doi:10.1016/j.jtcvs.2013.03.013
PMCID: PMC4004075  PMID: 23587468
19.  Unplanned reinterventions are associated with postoperative mortality in neonates with critical congenital heart disease 
Objective
Neonates with critical congenital heart disease remain at risk of adverse outcomes after cardiac surgery. Residual or undiagnosed anatomic lesions might be contributory. The present study aimed to describe the incidence and type of cardiac lesions that lead to early, unplanned cardiac reintervention, identify the risk factors for unplanned reintervention, and explore the associations between unplanned reinterventions and hospital mortality.
Methods
The present single-center retrospective cohort study included 943 consecutive neonates with critical congenital heart disease who underwent cardiac surgery from 2002 to 2008. An unplanned cardiac reintervention was defined as a cardiac reoperation or interventional cardiac catheterization performed during the same hospitalization as the initial operation. Multivariate logistic regression analyses were used to identify the risk factors for unplanned cardiac reintervention and hospital mortality.
Results
Of the 943 neonates, 104 (11%) underwent an unplanned cardiac reintervention. The independent predictors of unplanned reintervention included prenatal diagnosis, lower birth weight, need for mechanical ventilation before the initial cardiac operation, lower attending surgeon experience, and greater Risk Adjustment in Congenital Heart Surgery, version 1, category. Those who underwent reintervention had increased hospital mortality (n = 33/104, 32%) relative to those who did not (n = 31/839, 4%; adjusted odds ratio, 8.6; 95% confidence interval, 4.7 to 15.6; P < .001). The mortality rates among patients undergoing surgical reintervention (23/66, 35%) or transcatheter reintervention (4/16, 25%), or both (6/22, 27%) were similar (P = .66).
Conclusions
The need for unplanned cardiac reintervention in neonates with critical congenital heart disease is strongly associated with increased mortality. Early unplanned reinterventions might be an important covariate in outcomes studies and useful as a quality improvement measure.
doi:10.1016/j.jtcvs.2012.03.078
PMCID: PMC4256957  PMID: 22578897
20.  Minimally-Invasive Fibrillating Mitral Valve Replacement for Patients with Advanced Cardiomyopathy: a Safe and Effective Approach to Treat a Complex Problem 
Objective
The optimal management of mitral regurgitation (MR) in patients with cardiomyopathy is controversial. Mini-MVR may limit post-operative morbidity and mortality by minimizing recurrent MR. We hypothesized that minimally-invasive fibrillating mitral valve replacement (mini-MVR) with complete chordal sparing would offer a low mortality and halt left ventricular (LV) remodeling in patients with severe cardiomyopathy and severe MR.
Methods and Results
Between 1/06 - 8/09, 65 patients with LVEF ≤ 35% underwent mini-MVR. Demographic, echocardiographic, and clinical outcomes were analyzed.
Results
Operative mortality compared to Society for Thoracic Surgery (STS)-predicted mortality was 6.2 versus 6.6%; 5.6 versus 7.4% among patients with LVEF ≤ 20%; and 8.3 versus 17.9% among patients with STS-predicted mortality of ≥ 10%. At median follow-up of 17 months there was no recurrent MR or change in LV dimensions or LVEF, but there was a decrease (p = 0.02) in right ventricular systolic pressure (RVSP). At the first post-operative visit and longest follow-up, NYHA class decreased from 3.0 ± 0.6 to 1.7 ± 0.7 and 2.0 ± 1.0, respectively (both p < 0.0001). Patients with LVEF ≤ 20% and LVEDD ≥ 6.5cm were more likely to meet a composite of death, transplant, or LV assist device insertion (p = 0.046).
Conclusions
Mini-MVR is safe in advanced cardiomyopathy, and resulted in no recurrent MR, stabilization of LVEF and LV dimensions, and a decrease in RVSP. This mini-MVR fibrillating technique can be used to address severe MR in patients with advanced cardiomyopathy.
doi:10.1016/j.jtcvs.2013.10.062
PMCID: PMC4050032  PMID: 24332110
Mitral valve; surgery; cardiomyopathy; echocardiography
21.  Rodent Brain Slice Model for the Study of White Matter Injury 
The Journal of thoracic and cardiovascular surgery  2013;146(6):10.1016/j.jtcvs.2013.02.071.
OBJECTIVE
Cerebral white matter (WM) injury is common after cardiac surgery in neonates and young infants who have brain immaturity and genetic abnormalities. In order to understand better the mechanisms associated with WM injury, we tested the adequacy of a novel ex-vivo brain slice model, with a particular focus on how the maturational stage modulates the injury.
METHODS
To replicate conditions of cardiopulmonary bypass living brain slices were transferred to a closed chamber perfused by artificial cerebrospinal-fluid under controlled temperature and oxygenation. Oxygen-glucose deprivation (OGD) simulated circulatory arrest. The effects of maturation were investigated in 7 and 21-day-old mice (P7, P21) that are equivalent in maturation stage to the human fetus and young adult.
RESULTS
There were no morphological changes in axons after 60 min OGD at 15°C in both P7 and P21 WM. Higher temperature and longer duration of OGD were associated with significantly greater WM axonal damage, suggesting that the model replicates the injury seen after hypothermic circulatory arrest. The axonal damage at P7 was significantly less than at P21 demonstrating that immature axons are more resistant than mature axons. Conversely, a significant increase in caspase3+ oligodendrocytes in P7 mice was identified relative to P21, indicating that oligodendrocytes in immature WM are more vulnerable than oligodendrocytes in mature WM.
CONCLUSIONS
Neuroprotective strategies for immature WM may need to focus on reducing oligodendrocyte injury. The brain slice model will be helpful in understanding the effects of cardiac surgery on the immature brain and the brain with genetic abnormalities.
doi:10.1016/j.jtcvs.2013.02.071
PMCID: PMC3724768  PMID: 23540655
22.  Short-term reduction in intrinsic heart rate during biventricular pacing after cardiac surgery: A substudy of a randomized clinical trial 
The Journal of thoracic and cardiovascular surgery  2013;146(6):10.1016/j.jtcvs.2013.06.056.
Background
The Biventricular Pacing After Cardiac Surgery trial investigates hemodynamics of temporary pacing in selected patients at risk of left ventricular dysfunction. This trial demonstrates improved hemodynamics during optimized biventricular pacing compared with atrial pacing at the same heart rate 1 and 2 hours after bypass and reduced vasoactive-inotropic score over the first 4 hours after bypass. However, this advantage of biventricular versus atrial pacing disappears 12 to 24 hours later. We hypothesized that changes in intrinsic heart rate can explain variable effects of atrial pacing in this setting.
Methods
Heart rate, mean arterial pressure, cardiac output, and medications depressing heart rate were analyzed in patients randomized to continuous biventricular pacing (n = 16) or standard of care (n = 18).
Results
During 30-second testing periods without pacing, intrinsic heart rate was lower in the paced group 12 to 24 hours after bypass (76.5 ± 17.5 vs 91.7 ± 13.0 beats per minute; P = .040) but not 1 or 2 hours after bypass. Cardiac output (4.4 ± 1.2 vs 3.6 ± 1.9 L/min; P = .054) and stroke volume (53 ± 2 vs 42 ± 2 mL; P = .051) increased overnight in the paced group. Vasoactive medication doses were not different between groups, whereas dexmedetomidine administration was prolonged over postoperative hours 12 to 24 in the paced group (793 ± 528 vs 478 ± 295 minutes; P = .013).
Conclusions
These observations suggest that hemodynamic benefits of biventricular pacing 12 to 24 hours after cardiopulmonary bypass lead to withdrawal of sympathetic drive and decreased intrinsic heart rate. Depression of intrinsic rate increases the apparent benefit of atrial pacing in the chronically paced group but not in the control group. Additional study is needed to define clinical benefits of these effects.
doi:10.1016/j.jtcvs.2013.06.056
PMCID: PMC3887446  PMID: 24075465
23.  Attaining proficiency with endobronchial ultrasound-guided transbronchial needle aspiration 
Objectives
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is becoming the preferred method of mediastinal staging for lung cancer. We investigated the learning curve for EBUS-TBNA using risk-adjusted cumulative sum (Cusum).
Methods
A retrospective study of EBUS-TBNA was performed at a single academic institution for patients with mediastinal or hilar lymphadenopathy in the setting of proven or suspected lung cancer. A sampling pass was defined as a full retraction and repositioning of the aspiration needle. Rapid on-site evaluation was not available. To track proficiency, risk-adjusted Cusum analysis was performed using acceptable and unacceptable failure rates of 10% and 20%, respectively. Failure was defined as false negative or nondiagnostic results.
Results
During the study period, 231 patients underwent EBUS-TBNA. Prevalence of mediastinal or hilar malignancy was 66.7% (154 out of 231). Sensitivity was 92.2% (142 out of 154), and negative predictive value was 87.9% (58 out of 66). Node size was identified as a significant predictor of EBUS-TBNA success by multiple regression. Risk-adjusted Cusum analysis demonstrated that the first and only unacceptable decision interval was crossed at 22 cases. Individual practitioner learning curves were highly variable, and the operator with the highest volume was the most consistently proficient.
Conclusions
In our experience, attainment of an acceptable failure rate for EBUS-TBNA required 22 cases. Node size is a predictor of EBUS-TBNA success. Risk-adjusted Cusum proved a powerful evaluative tool to monitor the training process of this new procedure.
doi:10.1016/j.jtcvs.2013.07.077
PMCID: PMC3981557  PMID: 24075565
25.  Factors Associated with In-Hospital Mortality in Infants Undergoing Heart Transplantation in the United States 
Objective
Infants undergoing heart transplantation have the highest early posttransplant mortality of any age group. We sought to determine the pretransplantation factors associated with in-hospital mortality in transplanted infants in the current era.
Methods
All infants under 12 months of age who underwent primary heart transplantation during a recent 10-year period (1999-2009) in the United States were identified using the Organ Procurement and Transplant Network database. Multivariable logistic regression was used to identify independent pretransplantation factors associated with in-hospital mortality.
Results
Of 730 infants in the study (median age 3.8 months), 462 (63%) had congenital heart disease, 282 (39%) were supported by a ventilator, 94 (13%) with extracorporeal membrane oxygenation, and 22 (3%) with a ventricular assist device at the time of transplantation. Overall, 82 (11.2%) infants died before their initial hospital discharge. In adjusted analysis, in-hospital mortality was associated with repaired congenital heart disease (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.8, 7.2), unrepaired congenital heart disease not on prostaglandin E (OR, 2.8; CI, 1.3, 6.1), extracorporeal membrane oxygenator support (OR, 6.1; CI, 2.8, 13.4), ventilator support (OR, 4.4; CI, 2.3, 8.3), creatinine clearance less than 40 mL · min−1 · 1.73 m−2 (OR, 3.1; CI, 1.7, 5.3), and dialysis (OR, 6.2; CI, 2.1, 18.3) at transplantation.
Conclusions
One in 9 infants undergoing heart transplantation dies before hospital discharge. Pretranplantation factors associated with early mortality include congenital heart disease, extracorporeal membrane oxygenator support, mechanical ventilation, and renal failure. Risk stratification for early posttransplant mortality among infants listed for heart transplantation may improve decision-making for transplant eligibility, organ allocation, and posttransplant interventions to reduce mortality.
doi:10.1016/j.jtcvs.2010.10.025
PMCID: PMC4249584  PMID: 21241863

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