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Cardiac surgeons have variable exposure to thoracic aortic EndoVascular repair (TEVAR) as the primary surgeon. As paradigms evolve and EndoVascular structural heart interventions expand, TEVAR utilization by cardiac surgeons is of particular interest. In order to definitively manage thoracic aortic pathologies in the modern era, cardiac surgeons must incorporate TEVAR into their armamentarium during surgical training or risk a prolonged learning curve.

The American Heart Association and American College of Cardiology published practice guidelines for the management of adult congenital heart disease in 2018 and the European Society of Cardiology published analogous guidelines in 2020. Although there are broad areas of consensus between the 2 documents, there are important differences that impact patient management. This review discusses key areas of agreement and disagreement between the 2 guidelines, with discussion of possible reasons for disagreement and potential implications.

Objective(s): Trainee assessments aim to identify areas for improvement and address problems within training programs. However, effectiveness is limited by an inability to assess programs anonymously. We hypothesized concern for undesired repercussions may discourage honest responses. To test this, we conducted a comprehensive survey of trainees to assess their educational and work-related experiences anonymously. Design: A 51-question survey was distributed electronically to the Thoracic Surgery Residents Association (TSRA) membership. Questions were multiple-choice. The Likert scale was utilized. Setting: The survey was accessed electronically and was completed by participants nationwide. Participants: Trainees were incentivized to complete the survey with the opportunity to receive a $50 gift card or TSRA textbook. 109 of 551 cardiothoracic surgery trainees completed the survey. Results: 109 trainees (109/551, 19.8%) completed the survey. 57.8% of respondents reported complying with work hour restrictions, but 32.2% (n=35) did not feel comfortable reporting violations honestly. The majority of respondents agreed or strongly agreed that their program was preparing them to independently perform low risk cardiac (4.19 [1.22]) and thoracic (4.08 [1.13]) cases independently, 30.3% of chief residents reported planning to pursue additional training. 66% of respondents stated they would select the same program again. 33% reported having high morale, 47.7% moderate and 19.3% poor or declining morale. 84.4% of respondents did not feel their race or gender significantly impacted their training, 26.6% reported systemic bias in recruitment of new trainees or faculty, and 38.5% believed there was inadequate diversity among faculty and trainees. 30.3% reported experiencing verbal or physical harassment by an attending or fellow (14.7%). Conclusions: Despite reporting an overall positive operative experience, a significant number of trainees plan to pursue additional training. The survey identifies important areas for attention including underreporting of issues related to diversity, as well as verbal and physical harassment by fellows and attendings.

The optimal timing for pursuing tracheostomy in patients with prolonged mechanical ventilation with either veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is a discussion of risk versus benefit. Depending on the etiology, cardiothoracic surgical patients carry some of the highest risk for respiratory failure postprocedure. Given that patients with end-stage cardiopulmonary status may be fraught with substantial comorbidities, it is critically important to manage the risk-benefit profile of performing a tracheostomy procedure on a patient requiring ECMO support. These cohorts have risk factors that may depend on each patient's inflammatory state, lung de-recruitment peri-procedure and postprocedure and bleeding requiring transfusions to name a few. We provide a descriptive analysis of ECMO patients on both VA and VV configurations who survived to hospital discharge receiving tracheostomy either during or after their ECMO course.A retrospective single-institutional study collected all consecutive patients age 18 and above who received any form of ECMO between 2016 and 2020. Five hundred forty-five patients were screened based on having received ECMO. Patients with mixed EMCO modality were excluded due to heterogeneity of disease process. A total of 521 patients received either VV or VA ECMO. A total of 54 patients received tracheostomy and had sufficiently clean data for analysis. Tracheostomy patients were compared based on survival to discharge, tracheostomy surgical complications, ECMO duration, ECMO configuration, inotrope and vasopressor use, transfusion rates, total ventilator days, total days on intravenous sedation, and history of cardiotomy or heart transplant were assessed. Baseline characteristics of race, age, gender, and body mass index (BMI) were also collected.A total of 54 patients received tracheostomy. Twenty-nine of those patients received tracheostomy during the course of their ECMO, of whom 13 were on VV ECMO, 16 on VA ECMO. Another 25 patients underwent tracheostomy after successful ECMO explant; 8 of those were VV ECMO with the remaining 17 were on VA ECMO before explantation, with mean delay to tracheostomy, 10 and 19 days after explant between both modalities, respectively. A statistically significantly greater proportion of VV ECMO patients received a tracheostomy at any point versus VA ECMO patients (25.93% vs. 8.35%, p ≤ .0001). No statistically significant difference was noted in timing of tracheostomy when stratified by EMCO modality (VA 51.51% after explant vs. VV 38.10% after explant, p = .33). There was a greater frequency of minor tracheostomy complications in patients who were on ECMO at the time of their tracheostomy (p = .014) than in those who received their tracheostomy after being explanted. However, these minor complications did not contribute to a change in survival to hospital discharge (p = .58). Similarly, the small number of major complications (n = 13) did not impair survival to hospital discharge (p = .84). Finally, mean duration of ECMO was longer in those who received tracheostomy during ECMO versus after ECMO. (488.45 vs. 259.72 h, p .01).Tracheostomy is known to increase patient mobility, clinical participation, and overall decrease in sedation use. Pursuing tracheostomy during ECMO is feasible, does not result in major bleeding, and is associated with only minor complications that overall do not decrease survival. While there is an increased duration of ECMO support in the tracheostomy cohort, this may be due to existing patient conditions, and may not be causal. Research is needed to further determine the external patient factors and specific timing to optimize both VV and VA ECMO courses.We hope that our analysis will pave the initial pathway for an evidence-based guideline on optimal timing of tracheostomy in ECMO patients, whether initiated during or after ECMO and taking into consideration ECMO configuration, its expected duration, and patient comorbidities.

The American Heart Association and American College of Cardiology published practice guidelines for the management of adult congenital heart disease in 2018 and the European Society of Cardiology published analogous guidelines in 2020. Although there are broad areas of consensus between the 2 documents, there are important differences that impact patient management. This review discusses key areas of agreement and disagreement between the 2 guidelines, with discussion of possible reasons for disagreement and potential implications.

Study design Retrospective cohort study. Objective To evaluate the diagnostic yield of computed tomography (CT) imaging of the axial skeleton in pediatric patients evaluated a level I trauma center. Summary of background data CT imaging has become ubiquitous in the assessment of axial skeletal injuries in trauma patients. Methods This is a retrospective study from one Level I trauma center of patients undergoing CT imaging during pediatric trauma assessment. Medical records of pediatric trauma patients 18-year old and younger who underwent axial skeletal CT imaging from 2013 to 2015 were evaluated. The following were assessed: mechanism of injury, age, sex, race/ethnicity, presence of fracture, management of fracture. Results A total of 831 patients were assessed, there were 355 (42.7%) females and 476 males (57.3%) with an average age of 15.4 (2 mo-18 yrs). 588 (70.8%) were White, 164 (19.7%) were African-American, 12 (1.4%) were Asians, 67 (8.1%) other, and 46 (5.5%) identified as Hispanic. There were 45 patients (5.4%) who sustained 52 fractures. Common mechanisms were motor vehicle accidents (MVA) 28%, sports injuries (18%), and fall from height (15%). 35.9% of fractures were identified on plain radiographs. Nine injuries were treated surgically (one cervical, two thoracic, two lumbar, and four pelvic); three of these were identified on radiographs. From the 14 patients with cervical spine fractures none were detected on radiographs. Conclusion In this large series of 831 pediatric patients undergoing axial CT imaging, the rate of axial fractures was 5.4%. The majority of these fractures were managed non-surgically. Only 35.9% of fractures were identified on radiographs.Level of Evidence: 3.

Objective The Thoracic Surgery Residents Association (TSRA) is a resident-led organization established in 1997 under the guidance of the Thoracic Surgery Directors Association to represent the interests and educational needs of cardiothoracic surgery residents. We aim to describe the past contributions, current efforts, and future directions of the TSRA within a conceptual framework of the TSRA mission. Methods Primary review of educational resources was performed to report goals and content of past contributions. TSRA Executive Committee input was used to describe current resources and activities, as well as the future goals of the TSRA. Podcast analytics were performed to report national and global usage. Results Since 2011, the TSRA has published 3 review textbooks, 5 reference guides, 3 test-preparation textbooks, 1 supplementary publication, and 1 multiple-choice question bank and mobile application, all written and developed by cardiothoracic surgery trainees. In total 108 podcasts have been recorded by mentored trainees, with more than 175,000 unique listens. Most recently, the TSRA has begun facilitating trainee submissions to Young Surgeon's Notes, fostered a trainee mentorship program, developed the monthly TSRA Newsletter, and established a wide-reaching presence on Facebook, Twitter, and Instagram to help disseminate educational resources and opportunities for trainees. Conclusions The TSRA continues to be the leading cardiothoracic surgery resident organization in North America, providing educational resources and networking opportunities for all trainees. Future directions include development of an integrated disease-based resource and continued collaboration within and beyond our specialty to enhance the educational opportunities and career development of cardiothoracic trainees.

The Thoracic Surgery Residents Association (TSRA) was established in 1997 as a trainee-led organization under the guidance of the Thoracic Surgery Directors Association (TSDA) to represent the interests and meet the educational needs of cardiothoracic surgery residents across North America. Since its founding, the TSRA has continuously evolved and expanded to further its primary mission. In addition to now offering text- and audio-based educational resources, the TSRA acts to connect students, trainees, and faculty, with the ultimate goal of fostering relationships that will benefit not only individuals but also the field of cardiothoracic surgery as a whole.

As median survival for left ventricular assist device (LVAD) patients increases, the incidence of adverse events requiring device exchange is likely to increase as well. Less invasive surgical approaches for device exchange of older generation pumps have demonstrated multiple potential benefits compared with median sternotomy. However, there remains a paucity of data in regard to less invasive surgical techniques for the exchange of the newest generation intrapericardial devices. In this report we describe a complete sternal-sparing technique for the LVAD exchange of a HeartMate 3 via bilateral minithoracotomies.

Repair of truncus arteriosus often requires early right ventricular outflow tract (RVOT) reoperation. Using a modified repair, the branch pulmonary arteries are left in situ, which may avoid earlier RVOT reoperation. We hypothesized that our modified repair for type I and II truncus arteriosus would extend the time to RVOT reoperation. Infants with truncus arteriosus were divided into 2 groups: (1) traditional technique where the branch pulmonary arteries are excised from the truncal root, or (2) modified repair where the branch pulmonary arteries are left in situ and septated from the truncal root. Regardless of the approach, a bioprosthetic conduit or homograft was used to establish right ventricular to pulmonary artery continuity. Follow-up pulmonary artery angiograms were used to assess for branch pulmonary artery stenosis. From 54 infants (modified repair: 33, traditional technique: 21), there were no significant differences in age at repair, gender, or type of truncus arteriosus. With 100% follow-up, use of the modified repair resulted in a lower rate of branch pulmonary artery stenosis, and greater freedom from surgical branch pulmonary arterioplasty. Five- and 10-year freedom from RVOT reoperation (5 years: modified-81.5% vs traditional-30.5%, P = 0.004; 10 years: modified-53.3% vs traditional-30.5%, P = 0.01) favored the modified repair. Cox regression analysis demonstrated that the modified repair was associated with an independently lower risk for RVOT reoperation (hazard ratio: 0.08, confidence interval: 0.01, 0.75, P = 0.02). Thus, maintaining the branch pulmonary artery architecture resulted in greater freedom from RVOT reoperation.

Study: The aim of this single-center, a retrospective study was to evaluate early and long-term adverse events in advanced heart failure patients with cardiogenic shock who underwent ventricular assist device (VAD) implantation. We hypothesize that outcomes in patients implanted with LVAD with INTERMACS 1 have increased the risk of perioperative bleeding and infection. Methods: We evaluated outcomes in 191 patients with a HeartMate II LVAD implanted between May 2008 and June 2014 at the University of Rochester Medical Center, enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Registry. Patients were divided into two groups: A) INTERMACS level 1 (cardiogenic shock) or B) INTERMACS level>1 (noncardiogenic shock). Preoperative characteristics, as well as post-surgical bleeding, infection and all-cause mortality, were assessed. The original LVAD database has received exempt status from the RSRB (RSRB00043111). Results: From 191 patients, there were 59 patients with INTERMACS level 1, and 132 with INTERMACS level greater than 1. Patients with INTERMACS level 1 at LVAD implantation were younger. Following LVAD implantation, INTERMACS level 1 patients had a trend towards bleeding and infection.

Purpose The purpose of the present study is to examine the effect of operative time of day on outcomes in orthotopic heart transplant (OHT) recipients. We hypothesized that nighttime OHT operations would be associated with increased 1-year mortality when compared to daytime OHT operations. Methods We performed a retrospective analysis of adult heart transplant recipients in the United Network for Organ Sharing (UNOS) database from January 2000 to December 2019. Operative time of day was derived from the donor cross-clamp time (night, 6 pm-4 am; day, 4 am-6 pm). The primary outcome was survival at 1 year. Kaplan-Meier curves and log-rank statistics were generated to compare the effect of operative time and were further stratified by age, transplant center yearly volume (low volume, Results Of the 42,007 patients included in the study, 24,200 (57.6%) underwent nighttime and 17,807 (42.4%) daytime OHT (Table 1). Preoperative patient characteristics were similar between cohorts. 1-year survival (Figures 1) was not different between the cohorts (89.7 vs 89.5%, p=0.630). When further stratified by age, center volume, or VAD status, 1-year survival between operative times still remained insignificant. Conclusion There is no significant association between nighttime operations and 1-year post-transplant survival in adult heart transplant recipients.

PURPOSE OF REVIEW The modern field of clinical genetics has advanced beyond the traditional teachings familiar to most practicing cardiologists. Increased understanding of the roles of genetic testing may improve uptake and appropriateness of use. RECENT FINDINGS Clinical genetics has become integral to the management of patients with hereditary arrhythmia and cardiomyopathy diagnoses. Depending on the condition, genetic testing may be useful for diagnosis, prognosis, treatment, family screening, and reproductive planning. However, genetic testing is a powerful tool with potential for underuse, overuse, and misuse. In the absence of a substantial body of literature on how these guidelines are applied in clinical practice, we use a case-based approach to highlight key lessons and pitfalls. Importantly, in many scenarios genetic testing has become the standard of care supported by numerous class I recommendations; genetic counselors can improve accessibility to and appropriate use and application of testing. SUMMARY Optimal management of hereditary arrhythmias and cardiomyopathies incorporates genetic testing, applied as per consensus guidelines, with involvement of a multidisciplinary team.

Background: Congenital ion channel disorders, including congenital long QT syndrome (LQTS), cause significant morbidity in pediatric patients. When medication therapy does not control symptoms or arrhythmias, more invasive treatment strategies may be necessary. This study examines our institution’s clinical experience with surgical cardiac denervation therapy for management of these arrhythmogenic disorders in children. Methods: An institutional review board–approved retrospective review identified ten pediatric patients with congenital ion channelopathies who underwent surgical cardiac denervation therapy at a single institution between May 2011 and April 2014. Eight patients had a diagnosis of congenital LQTS, two patients were diagnosed with catecholaminergic polymorphic ventricular tachycardia (CPVT). All patients underwent sympathectomy and partial stellate ganglionectomy via video-assisted thoracoscopic surgery (VATS). Results: Six of the ten patients had documented ventricular arrhythmias preoperatively, and 70% of the patients had preoperative syncope. The corrected QT interval decreased in 75% of patients with LQTS following sympathectomy. Postoperative arrhythmogenic symptoms were absent in 88% of congenital LQTS patients, but both patients with CPVT continued to have symptoms throughout the duration of follow-up. All patients were alive after a median follow-up period of 10 months. Conclusions: Surgical cardiac denervation therapy via VATS is a useful treatment strategy for congenital LQTS patients who fail medical management, and its potential benefit in the management of CPVT is unclear. A prospective comparison of the efficacy of surgical cardiac denervation therapy and implantable cardioverter-defibrillator use in congenital ion channelopathies is timely and crucial.

BACKGROUND CONTEXT Computed tomography (CT) scans have become ubiquitous in the assessment of the trauma patient because of its diagnostic acuity in assessing head and axial skeletal pathology. Consensus recommendations exist for limiting the ionizing radiation dose as it pertains to CT head imaging in the pediatric population. However, little published data exist assessing the diagnostic yield of current practices in the pediatric population. As pressure mounts to diagnose emergent pathologies in the emergency department, children are at risk for a relatively high cumulative burden as sequela of medical imaging such as an increased lifetime attributable risk of cancer. PURPOSE To evaluate the diagnostic yield of CT scans of the spine in pediatric trauma patients STUDY DESIGN/SETTING Retrospective, Level I trauma center. PATIENT SAMPLE Patients 18 and under, undergoing CT scans in the ER 1/2013-12/2015. OUTCOME MEASURES Presence of fracture. METHODS Medical records of pediatric trauma patients who arrived at the emergency department and underwent spinal CT were reviewed. We reviewed the CT scans as well as the radiology reports for fractures. Medical records were reviewed for mechanism of injury and management for these patients as well as demographics. Factors associated with pediatric patients with fractures were then compared to those without fractures. RESULTS A total of 831 patients underwent CT scans in to the ER. Average age was 13.86 years (0.24-18.99) with 43% (355) females and 57% (476) males. The racial demographics were as follows: 70% Caucasian, 20% African American, 1.4% Asian, with the remainder listed as other or not available. The most common mechanism of injury (MOI) was motor vehicle accident (MVA) (26%) followed by sports injury (18%), then fall from height (15%) bicycle/motor bike (14%). Other mechanisms of injury were pedestrian struck (9.5%), assault (5%), syncope (3%), direct head blow (3%), neck pain (2%), fall from standing (1%), seizure (1%), strangulation/hanging ( CONCLUSIONS It is important to consider the long-term implications when deciding to expose a pediatric patient to radiation. In this study we found the overall axial fracture rate to be low (6.1%). The fractures were distributed throughout the mobile spine and sacrum. Of the fractures that were detected 54% were transverse process and compression fractures. Pediatric trauma CT scanning best practices focusing on MOI most likely resulting in spine fractures (MVA, bike/motor bike, sport injuries) should be investigated. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The objective of this study was to examine a large institutional experience of patients with trisomy 13 and trisomy 18 in the setting of comorbid congenital heart disease and present the outcomes of surgical versus expectant management. It is a retrospective single-institution cohort study. Institutional review board approved this study. Thirteen consecutive trisomy 18 patients and three consecutive trisomy 13 patients (sixteen patients in total) with comorbid congenital heart disease who were evaluated by our institution's Division of Cardiovascular Surgery between January 2008 and December 2013 were included in the study. The primary outcome measures evaluated were operative mortality (for patients who received surgical management), overall mortality (for patients who received expectant management), and total length of survival during follow-up. Of the thirteen trisomy 18 patients, seven underwent surgical management and six received expectant management. With surgical management, operative mortality was 29 %, and 80 % of patients were alive after a median follow-up of 116 days. With expectant management, 50 % of patients died before hospital discharge. Of the three patients with trisomy 13, one patient underwent surgical management and two received expectant management. The patient who received surgical management with complete repair was alive at last follow-up over 2 years after surgery; both patients managed expectantly died before hospital discharge. Trisomy 13 and trisomy 18 patients with comorbid congenital heart disease can undergo successful cardiac surgical intervention. In this population, we advocate that nearly all patients with cardiovascular indications for operative congenital heart disease intervention should be offered complete surgical repair over palliative approaches for moderately complex congenital cardiac anomalies.