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Background: Outcomes after hemiarch repair for acute DeBakey type I aortic dissection (ADTI) remain unfavorable, with high rates of major adverse events and negative aortic remodeling. The PERSEVERE study evaluates the safety and effectiveness of the AMDS Hybrid prosthesis, a novel bare metal stent, in patients presenting with preoperative malperfusion., Methods: PERSEVERE is a prospective single-arm investigational study conducted at 26 sites in the United States. Ninety-three patients underwent ADTI aortic dissection repair with AMDS implantation. The 30-day primary endpoints are a composite rate of 4 major adverse events and the rate of distal anastomotic new entry tears. The secondary endpoints include aortic remodeling., Results: Clinical malperfusion was documented in 76 patients (82%); only radiographic malperfusion, in 17 (18%). The median follow-up in the 93 patients was 5.6 months. Within 30 days, 9 patients died (9.7%), 10 patients (10.8%) experienced new disabling stroke, and 18 patients (19.4%) had new-onset renal failure requiring ≥1 dialysis treatment. There were no cases of myocardial infarction. The composite rate of major adverse events (27%) was lower than that reported in the reference cohort (58%). There were no distal anastomotic new entry tears. Technical success was achieved in 99% of patients. Early remodeling indicated total aortic diameter stability, true lumen expansion, and false lumen reduction in the treated aortic segment., Conclusions: Early results show significant reductions in major adverse events and distal anastomotic new entry tears, successfully meeting both primary endpoints. The technical success rate was high. AMDS can be used safely in patients with ADTI dissection with malperfusion., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Background: The relationship between the number and type of postoperative complications and mortality in the setting for surgery for acute type A aortic dissection (ATAAD) remains underexplored despite its critical role in the failure-to-rescue (FTR) metric., Methods: This retrospective study used data from the Society of Thoracic Surgeons Adult Cardiac Surgical Database on ATAAD surgeries performed between January 2018 and December 2022. Patients were categorized based on their number of major complications. The primary outcome was FTR. We used multilevel regression and classification and regression tree models., Results: We included 19,243 patients (33% females), with a median age of 61 years. Regarding complications, 47.7% of patients had 0, 20.2% had 1, 12.7% had 2, and 19.4% experienced 3 or more. The most frequently reported complications were prolonged mechanical ventilation (30.3%), unplanned reoperation (19.5%), and renal failure (17.2%). Cardiac arrest occurred in 7.1% of cases. FTR increased from 13% in patients with 1 complication to >30% in those with 4 or more complications. Cardiac arrest (adjusted odds ratio [aOR], 10.9) and renal failure (aOR, 5.3) had the highest odds for mortality, followed by limb ischemia (aOR, 2.7), stroke (aOR, 2.6), and gastrointestinal complications (aOR, 2.4). Hospitals in the top performance quartile consistently showed lower FTR rates across all levels of complication., Conclusions: The study validates a dose-response association between postoperative complications and mortality in patients undergoing surgery for ATAAD. Top-performing hospitals consistently show lower FTR rates independent of the number of complications. Future research should focus on the timing of complications and interventions to reduce the burden of complications., Competing Interests: Conflict of Interest Statement I.S. and D.S. receive institutional research support from Abbott, Medtronic, Boston Scientific, Cryolife, and Atricure; WS is an investigator, speaker and advisory board member for Edwards Lifesciences, Medtronic, Artivion, Terumo Aortic, Abbott. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Traditionally, acute uncomplicated type B aortic dissections are managed medically, and acute complicated dissections are managed surgically. Self-pay patients with medically managed acute uncomplicated type B aortic dissections may fare worse than their insured counterparts., Methods: In this single-center, retrospective cohort study, demographics, follow-up, and outcomes of patients with acute type B aortic dissections from 2011 to 2020 were analyzed., Results: In total, 159 patients presented with acute type B aortic dissections; 102 were complicated and managed with thoracic endovascular aortic repair, and 57 were uncomplicated and managed medically. A total of 32% (n = 51) were self-pay. Self-pay patients were from areas with worse area deprivation indices (71% vs 63%, P = .024). They more often reported alcohol abuse (28% vs 7%, P < .001), cocaine/methamphetamine use (16% vs 5%, P = .028), and nonadherence to home antihypertensives (35% vs 11%, P < .001). Self-pay patients less often had a primary care physician (65% vs 7%, P < .001) or took antihypertensives before admission (31% vs 58%, P = .003). Self-pay patients frequently required financial assistance at discharge (63%), most often using charity funds (46%). Few patients (7%) qualified for our hospital's financial assistance program, and most (78%) remained uninsured at the first follow-up. Self-pay acute uncomplicated type B aortic dissections patients had the lowest rate of follow-up (31% vs 66%, P < .001) and were more likely to represent emergently (75% vs 0%, P = .033) compared to insured acute uncomplicated type B aortic dissections patients. Self-pay patients were more likely to follow up after thoracic endovascular aortic repair for acute complicated type B aortic dissections (82% vs 31%, P < .001)., Conclusion: Self-pay patients have multiple, interconnected, complex socioeconomic factors that likely influence preadmission risk for dissection and post-discharge adherence to optimal medical management. Further research is needed to clarify treatment strategies in this high-risk group., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The COVID-19 pandemic significantly affected health care and in particular surgical volume. However, no data surrounding lost hospital revenue due to decreased cardiac surgical volume have been reported. The National Inpatient Sample database was used with decreases in cardiac surgery at a single center to generate a national estimate of decreased cardiac operative volume. Hospital charges and provided charge to cost ratios were used to create estimates of lost hospital revenue, adjusted for 2020 dollars. The COVID period was defined as January to May of 2020. A Gompertz function was used to model cardiac volume growth to pre-COVID levels. Single center cardiac case demographics were internally compared during January to May for 2019 and 2020 to create an estimate of volume reduction due to COVID. The maximum decrease in cardiac surgical volume was 28.3%. Cumulative case volume and hospital revenue loss during the COVID months as well as the recovery period totaled over 35 thousand cases and 2.5 billion dollars. Institutionally, patients during COVID months were younger, more frequently undergoing a CABG procedure, and had a longer length of stay. The pandemic caused a significant decrease in cardiac surgical volume and a subsequent decrease in hospital revenue. This data can be used to address the accumulated surgical backlog and programmatic changes for future occurrences., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To determine the relationship between volume of cases and failure-to-rescue (FTR) rate after surgery for acute type A aortic dissection (ATAAD) across the United States., Methods: The Society of Thoracic Surgeons adult cardiac surgery database was used to review outcomes of surgery after ATAAD between June 2017 and December 2021. Mixed-effect models and restricted cubic splines were used to determine the risk-adjusted relationships between ATAAD average volume and FTR rate. FTR calculation was based on deaths associated with the following complications: venous thromboembolism/deep venous thrombosis, stroke, renal failure, mechanical ventilation >48 hours, sepsis, gastrointestinal complications, cardiopulmonary resuscitation, and unplanned reoperation., Results: In total, 18,192 patients underwent surgery for ATAAD in 832 centers. The included hospitals' median volume was 2.2 cases/year (interquartile range [IQR], 0.9-5.8). Quartiles' distribution was 615 centers in the first (1.3 cases/year, IQR, 0.4-2.9); 123 centers in the second (8 cases/year, IQR, 6.7-10.2); 66 centers in the third (15.6 cases/year, IQR, 14.2-18); and 28 centers in the fourth quartile (29.3 cases/year, IQR, 28.8-46.0). Fourth-quartile hospitals performed more extensive procedures. Overall complication, mortality, and FTR rates were 52.6%, 14.2%, and 21.7%, respectively. Risk-adjusted analysis demonstrated increased odds of FTR when the average volume was fewer than 10 cases per year., Conclusions: Although high-volume centers performed more complex procedures than low-volume centers, their operative mortality was lower, perhaps reflecting their ability to rescue patients and mitigate complications. An average of fewer than 10 cases per year at an institution is associated with increased odds of failure to rescue patients after ATAAD repair., Competing Interests: Conflict of Interest Statement I.S. and D.S.G. report institutional research support from Abbott, Medtronic, Boston Scientific, CryoLife, and AtriCure (none relevant). W.Y.S. reports Edwards Lifesciences, Medtronic, Artivion, Terumo Aortic, Abbott: investigator, speaker, advisory board. D.C. reports Sanamedi, Inc: proctor, consultant; and The Osler Institute: faculty. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023. Published by Elsevier Inc.)

Mechanical ventilation during cardiothoracic surgery is life-saving but can lead to ventilator-induced diaphragm dysfunction (VIDD) and prolong ventilator weaning and hospital length of stay. Intraoperative phrenic nerve stimulation may preserve diaphragm force production to offset VIDD; we also investigated changes in mitochondrial function after stimulation. During cardiothoracic surgeries ( n = 21), supramaximal, unilateral phrenic nerve stimulation was performed every 30 min for 1 min. Diaphragm biopsies were collected after the last stimulation and analyzed for mitochondrial respiration in permeabilized fibers and protein expression and enzymatic activity of biomarkers of oxidative stress and mitophagy. Patients received, on average, 6.2 ± 1.9 stimulation bouts. Stimulated hemidiaphragms showed lower leak respiration, maximum electron transport system (ETS) capacities, oxidative phosphorylation (OXPHOS), and spare capacity compared with unstimulated sides. There were no significant differences between mitochondrial enzyme activities and oxidative stress and mitophagy protein expression levels. Intraoperative phrenic nerve electrical stimulation led to an acute decrease of mitochondrial respiration in the stimulated hemidiaphragm, without differences in biomarkers of mitophagy or oxidative stress. Future studies warrant investigating optimal stimulation doses and testing post-operative chronic stimulation effects on weaning from the ventilator and rehabilitation outcomes.

Objectives: The study objectives were to determine the prevalence of swallowing impairment in adults after cardiac surgery and examine associated risk factors and health-related outcomes., Methods: A prospective single-center study was conducted in postoperative adult cardiac surgery patients with no history of dysphagia. A standardized fiberoptic endoscopic evaluation of swallowing was performed within 72 hours of extubation. Blinded raters completed validated outcomes of swallowing safety and efficiency. Demographic, surgical, and postoperative health-related outcomes were collected. Univariate and multivariable regression analyses were performed with odds ratios (OR) and 95% confidence intervals (CIs)., Results: In 182 patients examined, imaging confirmed inefficient swallowing (residue) in 52% of patients and unsafe swallowing in 94% (65% penetrators, 29% aspirators). Silent aspiration was observed in 53% of aspirators, and 32% did not clear aspirate material. Independent risk factors for aspiration included New York Heart Association III and IV (OR, 2.9; CI, 1.2-7.0); reoperation (OR, 2.0; CI, 0.7-5.5); transesophageal echocardiogram images greater than 110 (OR, 2.6; CI, 1.1-6.3); intubation greater than 27 hours (OR, 2.1; CI, 0.8-5.3); and endotracheal tube size 8.0 or greater (OR, 3.1; CI, 1.1-8.6). Patients with 3 or 4 identified risk factors had a 16.4 (CI, 3.2-148.4) and 22.4 (CI, 3.7-244.7) increased odds of aspiration, respectively. Compared with nonaspirators, aspirators waited an additional 85 hours to resume oral intake, incurred $49,372 increased costs, and experienced a 43% longer hospital stay (P < .05). Aspiration was associated with pneumonia (OR, 2.6; CI, 1.1-6.5), reintubation (OR, 5.7; CI, 2.1-14.0), and death (OR, 2.8; CI, 1.2-9.0)., Conclusions: Tracheal aspiration was prevalent, covert, and associated with increased morbidity and mortality., (Published by Elsevier Inc.)

Background: Combining clinical and research excellence has become an increasingly difficult endeavor for thoracic surgeons, with typical success rates for the National Heart, Lung and Blood Institute and the National Cancer Institute being 25.1% and 11.3%, respectively. The Thoracic Surgery Foundation (TSF), which is an arm of The Society of Thoracic Surgeons, provides research awards and grants aimed at early career faculty to assist in securing federal peer-reviewed funding. The aim of this study was to assess the impact of these awards., Methods: Faculty awardees of the TSF research awards from 1995 to 2019 were included in the study. The scholarly work of awardees was assessed by using Scopus , MEDLINE, and Google Scholar for publications, citations, and h-index. The National Institutes of Health (NIH) RePorter and the Federal RePorter were used to search for any grants awarded to these individuals. For publications and citations associated with a TSF grant, a 4-year window from the time of the research award was used., Results: Fifty-two research awards were given to early career faculty during this study period, and 8 (15%) were awarded to MD PhDs. Six (12%) of awardees were female. Cardiac faculty members were awarded 27 (52%) awards, and general thoracic faculty members were awarded 25 (48%); of the cardiac faculty, 4 (17.4%) were congenital cardiac faculty. In the 4-year period after the TSF grant award, the mean number of published articles per awardee was 23 (interquartile range [IQR], 12 to 36), with a median citation count of 147 (IQR, 32 to 327). The current median h-index was 26 (IQR, 15 to 36), with 2323 (IQR, 1173 to 4568) median citations. Forty-eight percent of all awardees received at least 1 subsequent grant; 40.4% of these awardees received grants from the NIH, and 25% had 2 or more NIH grants. Comparing academic position at the time of the award with current position, 54% of awardees had an advancement in their professional rank. On analyzing leadership positions, 42% of awardees were division chiefs, 21% were associate clinical directors, and 28% were clinical directors., Conclusions: Being a recipient of the TSF award may position an individual to excel in academic medicine, with a large portion of awardees improving their academic standing with time. The rate of successful NIH grant funding after being a TSF awardee is higher than typical institutional success rates., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to determine the incidence and contributing risk factors of vocal fold mobility impairment (VFMI) in postoperative cardiovascular patients and evaluate the impact of VFMI on health-related outcomes., Methods: This single-site prospective study enrolled adults undergoing sternotomy or thoracotomy procedures who underwent a fiberoptic laryngoscopy examination within 72 hours of extubation. Potential demographic and surgical risk factors and health-related outcomes were collected. A blinded laryngologist assessed VFMI and mucosal injury. Descriptives, univariate and multivariable regression analyses with odds ratios (OR) were performed., Results: Of 185 eligible examinations, VFMI was confirmed in 25% of patients (7 complete, 39 partial VFMI) with left-sided involvement in 83% of cases. Laryngeal mucosal injury included granuloma (38%), posterior cricoid hypertrophy (37%), edema (29%), bruising (23%), and hemorrhage (9%). Independent risk factors for complete VFMI were aortic arch procedure (odds ratio 6.1), body mass index less than 25 (OR: 7.2), and African-American or Hispanic race (OR: 6.0). Patients with two or more identified risk factors had a 33.0 increased odds of complete VFMI compared with patients not having two or more risk factors. Compared with patients having normal vocal fold motion, patients with complete VFMI had a 2.7 increased odds of pneumonia, 5.7 higher odds of reintubation, a 7.3 times higher odds of death, and increased length of hospital stay and cost of care (P < .05)., Conclusions: Interdisciplinary postoperative care and laryngoscopy examination are recommended for high-risk patients to facilitate early detection and improve patient outcomes., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study examined changes in aortic dissection (AD) mortality from 2006 to 2017 and assessed the impact of weekday versus weekend presentation upon mortality., Methods: This observational study analyzed all records in the Nationwide Emergency Department Sample (NEDS) database. NEDS aggregates discharge data from 984 hospitals in 36 states and the District of Columbia in the United States of America. All patients with thoracic and thoracoabdominal AD recorded as their principal diagnosis were identified via ICD codes., Results: Patient characteristics (weekday|weekend) count: 26,759|9,640, P = 0.016; age (years): 65.2 ± 15.8|64.7 ± 16.2, P = 0.016; women: 11,318 (42.3%)|4,086 (42.4), P = 0.883; Charlson comorbidity index: 2.3 ± 1.7|2.3 ± 1.6, P = 0.025. There were 36,399 ED visits with diagnosed AD. Annual AD diagnoses increased by 70% from 2006 to 2017. From 2012-2017, patients had lower in-hospital mortality (9.9% versus 11.9%, P < 0.001) compared with 2006-2011. Patients reporting during the weekend had higher in-hospital mortality (11.8% versus 10.4%, P < 0.001) compared with weekdays. On multivariable analysis, year of presentation remained independently associated with in-hospital mortality, with 2012-2017 being associated with reduced mortality (odds ratio (OR) 0.90, 95% CI: 0.82, 0.99, P = 0.031), as compared with 2006-2011. Weekend presentation remained independently associated with worse in-hospital mortality (OR 1.17, 95% CI: 1.05, 1.29, P = 0.003) compared with weekday presentation., Conclusion: Although AD mortality is decreasing, the patients presenting on the weekend were 13% more likely to die in the hospital compared with patients presenting during the week., (© 2021 Forum Multimedia Publishing, LLC)

Background: Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data., Methods: Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am., Results: Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference., Conclusions: A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population., (© 2020 Wiley Periodicals LLC.)

Tricuspid valve regurgitation (TR) can be associated with poor prognosis. Transcatheter valve technology was adopted to treat the upstream effects of severe TR by placing a transcatheter valve in the inferior vena cava (IVC). In this study, we report off-label transcatheter valve implantation into the stented IVC in patients with severe TR for compassionate use. From September 2018 to February 2020, 6 inoperable patients with severe TR who failed medical treatment underwent percutaneous caval valve implantation (CAVI). Severity of TR was confirmed by intraoperative transesophageal echocardiography. Z-stents (Cook, Inc., Bloomington, IN, USA) were placed in the proximal IVC, and then a transcatheter valve was deployed in the suprahepatic cava without rapid pacing. Six patients, 2 females and 4 males, with a mean ± SD age of 74.7 ± 8.0 years were included. The procedure was successfully performed in all 6 patients (100%) employing a 29-mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, CA, USA) with supranominal volume. No procedural complication was detected. At 30 days, TR improved from severe to trace in 1 patient, to mild-moderate in 3 patients, and 2 patients remained with severe TR. Among patients with improved TR, left ventricular ejection fraction increased from 47.5% ± 18.5% to 55% ± 20.4% ( P = 0.014). No patient had readmission at 30 days. Four patients needed rehospitalization within 6 months. Percutaneous CAVI is feasible and can be considered as a short-term palliative measure in patients with severe TR. CAVI can improve TR and potentially improve cardiac output in selected patients.

Background: Data on primary cardiac malignancies are limited to small single-center studies., Objectives: The aim of the current study was to provide detailed outcomes for treatment of primary cardiac malignancies from a multi-institutional database., Methods: Outcomes were acquired from the National Cancer Database for all solid primary cardiac malignancies from 2004 to 2016. The primary outcome was long-term survival. Logistic regression was used to determine factors associated with mortality., Results: A total of 100,317 cardiac tumors were identified, of which 826 (0.8%) were primary malignant tumors. After exclusion criteria, the cohort consisted of 747 patients (median age 53 years, 47.5% women). Most tumors were primary sarcomas (88.5%), the majority of which were hemangiosarcoma (40.4%). A total of 136 patients received no therapy, 113 received just chemotherapy, and 20 received just radiation. Surgery was performed in 442 (59.2%) patients including 255 patients undergoing multimodal therapy (surgery with chemotherapy, radiation, or chemoradiation). With surgery alone, 90-day mortality was 29.4%. Overall 30-day, 1-year, and 5-year survival rates were 81.2%, 45.3%, and 11.5%, respectively. The surgery group as compared with the no surgery groups had significantly better long-term survival (p < 0.0001). For stage III disease, there was a statistically significant improvement in survival with the addition of chemotherapy to surgery., Conclusions: Primary cardiac malignancies are rare cancers with dismal long-term survival despite mode of treatment. Patients who underwent surgery and those with stage III disease who received peri-operative chemotherapy had better survival compared with those who did not. However, there was likely a significant selection bias in patients chosen for surgical or medical therapy., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: We investigated the outcomes of patients who underwent Transcatheter Aortic Valve Replacement (TAVR) with and without Balloon Aortic Valvuloplasty (BAV) using the SAPIEN 3 (S3) valve., Methods: All patients who underwent TAVR using S3 valve were included. The primary outcomes were the incidence of stroke and significant paravalvular leak (PVL). Secondary outcomes were the incidence of mortality, balloon post dilation, and need for permanent pacemaker., Results: From July-2014 to April-2018, 34 (9%) patients underwent BAV prior to TAVR and 344 (91%) patients underwent direct TAVR without BAV using the S3 valve. The Society of Thoracic Surgeons (STS) risk score was similar between two groups; 5.8 ± 3.5 in no BAV group and 5.4 ± 3.3 in BAV group, p = 0.53. After TAVR, 6 (1.7%) patients in no BAV group but no patient in BAV group developed stroke (p = 1.0). No patient had severe PVL and only 5 patients (1.3%) had moderate PVL at 30-day; 4 (1.2%) in no BAV group and 1 (2.9%) in BAV group (p = 0.38). Forty-six patients (13.4%) in the no BAV group and 4 (11.8%) patients in the BAV group needed balloon post dilation (p = 1.0). Six (1.6%) patients died during hospitalization, all in the no BAV group (p = 1.0). Forty-five (11.9%) patients needed new pacemaker implantation; 44 (12.8%) patients in no BAV group and 1 (2.9%) patient in BAV group (p = 0.1). Two-year survival rate was 85% in no BAV group and 84% in BAV group (p = 0.46)., Conclusions: TAVR using S3 valves is associated with very low rates of post-TAVR stroke and significant PVL. Outcomes of direct TAVR are similar to the outcomes of TAVR with BAV, without an increased rate of stroke, significant PVL, or balloon post dilation., (Copyright © 2019. Published by Elsevier Inc.)

Background: The aim of this study was to evaluate the impact of medical student placement of Foley catheters on rates of postoperative catheter-associated urinary tract infection (CAUTI)., Study Design: We included adult surgical patients in our institutional National Surgical Quality Improvement Program (NSQIP) database, and defined CAUTI according to NSQIP criteria. A multivariable model risk-adjusting for patient and operative variables associated with CAUTI in univariate analysis (exploratory p < 0.20) evaluated the independent effect of medical student placement of Foley catheters on the odds of CAUTI., Results: There were 891 patients who had a Foley catheter placed by a surgical resident (61%; n = 547), operating room nurse (25%; n = 227), or medical student (13%; n = 117). After risk-adjustment, patients with Foleys placed by medical students were at a more than 4-fold increased risk of CAUTI (odds ratio [OR] 4.09, p = 0.02) compared with patients with catheters placed by nurses. Patients with catheters placed by residents did not have an increased risk-adjusted odds of CAUTI (OR 2.16, p = 0.15). Other significant predictors of postoperative CAUTI included female sex (OR 2.61, p = 0.01), partial/total functional dependence (OR 4.81, p = 0.008), blood transfusion (OR 34.7, p = 0.02), and increased length of Foley stay (OR 1.06, p < 0.001)., Conclusions: Surgical patients with Foley catheters placed by medical students are at increased risk-adjusted odds of postoperative CAUTI. More intense supervision of medical students during urinary catheter insertion in the operating room and improved education regarding sterile technique may be important factors in reducing rates of postoperative CAUTI in academic institutions., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Aim: We reviewed our institutional experience with tricuspid valve endocarditis to understand the impact of the opioid epidemic on the incidence of right heart endocarditis., Methods: We retrospectively reviewed all cases of tricuspid endocarditis managed surgically from January of 2011 to May of 2017. There were no exclusion criteria., Results: A total of 126 patients were identified. There were seven cases in 2011 and 36 in 2016. The average age of the patients decreased from 52.85 ± 19.6 years in 2011 to 39.2 ± 12.9 in 2017. Caucasians comprised 71% of the patients in 2011 and 75% in 2016. Tricuspid valve replacement was performed in 74 patients (58.73%) and repair was performed in 52 (41.27%). Thirty-day mortality was 11.11%. Reoperation, stroke and renal failure requiring dialysis during the index hospitalization were 5.6%, 0.8%, and 8%, respectively. Staphylococcus aureus, found in 43% of cases, was the most common isolate throughout the study period. Streptococcus was the second most common causative agent., Conclusions: In a span of 5 years, our institution has noted a fivefold increase in surgical volume for tricuspid endocarditis, most likely related to the impact of the opioid epidemic., (© 2018 Wiley Periodicals, Inc.)

Background: The Florida sleeve (FS) procedure was developed as a simplified approach for repair of functional type I aortic insufficiency secondary to aortic root aneurysm. We evaluated postoperative aortic valve function, long-term survival, and freedom from reoperation in Marfan syndrome patients who underwent the FS procedure at our center., Methods: All Marfan syndrome patients undergoing FS procedure from May 2002 to December 2014 were included. Echocardiography assessment included left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), ejection fraction, and degree of aortic insufficiency (none = 0, minimal = 1, mild = 2, moderate = 3, severe = 4). Social Security Death Index and primary care physicians' report were used for long-term follow-up., Results: Thirty-seven Marfan syndrome patients, 21 (56.8%) men and 16 (43%) women with mean age of 35.08 ± 13.45 years underwent FL repair at our center. There was no in-hospital or 30-day death or stroke. Two patients required reoperation due to bleeding. Patients' survival rate was 94% at 1 to 8 years. Freedom from reoperation was 100% at 8 years. Twenty-five patients had postoperative follow-up echocardiography at 1 week. Aortic insufficiency grade significantly decreased after the procedure (preoperative mean ± SD: 1.76 ± 1.2 versus 1-week postoperative mean ± SD: 0.48 ± 0.71, p < 0.001), and mean LVEDD decreased from 52.23 ± 5.29 mm to 47.53 ± 8.89 mm (p = 0.086). Changes in LVESD (35.33 ± 9.97 mm to 36.58 ± 9.82 mm, p = 0.58) and ejection fraction (57.65% ± 6.22% to 55% ± 10.83%, p = 0.31) were not significant., Conclusions: The FS procedure can be performed safely in Marfan syndrome patients with immediate improvement in aortic valve function. Long-term survival and freedom from reoperation rates are encouraging., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Complex aortic arch disease can be a formidable challenge and is often treated with a two-stage elephant trunk technique. We examined our experience with hybrid arch repair with combined zone 0 stent graft deployment., Methods: A retrospective review was conducted of all patients who underwent type 2 hybrid arch replacement and zone 0 antegrade endovascular stent graft deployments at a single university center from June 2010 to August 2015., Results: The review included 48 patients, 25 (52%) elective and 23 (48%) nonelective, with a mean ± SD age of 64 ± 11 years. Overall in-hospital mortality was 17% (8 of 48). Age exceeding 65 years (odds ratio, 9.5; 95% confidence interval, 1.2 to 36), preoperative international normalized ratio exceeding 1.3 (odds ratio, 14.2; 95% confidence interval, 2.1 to 95.87), and postoperative acute kidney injury (odds ratio, 5.6; 95% confidence interval, 1.1 to 29) were associated with in-hospital death. Postoperative stroke occurred in 3 patients (6%) and permanent paraplegia in 1 patient (2%). One (2%) patient underwent reoperation due to bleeding, and 6 patients (13%) experienced respiratory failure/reintubation. Acute kidney injury developed in 12 patients (25%), according to Acute Kidney Injury Network criteria, with 7 (14.6%) at stage 1 and 5 (10.4%) at stage 3. At the 1-year follow-up, type II endoleak developed in 2 of the 40 patients (5%), and 2 others required reoperation due to progression of chronic aortic dissection. Median follow-up time was 17 months (range, 1 to 63 months). The overall survival rate was 92% ± 0.04% at 6 months and 89% ± 0.05% at 1 and at 3 years., Conclusions: Hybrid repair of complex aortic arch pathology with antegrade stent graft deployment can be performed safely with high technical success while obviating the need for a second operation. Reasonable midterm survival can be anticipated; however, older age, preoperative coagulopathy, and postoperative acute kidney injury are factors associated with poor outcome., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: There has been debate regarding the safety of performing elective procedures in patients with vascular manifestations associated with Ehlers-Danlos syndrome (EDS). The purpose of this study was to review the surgical management and clinical outcomes of EDS patients undergoing vascular procedures at a tertiary medical center with multimodality expertise in connective tissue disorders., Methods: All patients with EDS undergoing endovascular and open vascular procedures at a single-institution academic medical center from 1994 to 2009 were retrospectively reviewed. Clinical data were evaluated including patient demographics, length of stay (LOS), and mortality outcomes during hospital course and long-term follow-up., Results: A total of 40 patients with EDS were identified, including individuals diagnosed with classic (n = 15), hypermobility (n = 16), and vascular (n = 9) types of EDS. These patients collectively underwent 45 endovascular and 18 open procedures for vascular disease during the time period, including embolization (n = 37), angioplasty (n = 8), arterial bypass (n = 5), and aortic aneurysm repair (n = 13). All cases were performed electively, except for one (2%) urgent endovascular and one (5%) emergent open procedure. Endovascular procedures were associated with a median LOS (interquartile range [IQR]) of 2 (1 to 3) days with no procedure-related mortality or in-hospital deaths among all EDS types, whereas open vascular procedures had median LOS (IQR) of 6 (5 to 8) days with one (6%) in-hospital death occurring in a vascular EDS patient. Survival free of any complication at 5 years was 85% and 54% following endovascular and open procedures, respectively., Conclusions: The elective surgical management of vascular disorders in EDS patients using open and endovascular procedures has been associated with good outcomes. Our results suggest that vascular interventions in these EDS patients can be safely performed and should not be withheld until rupture or acute symptoms arise., (Copyright 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Idiopathic pulmonary artery aneurysm is a rare clinical entity, and therefore the natural course and clinical management are not well established. We present the case of an elderly woman with a symptomatic idiopathic pulmonary artery aneurysm who underwent surgical repair along with simultaneous coronary artery bypass grafting. With long-term follow-up presented in this report, we describe the safety and durability of surgical repair.