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It has been postulated that a possible barrier to pursuing cardiothoracic surgery is a lack of exposure and mentorship during training. In 2006, The Society of Thoracic Surgeons began the Looking to the Future Scholarship to expand interest in the field. Undecided trainees with limited exposure were prioritized in the selection process. This report summarizes the career outcomes of general surgery resident and medical student recipients. Scholarship recipients and nonrecipients (control) were queried in a Google search. The percentage of those who were cardiothoracic surgeons or in cardiothoracic training (%CTS) was calculated, as well as the percentage of female surgeons in cardiothoracic surgery. From 2006 to 2021, there were 669 awardees. The %CTS was 63.7% for resident recipients and 31.4% for students, respectively. There was no significant difference in %CTS between resident and student recipients compared to nonrecipients. Notably, the percentage of female cardiothoracic surgeons was significantly greater for both resident and student recipients. The majority of resident recipients are now in cardiothoracic surgery, comparable to nonrecipients. While there was no significant difference between the percentage of recipients and non-recipients in cardiothoracic surgery, these groups differed substantially as nonrecipients had greater exposure and commitment to the field at the time of application. [ABSTRACT FROM AUTHOR]

With the implementation of the new heart allocation system, heart transplantation teams are prompted to reevaluate management of patients requiring mechanical circulatory support. The purpose of our study is to compare the outcomes of patients supported with extracorporeal membrane oxygenation (ECMO) before transplantation. The United Network for Organ Sharing database was queried for all adult patients (aged 18 years or more) who required support with ECMO before heart transplantation from 2001 to 2018. Patients were stratified into patients who did not require ECMO before transplantation, who were weaned off ECMO before transplantation, who were bridged immediately to transplantation from ECMO, and who were bridged to a left ventricular assist device (LVAD) before transplantation. Demographics and outcomes including 1-year survival, postoperative stroke, postoperative renal failure requiring dialysis, episodes of rejection, and graft failure were compared. Overall, 29,370 patients did not require ECMO before transplantation, 101 patients were weaned off ECMO before transplantation, 118 were bridged from ECMO directly to transplantation, and 55 patients were successfully bridged from ECMO to LVAD before transplantation. Kaplan-Meier survival estimates found a statistically significant decrease in 1-year survival for patients who were bridged from ECMO to transplantation compared with patients who were bridged to LVAD before subsequent transplantation (P <.001). Our study suggests bridging ECMO patients to an LVAD before transplantation will result in improved 1-year survival compared with patients bridged to immediate transplantation. With the new heart allocation system, continued evaluation of outcomes is required to inform management strategies. [ABSTRACT FROM AUTHOR]

Heart transplantation is the mainstay of treatment for patients in end-stage heart failure. This study sought to contrast survival after transplantation with that of the general population to quantify standardized mortality rates using a nested case-control study design. Control subjects were noninstitutionalized inhabitants of the United States identified through the National Longitudinal Mortality study. Case subjects were adults who underwent heart transplantation between 1990 and 2007 and identified through the Organ Procurement and Transplantation Network. Propensity-matching (5:1, nearest neighbor, caliper = 0.1) was utilized to identify suitable control subjects based on age, sex, race, and state of permanent residency. The primary study endpoint was 10-year survival. In all, 31,883 heart transplant recipients were matched to 159,415 noninstitutionalized residents of the United States. The 10-year survival of heart transplant recipients was 53%. The population expected mortality rate was 15.9 deaths per 100 person-years with an observed rate of 45.1 deaths per 100 person-years (standardized mortality rate [SMR] 2.84; 95% confidence interval, 2.82 to 2.87). The broadest gaps between observed and expected survival were evident in female (SMR 3.63), black (SMR 3.67), and Hispanic (SMR 4.12) recipients. Standardized mortality ratios declined over time (1990 to 1995, 3.09; 1996 to 2000, 2.90; 2001 to 2007, 2.58). The long-term standardized survival of older recipients was closest to that expected for their age. Heart transplant recipients have considerable long-term survival and have a threefold higher standardized long-term mortality rate than that of the noninstitutionalized population. Long-term mortality rates have consistently declined over time and will likely continue to decrease. [ABSTRACT FROM AUTHOR]

Survival after heart transplantation is typically reported only in terms of overall survival. Conditional survival may provide prognostic information for patients after surviving a given period. This study sought to provide an analysis of conditional survival in heart transplantation. Data from 29,000 patients who underwent heart transplantation between 2002 and 2016 were analyzed from the Organ Procurement and Transplantation Network database, and 5-year conditional survival rates were calculated according to age, sex, race, renal function, and hepatic function at transplantation. As time from transplantation increased from 0 to 5 years, the 5-year observed conditional survival changed from 74% to 82% for ages younger than 40 years, 79% to 82% for ages 40 to 49, 79% to 78% for ages 50 to 60, and 75% to 70% for ages older than 60 at transplantation. Conditional survival peaked at 1 and 2 years after transplantation for most subgroups. In recipients younger than 40 years, men had slightly higher conditional survival than women (absolute difference, 3%-4%). In recipients older than 60 years, women had slightly higher conditional survival (absolute difference, 1%-4%). Black recipients had lower survival than white and Hispanic recipients for nearly all time points. Recipients younger than 40 years with the worst renal (65% to 88%) and hepatic function (66% to 83%) at transplantation experienced the largest increase in conditional survival. The conditional survival of patients who undergo heart transplantation changes substantially over time. The largest increases in conditional survival are in young patients with impaired renal and hepatic function. Conditional survival can provide more accurate prognostic information for heart recipients who survive a given period after transplantation. [ABSTRACT FROM AUTHOR]

The utilization of multiorgan transplantation in cardiac transplantation has steadily increased over the past several years. We sought to characterize the trends and outcomes in simultaneous heart and other organ transplantation compared with heart transplantation alone. The United Network for Organ Sharing database was queried for all adult patients (age ≥ 18 y) who underwent isolated heart transplantation or simultaneous heart-lung or heart-kidney transplantation from 1987-2016. Patients were stratified into 3 equal time intervals. Demographics and postoperative outcomes were compared. A total of 58,060 patients were identified with a distribution based on era. Dual organ recipients had more factors associated with increased operative risk including higher rates of diabetes, pulmonary hypertension, intensive care unit admissions, and dialysis prior to transplantation. Heart-lung and heart-kidney recipients had decreased 1-year survival compared with isolated heart recipients from 2007-2016. However, heart-kidney recipients had significantly increased 5-year post-transplantation survival compared with isolated heart recipients with impaired renal function. For isolated heart transplants and heart-lung transplants, 5-year survival rates improved over time, whereas 5-year survival for heart-kidney recipients did not improve with time. We found a significantly increased 5-year survival rate for heart-kidney transplant recipients compared with isolated heart transplant recipients with renal impairment. Lack of improvement in 5-year postoperative outcomes for heart-kidney recipients in the setting of higher-risk pretransplant clinical characteristics suggests decreased selectivity regarding heart-kidney recipients. Continued scrutiny and evaluation of postoperative outcomes are required to ensure just and appropriate utilization of organs. [ABSTRACT FROM AUTHOR]

Left ventricular assist devices (LVADs) are the most common mode of circulatory support for patients awaiting heart transplantation. Unfortunately, a fraction of these patients require pump exchange during their course for pump-related adverse events. This study examined whether LVAD exchanges affect posttransplantation outcomes. This study focused on adult patients in the Organ Procurement and Transplantation Network database who were bridged to transplant with a LVAD implanted between 2007 and 2017. Patients who underwent LVAD exchange were compared with those supported with a single device. The primary end point was all-cause mortality at 1, 2, and 5 years after transplantation. The impact of device exchange on risk-adjusted outcomes was examined using Cox proportional hazards models. Among 8239 patients who met the inclusion criteria, there were 611 pump exchanges in 560 patients (7% of recipients). The pump exchange rate was 6.24 events per 100 patient-years. Survival at 5 years was lower for those who underwent LVAD exchange (69.4% vs 77.5%, log-rank P =.027). This finding was similar for risk-adjusted 5-year mortality (hazard ratio, 1.36; 95% confidence interval, 1.11 to 1.67; P =.003). Subgroup analysis revealed lower 5-year survival for female recipients who underwent LVAD exchange (55.4% vs 79.7%, log-rank P <.001). The interaction between female sex and LVAD exchange was associated with increased risk-adjusted 5-year mortality (hazard ratio, 1.65; 95% confidence interval, 1.05 to 2.59; P =.030). Recipients who underwent pump exchange while awaiting heart transplantation had a higher mortality compared with those on a primary device. Subgroup analysis revealed a marked increase in mortality of female recipients who experienced LVAD exchange. [ABSTRACT FROM AUTHOR]

Phenotypic matching in heart transplantation, where donors and recipients are matched based on physical characteristics, has been previously limited to only analyzing individual variables such as sex and age. This study examines the effects of phenotypic matching utilizing multiple factors simultaneously. Adult patients undergoing heart transplantation between 2006 and 2016 were identified from the Organ Procurement and Transplantation Network database. Phenotypic matching was defined based on six factors: body mass index difference >30%, age difference >30%, height difference >7%, non-identical ABO blood grouping, race, and sex. A value between 0 and 1 mismatched characteristics was considered phenotypically like matching, whereas 2-6 mismatches was considered phenotypically unlike matching. The primary study endpoint was 1-year survival. Risk-adjusted mortality was examined with multivariable Cox regression models. During the study period, 20,052 adult patients underwent heart transplantation, of whom 9595 (47.9%) were phenotypically like and 10,457 (52.1%) were phenotypically unlike matched. No differences in 1-year survival were seen between like and unlike matched patients (risk-adjusted odds ratio 1.05, 95% confidence interval 0.96-1.15, P =.305) after controlling for clinically relevant covariates. Subgroup analyses did not demonstrate survival differences after stratification based on hospital transplant volume and initial waitlist status. Phenotypically like matched patients had longer waiting times compared with unlike matched patients overall (225 days vs 192 days, P <.001). Waiting for a phenotypically matched heart provides no survival benefit and exposes patients to prolonged waitlist times. These findings challenge the notion that a perfect donor heart exists, when in fact this concept may be a misnomer. [ABSTRACT FROM AUTHOR]

Left ventricular assist devices (LVADs) are an effective therapy in bridging patients with end-stage heart failure to heart transplantation. The aim of this study was to identify the role of race in survival of patients bridged to heart transplantation with a LVAD. The United Network of Organ Sharing database was queried for all adult heart transplant recipients (age 18 years or older) who were bridged to transplantation with a LVAD from 2005 to 2018. Patients were stratified based on their race, with whites as the reference group. Demographic characteristics, 5-year survival, and graft failure after transplantation were assessed with χ2 test, analysis of variance, Kaplan-Meier survival analyses, log-rank tests, and Cox proportional hazards modeling or logistic regression modeling as appropriate. Patients (N = 6476) successfully bridged with a LVAD to heart transplantation were identified. There were 4263 whites, 1536 African Americans, 508 Hispanics, and 169 Asians. Compared with whites, African Americans had higher body mass indexes, were more likely to be women, pay with private insurance, and be working for income at the time of transplantation. African Americans were found to have increased odds of graft failure (odds ratio 1.27, P =.048) compared with whites. In addition, African Americans were found to have increased risk of mortality at 5 years (hazard ratio 1.26, P =.003). The African American race is associated with increased rates of graft failure after transplantation and decreased 5-year survival compared with the white race. Given these findings, directed clinical attention may be warranted in African American patients bridged to heart transplantation with a LVAD. [ABSTRACT FROM AUTHOR]

Left ventricular assist devices are increasingly used as bridge-to-transplantation in eligible patients. The HeartMate 3 (HM3; Abbott Laboratories, Abbot Park, IL) is the latest device to obtain US Food and Drug Administration approval as bridge-to-transplantation. This study examines early outcomes of transplant recipients after HM3 in comparison with recipients bridged with the HeartMate 2 (HM2; Abbott Laboratories) and HeartWare Ventricular Assist System (HVAD; Medtronic, Minneapolis, MN) devices. Using the Organ Procurement and Transplantation Network database, we identified all adult patients who were slated for bridge-to-transplantation with a continuous-flow left ventricular assist devices (HM2, HVAD, or HM3) between April 1, 2015 and January 31, 2018. The primary endpoint was all-cause mortality 6 months after transplantation. The independent influence of the bridging device on outcomes was determined using Cox proportional hazard models. Patients (N = 1,978) were successfully bridged to transplantation with the HM2 (n = 881), HVAD (n = 920), or HM3 (n = 177) device. Six-month mortality rates were similar across these devices (HM2, 5.9%; HVAD, 7.7%; HM3, 4.7%; log-rank p = 0.30). On average HM2 patients were on a left ventricular assist device for 2 months longer (p < 0.01). The HVAD had the lowest rate of device exchange before transplant (p = 0.01). The HM3 had no events of pump thrombosis (p < 0.01). HVAD patients had the lowest rate of device malfunction before to transplant (p < 0.01). Panel reactive antibodies at the time of transplantation were lower for HM3 patients (p < 0.01); however rates of graft rejection at 6 months were not different (p = 0.25). The HM3 device provides excellent early outcomes as a bridge to transplantation and may be associated with a reduction in comorbidities. Longer follow-up is needed to better define differences between durable left ventricular assist devices. [ABSTRACT FROM AUTHOR]

Background This study evaluated outcomes of reoperative mitral valve surgery (MVS) in the United States. Methods Adults undergoing isolated MVS with prior open-heart operation in The Society of Thoracic Surgeons (STS) National Database between July 2011 and September 2016 were included. Urgent or emergent operations as well as all indications and causes for MVS were included. Primary outcomes were operative mortality and morbidity. Multivariable models were used for risk-adjustment, incorporating variables from the STS Valve Risk Model as well as type of prior operation and reoperative approach. Results A total of 17,195 patients underwent isolated reoperative MVS at 962 centers. The STS predicted risk of mortality was 8.0%, with 20% having an STS predicted risk of mortality greater than 10%. Prior cardiac operations included previous MVS (61%), coronary artery bypass (39%), aortic valve surgery (18%), and tricuspid valve surgery (6%). Operative mortality for the overall study cohort was 6.6%, and postoperative stroke occurred in 2.4%. Observed-to-expected mortality for the overall cohort was 0.82. The strongest independent predictors of operative mortality included salvage operation, preoperative dialysis dependence, congestive heart failure, recent myocardial infarction, and active endocarditis. Prior aortic valve replacement was associated with increased mortality risk, whereas prior MVS reduced mortality risk. Surgical approach did not affect mortality. For patients with prior MVS undergoing elective, non-endocarditis operations, the operative mortality was 3.4%. Conclusions Despite a high-risk patient profile, surgical outcomes of reoperative MVS were acceptable, particularly in patients with prior MVS and without endocarditis undergoing elective operations. [ABSTRACT FROM AUTHOR]

Background Long-term survivors after implantation of left ventricular assist devices (LVADs) are increasing in prevalence. We describe the characteristics and outcomes in patients surviving longer than 4 years on LVAD support. Methods We performed a multicenter, retrospective analysis of patients surviving at least 4 years on continuous-flow LVAD (CF-LVAD) support with a HeartMate II at centers participating in the Evolving Mechanical support Research Group. Results Between 2005 and 2010, 156 long-term survivors were identified with a mean survival of 7.1 years (95% confidence interval: 6.7 to 7.5 years). The mean age was 58.2 ± 15.2 years and 30.1% were women. Readmission rate was low at 1.1 events per patient per year with the most common reasons leading to readmission being infection (0.10 readmissions per patient per year) and gastrointestinal bleeding (0.07 readmissions per patient per year). Two years after implantation, 97% of patients were either New York Heart Association functional class I or II, with 92% at 4 years. Conclusions Patients surviving 4 years on CF-LVAD support can anticipate ongoing long-term survival with sustained improvements in functionality and low rates of rehospitalization. [ABSTRACT FROM AUTHOR]

Background In this study we derive and validate a composite risk index termed the Assessment of Thoracic Endografting Operative Mortality, or ATOM, risk score. Methods All thoracic endovascular aortic repairs (TEVAR) in the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) between 2005 and 2012 were identified. The primary outcome was operative mortality. After evaluating the association of over 60 preoperative variables and operative mortality in univariate analysis, a multivariable model was developed. Significant risk factors were assigned points equivalent to their odds ratio rounded to the nearest whole integer in the final multivariable model. Results Overall, 1,981 patients comprised the study population, including 1,486 (75.0%) in the derivation and 495 (25.0%) in the validation cohort. There were 173 (8.7%) operative mortalities. A 30-point risk score incorporating 10 risk factors was generated and found to be highly predictive of operative mortality in the derivation (odds ratio [OR] 1.36, p < 0.001) and validation cohorts (OR 1.24, p < 0.001). The models used to create and validate the ATOM score were robust (C indices 0.84 and 0.83, respectively). There was strong correlation between predicted mortality rates based on the derivation cohort and actual mortality rates in the validation cohort (r = 0.75, p < 0.001). Operative mortality based on low (ATOM < 5), moderate (ATOM 5 to 9), and high risk (ATOM ≥ 10) was 1.3%, 6.6%, and 24.0%, respectively ( p < 0.001). Higher ATOM scores also correlated with higher complication rates and longer hospital stays. Conclusions The ATOM score is a significant predictor of operative mortality in TEVAR and can be used for preoperative risk stratification. [ABSTRACT FROM AUTHOR]

This report describes the case of a 49-year-old man with a medical history significant for congenital aortic stenosis. The patient presented with progressive shortness of breath and decreased stamina and was found to have a concentric, diminutive porcelain ascending aorta with diffuse supravalvular aortic stenosis. We describe treatment with an aortic root augmentation and Bentall procedure using hypothermic circulatory arrest. [ABSTRACT FROM AUTHOR]

Pseudoachalasia is a rare clinical diagnosis with diverse manifestations. We present the case of a 22-year-old male with esophageal adenocarcinoma who was initially diagnosed with achalasia. This unfortunate presentation reinforces the importance of a careful preoperative workup for dysphagia irrespective of age. [ABSTRACT FROM AUTHOR]

Background: With the relative paucity of acceptable donors for lung transplantation, criteria for extended donor consideration are being explored. We sought to evaluate the suitability of donors whose cause of death was asphyxiation or drowning (A/D) as a potential option to enlarge the donor pool., Methods: We queried the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research registry for lung transplantation from 1987 to 2010 to assess associations between cause of death and recipient survival using the Kaplan-Meier method. To adjust for potential confounders, we used a Cox proportional hazards model and a logistic regression model to evaluate incidence of rejection within the first year., Results: There were 18,250 adult primary lung transplantations performed, with 309 A/D donors. There was no difference in survival between groups (log-rank, p = 0.52). There were no differences in demographics, length of stay, airway dehiscence, lung allocation score (LAS), or ischemic time in univariate analysis (all p > 0.05). The A/D lung recipients had fewer deaths from pulmonary causes (5.8% versus 9.5%; p = 0.02). Proportional hazards analysis was significant for double lung transplantation (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.8-0.9), height difference (HR, 1.002; 95% CI, 1.00-1.003), donor age greater than 50 years (HR, 0.89; 95% CI, 0.83-0.96), and recipient age greater than 55 years (HR, 0.8; 95% CI, 0.76-0.84). A/D cause of death did not impact survival in multivariate analysis., Conclusions: A/D as a donor cause of death was not associated with poor long-term survival or incidence of rejection in the first year after transplantation. Donor cause of death by A/D, when carefully evaluated and selected, should not automatically exclude the organ from transplant consideration. These results provide important justification for potentially broadening the donor pool safely., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)