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BACKGROUND Intra-aortic balloon pumps (IABP) are used to bridge select end-stage heart disease patients to heart transplant (HT). IABP use and exception requests both increased dramatically after the UNOS policy change (PC). The purpose of this study was to evaluate the effect of PC and exception status requests on waitlist and post-transplant outcomes in patients bridged to HT with IABP support. METHODS We analyzed adult, first-time, single-organ HT recipients from the UNOS Registry either on IABP at the time of registration for HT or at the time of HT. We compared waitlist and post-HT outcomes between patients from the PRE (October 18, 2016 to May 30, 2018) and POST (October 18, 2018 to May 30, 2020) eras using Kaplan-Meier curves and time-to-event analyses. RESULTS A total of 1267 patients underwent HT from IABP (261 pre-policy/1006 post-policy). On multivariate analysis, PC was associated with an increase in HT (sub-distribution hazard ratio (sdHR): 2.15, p

Objective To compare outcomes with wrapped (pulmonary autograft inclusion) versus unwrapped techniques in adults with bicuspid aortic valves undergoing the Ross procedure. Methods Between 1992 and 2019, 129 adults with bicuspid aortic valves (aged ≥18 years) underwent the Ross procedure by a single surgeon. Patients were divided into those without autograft inclusion (unwrapped, n = 71) and those with autograft inclusion (wrapped, n = 58). Median follow-up was 10.3 years (interquartile range, 3.0-16.8 years). Need for autograft reintervention was analyzed using competing risks. Results Pre- and intraoperative characteristics as well as 30-day morbidity or mortality did not differ between cohorts. Survival at 1, 5, and 10 years, respectively, was 97.2%, 97.2%, and 95.6% in the unwrapped cohort and 100%, 100%, and 100% in the wrapped cohort (P = .15). Autograft valve failure occurred in 25 (35.2%) of the unwrapped and 3 (5.2%) of the wrapped patients. Competing risks analysis demonstrated the wrapped cohort to have a lower need for autograft reintervention (subhazard ratio, 0.28, 95% confidence interval, 0.08-0.91; P = .035). The cumulative incidence of autograft reintervention (death as a competing outcome) at 1, 5, and 10 years, respectively, was 10.2%, 14.9%, and 26.8% in the unwrapped cohort and 4.0%, 4.0%, and 4.0% in the wrapped cohort. Conclusions In adults with bicuspid aortic valves, the Ross procedure with pulmonary autograft inclusion stabilizes the aortic root preventing dilatation and reduces the need for reoperation. The autograft inclusion technique allows the Ross procedure to be performed in this population with excellent long-term outcomes.

OBJECTIVES: To compare outcomes after the development of early (≤30 days) versus delayed (>30 days) deep sternal wound infection (DSWI) after cardiac surgery. METHODS: Between 2005 and 2016, 64 patients were treated surgically for DSWI following cardiac surgery. Thirty-three developed early DSWI, while 31 developed late DSWI. Mean follow up was 34.1 ± 32.3 months. RESULTS: Survival for the entire cohort at 1, 3, and 5 years was 93.9, 85.1, and 80.8%, respectively. DSWI diagnosed early and attempted medical management were strongly associated with overall mortality (hazard ratio (HR), 25.0 and 9.9; 95% confidence intervals (CI), 1.18–528 and 1.28–76.5; p-value 0.04 and 0.04, respectively). Survival was 88.1, 77.0, 70.6 and 100, 94.0 and 94.0% at 1,3, and 5 years in the early and late DSWI groups, respectively (Log-rank = 0.074). Those diagnosed early were more likely to have a positive wound culture (odds ratio (OR), 0.06, 95% CI 0.01–0.69, p=0.024) and diagnosed late were more likely to be female (OR 8.75, 95% CI 2.0–38.4, p=0.004) and require an urgent DSWI procedure (OR 9.25, 95% CI 1.86–45.9, p=0.007). Both early diagnosis of DSWI and initial attempted medial management were strongly associated with mortality (hazard ratio 7.48, 95% CI 1.38–40.4, p=0.019 and hazard ratio 7.76, 95% CI 1.67–35.9, p=0.009, respectively). CONCLUSIONS: Early aggressive surgical therapy for deep sternal wound infection after cardiac surgery results in excellent outcomes. Those diagnosed with DSWI early and have failed initial medical management have increased mortality.

Graphical abstract A retrospective cohort study was conducted in which 129 adult patients with bicuspid aortic valves underwent the Ross procedure with either a standard root inclusion technique or a modified technique whereby the pulmonary autograft is wrapped in a vascular conduit. Primary outcomes were survival and the need for pulmonary autograft reintervention. Competing risk analysis demonstrated the wrapped technique reduced pulmonary autograft reintervention.

Cardiovascular computed tomographic angiography (CCTA) 3-D thoracic reconstruction can serve as a “virtual patient avatar” providing surgical views for approach to complex anomalous coronary artery anatomy. Images demonstrated a single coronary artery ostium arising from the right aortic sinus with trifurcation into a prepulmonic left anterior descending coronary artery (LAD), an interarterial circumflex with a subsequent intraseptal course, and normal course of the right coronary artery. Virtual 3-D CCTA reconstructions were important to planning an incisional plane for surgical correction.

Background The feasibility and efficacy of a web-based curriculum in supplementing thoracic surgical training was previously shown. However, the impact of curricular participation on validated knowledge tests remains unknown. We compared in-service training examination (ITE) results among trainees, stratified by curricular use. Methods The national online curriculum was implemented in August 2013. We retrospectively reviewed trainees who participated in thoracic surgical training programs in both 2012 to 2013 and 2013 to 2014. Scores from the 2013 and 2014 ITEs were obtained, and curricular usage data were collected from site analytics. Trainees were separated into three groups according to 2013 ITE scores; within each group, changes in score for high- versus low-volume users were compared. Results 187 trainees took the ITE both years, with exposure to the online curriculum during only the second year. High-volume users' scores trended toward greater improvement than scores of low-volume users (+18.2% versus +13.0%, p = 0.199). When stratified by 2013 score, the lowest scoring quartile improved substantially, and the highest scoring quartile improved modestly, regardless of curricular use. However, for those individuals who achieved mid-range scores in 2013, there was a trend toward much greater improvement in score with heavier use of the curriculum (+17.0% versus +7.0%, p = 0.094). Conclusions Among trainees who had access to the novel online curriculum during the second of 2 consecutive years, we evaluated the impact of curricular participation on ITE scores. The effect appears to be most pronounced in individuals with mid-range scores, in whom high curricular use led to the greatest improvement.

Anomalous coronary arteries are a relatively rare finding that may be asymptomatic or follow classical courses that often necessitate surgical intervention due to hemodynamic consequences. Less frequently encountered anomalies may still need investigation for surgery, especially in the setting of

Objectives In an effort to stimulate residents and trainers to increase their use of simulation training and the Thoracic Surgery Curriculum, a gamification strategy was developed in a friendly but competitive environment. Methods "Top Gun." Low-fidelity simulators distributed annually were used for the technical competition. Baseline and final video assessments were performed, and 5 finalists were invited to compete in a live setting from 2013 to 2015. "Jeopardy." A screening examination was devised to test knowledge contained in the Thoracic Surgery Curriculum. The top 6 2-member teams were invited to compete in a live setting structured around the popular game show Jeopardy . Results "Top Gun." Over 3 years, there were 43 baseline and 34 final submissions. In all areas of assessment, there was demonstrable improvement. There was increasing evidence of simulation as seen by practice and ritualistic behavior. "Jeopardy." Sixty-eight individuals completed the screening examination, and 30 teams were formed. The largest representation came from the second-year residents in traditional programs. Contestants reported an average in-training examination percentile of 72.9. Finalists reported increased use of the Thoracic Surgery Curriculum by an average of 10 hours per week in preparation. The live competition was friendly, engaging, and spirited. Conclusions This gamification approach focused on technical and cognitive skills, has been successfully implemented, and has encouraged the use of simulators and the Thoracic Surgery Curriculum. This framework may capitalize on the competitive nature of our trainees and can provide recognition of their achievements.

The Ross procedure is an alternative for patients with aortic valve disease not amenable to repair. Long-term follow-up after a Ross has demonstrated the need for autograft (left ventricular outflow tract [LVOT]) and homograft (right ventricular outflow tract [RVOT]) reinterventions. We assessed the age-stratified outcomes of the LVOT and RVOT after the Ross procedure performed by a single surgeon during a 20-year period.We retrospectively reviewed 305 consecutive patients aged 4 days to 70 years, stratified by age younger than than 1 (n = 41), 1 to 10 (n = 85), 10 to 20 (n = 84), 20 to 40 (n = 59), and older than 40 years (n = 36). Median follow-up was 8.2 years (interquartile range, 1 month to 19.2 years). Primary end points were survival and freedom from reintervention on the LVOT and RVOT. Outcomes were compared by Kaplan-Meier analysis.A total of 173 patients (57%) had prior intervention on their aortic valve, 95 (31%) had isolated regurgitation, 91 (30%) had stenosis, and 119 (39%) had mixed pathology. There were 92 concomitant procedures (43 congenital lesions, 18 aorta, 9 mitral valve). In-hospital morbidity was 11.5% (35 of 305); mortality was 3.6% (11 of 305) and highest in infants. Need for an emergency operation (p0.05) predicted mortality in infants. The LVOT reintervention rate was lowest in infants compared with older patients (p0.05); conversely, age was directly related to RVOT reintervention (p0.01). Autograft encasement in a Hemashield (Atrium, Hudson, NH) tube in patients aged older than 10 years improved 5-year freedom from reintervention on the LVOT from 81% to 91% (p0.001). At last follow-up, aortic insufficiency was mild or less in 290 (95%) patients, and heart function was normal in 285 (93%).The Ross procedure is a safe, effective, and anti-coagulation-free alternative for aortic valve replacement across all age groups. Long-term survival and preservation of heart function are highly favorable. Surgical mortality is related to salvage procedures in infants. When feasible, autograft durability can be improved by using a Hemashield graft for support.

Left atrial-esophageal fistula after endovascular radiofrequency ablation for cardiac arrhythmias is a life-threatening complication. Immediate surgical repair offers the best chance for survival. The optimal surgical technique is unknown. We describe our recommended surgical approach.

Web-based curricula provide login data that can be advantageously used to characterize and analyze study habits. We sought to compare thoracic surgical trainee In-Training Examination percentiles with regard to their study habits (ie, cramming), as characterized by curriculum login frequency to the national Web-based Thoracic Surgery Curriculum. Furthermore, we then aimed to characterize the curriculum login frequency of trainees as stratified by their performance on the In-Training Examination and their improvement on the In-Training Examination over subsequent years.We performed a retrospective review of trainees who accessed the curriculum before the 2014 In-Training Examination, with curriculum login data collected from site analytics. Scores were compared between trainees who crammed (≥30% increase in logins in the month before the In-Training Examination) and those who did not. Trainees were stratified on the basis of 2014 In-Training Examination percentile and improvement in percentile from 2013 to 2014 into high, medium, and low scorers and improvers.Of 256 trainees who took the 2014 In-Training Examination, 63 (25%) met criteria as crammers. Crammers increased total study sessions immediately before the In-Training Examination (P .001), but without impact on 2014 In-Training Examination percentile (P = .995) or year-to-year improvement (P = .234). Stratification by In-Training Examination percentile demonstrated that highest scoring trainees used the curriculum more frequently in the final month than medium-range scorers (P = .039). When stratified by extent of year-to-year improvement, those who improved the most accessed the curriculum significantly more often in the last month compared with baseline (P = .040). Moreover, those with greatest improvement logged in more in the final month than those with least improvement (P = .006).Increasing the frequency of study periods on the national Web-based thoracic surgery curriculum before the In-Training Examination may have a unique benefit to trainees who initially score low to allow them to significantly improve their subsequent year In-Training Examination performance.

The landscape of graduate medical education has changed dramatically over the past decade and the traditional apprenticeship model has undergone scrutiny and modifications. The mandate of the 80-hour work-week, the introduction of integrated residency programs, increased global awareness about patient safety along with financial constraints have spurred changes in graduate educational practices. In addition, new technologies, more complex procedures, and a host of external constraints have changed where and how we teach technical and procedural skills. Simulation-based training has been embraced by the surgical community and has quickly become an essential component of most residency programs as a method to add efficacy to the traditional learning model. The purpose of this paper is twofold: (1) to describe the development of a perfused cadaver model with dynamic vital sign regulation, and (2) to assess the impact of a curriculum using this model and real world scenarios to teach surgical skills and error management. By providing a realistic training environment our aim is to enhance the acquisition of surgical skills and provide a more thorough assessment of resident performance. Twenty-six learners participated in the scenarios. Qualitative data showed that participants felt that the simulation model was realistic, and that participating in the scenarios helped them gain new knowledge, learn new surgical techniques and increase their confidence performing the skill in a clinical setting. Identifying the importance of both technical and nontechnical skills in surgical education has hastened the need for more realistic simulators and environments in which they are placed. Team members should be able to interact in ways that allow for a global display of their skills thus helping to provide a more comprehensive assessment by faculty and learners.

Background The purposes of this study were to develop a comprehensive framework for professionalism in surgery and to determine which attributes are most valued by medical students. Methods A framework for professionalism in surgery, consisting of 11 attribute categories, was developed. All 3rd-year medical students (n = 168) participated in a focus group and completed a questionnaire regarding their perceptions about professionalism. Students' responses were transcribed verbatim, coded, and assigned attribute categories. Results Students rated respect as the most important attribute of professionalism (56%), followed by altruism (21%) and interpersonal skills (8%). Fifty-three percent of students witnessed unprofessional behavior among faculty members while on the surgical clerkship. Of these incidents, 74% were related to respect, 28% to practice improvement, and 1% to altruism. Conclusions Respect was rated as the single most important characteristic of professionalism and was the attribute with the most witnessed violations.

Isolated cardiac involvement of recurrent metastatic hepatocellular carcinoma (HCC) is extremely rare. We report a patient with left ventricular outflow tract (LVOT) obstruction due to isolated recurrent HCC involving the interventricular septum (IVS). A ventriculotomy with resection of the tumor and patch repair of the IVS was performed with successful relief of LVOT obstruction. The patient was discharged home 6 days later symptom-free.

The need for hemodialysis is a known risk factor for mortality after isolated coronary artery bypass grafting (CABG). This study evaluated outcomes after isolated CABG in hemodialysis-dependent (HDD) and non-HDD patients. A retrospective cohort study of 778 patients undergoing isolated CABG between

Background Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair. Methods Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality. Results Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p Conclusions A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.

The presentation and treatment of a patient with a type B interrupted aortic arch with an isolated left subclavian artery is described.

Cardiovascular computed tomographic angiography (CCTA) has led to a paradigm shift in planning and performance of cardiothoracic surgical procedures, providing information essential to decisions regarding surgical intervention. As the operating room and interventional cardiology laboratory have evolved, merging into a hybrid space, CCTA has assumed an essential role in determination of the optimal therapeutic modality and path of approach for percutaneous, minimally invasive robotic and open surgical approaches in this setting. CCTA has particular significance to planning of reoperation for coronary artery disease, valvular heart disease, pericardial disease, congenital heart disease, cardiac masses, and advanced heart failure. Communication of the data beyond the written report can be achieved through images relevant for orientation and interventional approach. Review of these virtual views with the multidisciplinary team is important for maximal application and impact of this technology.

Objective A paradigm shift in surgical training has led to national efforts to incorporate simulation-based learning into cardiothoracic residency programs. Our goal was to determine the feasibility of developing a cardiac surgery simulation curriculum using the formal steps of curriculum development. Methods Cardiothoracic surgery residents (n = 6) and faculty (n = 9) evaluated 54 common cardiac surgical procedures to determine their need for simulation. The highest scoring procedures were grouped into similarly themed monthly modules, each with specific learning objectives. Educational tools consisting of inanimate, animate, and cadaveric facilities and a newly created virtual operating room were used for curriculum implementation. Resident satisfaction was evaluated by way of a 5-point Likert scale. Perceived competency (scale of 1–10) and pre–/post–self-confidence (scale of 1–5) scores were collected and analyzed using cumulative mean values and a paired t -test. Results Of the 23 highest scoring procedures (mean score, ≥4.0) on the needs assessment, 21 were used for curriculum development. These procedures were categorized into 12 monthly modules. The simulation curriculum was implemented using the optimal simulation tool available. Resident satisfaction (n = 57) showed an overwhelmingly positive response (mean score, ≥4.7). The perceived competency scores highlighted the procedures residents were uncomfortable performing independently. The pre–/post–self-confidence scores increased throughout the modules, and the differences were statistically significant ( P Conclusions It is feasible to develop and implement a cardiac surgery simulation curriculum using a structured approach. High-fidelity, low-technology tools such as a fresh tissue cadaver laboratory and a virtual operating room could be important adjuncts.

But Rapporter une experience mono-centrique du traitement par endoprothese aortique des dissections aortiques aigues compliquees de type B. Methodes Une revue retrospective des donnees obtenues a partir de tous les patients qui ont subi une endoprothese pour dissection aortique aigue de type B entre 2006 et 2009 a ete realisee. Les criteres d'evaluation etaient les taux de mortalite et de morbidite a 30 jours, respectivement. Resultats Au total, 104 traitements endovasculaires de l'aorte thoracique ont ete realises au cours de la periode de l'etude. Neuf (8,6%) patients (six hommes ; âge moyen : 65 ans) ont subi un traitement endovasculaire pour dissection de l'aorte thoracique aigue, compliquee, de type B. Sept patients (78%) avaient une hypertension non controlee a l'arrivee. L'extension aux branches viscerales de la dissection se limitait a l'origine du tronc cœliaque chez un patient sans evidence de malperfusion viscerale. L'indication pour le traitement etait la rupture aortique chez cinq patients, la malperfusion renale chez deux, et une douleur persistante chez les deux autres. Le delai moyen de la presentation a la chirurgie etait de 5,5 jours. Deux patients se presentant avec des ruptures aortiques avaient une extension retrograde de la dissection qui a necessite le remplacement de la valve aortique et de l'aorte ascendante. La longueur moyenne de l'aorte thoracique couverte etait de 21 cm. La couverture complete de l'artere sous-claviere gauche a ete necessaire chez trois patients et la couverture partielle chez deux. Sur l'angiographie finale, des endofuites de type I et II ont ete detectees, dont une a ete resolue le 5 e jour postoperatoire. Le taux de mortalite a 30 jours etait de 22%. Un deces etait secondaire a une rupture aortique. L'autre deces etait du a une defaillance d'organes multiples. Sept patients (78%) ont eu une ou plusieurs complications majeures. Il n'y a eu aucun accident vasculaire cerebral ou aucune paraplegie. Conclusion Le taux de morbidite et de mortalite avec l'endoprothese aortique pour dissection de type B aigue, compliquee, est significatif, ce qui reflete tres probablement le caractere mortel de la maladie. Le role precis du traitement endovasculaire chez ces patients reste a definir.

Objective Phrenic nerve injury resulting in hemidiaphragm paresis leads to morbidity in children undergoing repair of congenital heart defects. Previous studies have documented short-term benefits of diaphragm plication, but little is known about the return of diaphragm function. Methods We reviewed 46 consecutive patients undergoing hemidiaphragm plication after repair of congenital heart defects. The function of plicated diaphragms was measured at follow-up fluoroscopy using excursion of the unplicated side as a control. Results The median age at the procedure resulting in phrenic nerve injury was 6.4 months (0–62 months). Among the 46 patients, 29 (63%) and 17 (37%) had repair for single and 2-ventricle defects, respectively. Hemidiaphragm paresis occurred on the left side in 32 patients (70%). Phrenic nerve injury was documented at a median of 8 days (1–84 days) after operation. The median time from diagnosis to plication was 2 days (0–21 days). Five patients required prolonged ventilation after plication. One patient died 10 weeks later, and 4 patients required tracheostomy. The remaining 41 patients were extubated within 2 days (0–19 days). In 17 patients, fluoroscopy assessing diaphragm motion was performed at a mean interval of 16.4 months after plication. Excursion of the plicated diaphragm was 77% of the contralateral side. There was a trend toward improved function over time. Conclusions Hemidiaphragm paresis results in significant morbidity after repair of congenital heart defects. Early diagnosis and plication result in timely extubation. The plicated diaphragm demonstrates return of function that may improve over time. This is the first study to numerically quantitate the degree of diaphragm recovery.

Objectives Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy. Methods Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed. Results Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups. Conclusion Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted.

Simulation is increasingly recognized as an integral aspect of thoracic surgery education. A number of simulators have been introduced to teach component cardiothoracic skills; however, no good model exists for numerous essential skills including redo sternotomy and internal mammary artery takedown. These procedures are often relegated to thoracic surgery residents but have significant negative implications if performed incorrectly. Fresh tissue dissection is recognized as the gold standard for surgical simulation, but the lack of circulating blood volume limits surgical realism. Our aim is to describe the technique of the pressurized cadaver for use in cardiothoracic surgical procedures, focusing on internal mammary artery takedown.

Background Complex reconstruction of the aorta can be complicated by compression within the aortopulmonary space resulting in airway or pulmonary artery narrowing. Pulmonary artery compression is especially problematic in children with single ventricle physiology in which an increase in pulmonary vascular resistance may impair systemic venous flow and reduce cardiac output. Methods We operated on 7 patients (mean age, 2.9 years) with pulmonary artery stenosis presenting after a complex neonatal aortic reconstruction. All 7 patients underwent aortic extension with a polytetrafluoroethylene interposition graft and homograft patch angioplasty of the pulmonary artery to open the aortopulmonary space and relieve pulmonary artery narrowing. Five patients (hypoplastic left heart syndrome, n=2; transposition of the great arteries with tricuspid atresia and aortic hypoplasia, n=1; double outlet right ventricle with aortic hypoplasia, n=2) had previously undergone first stage repairs for single ventricle morphology. Two of the patients had multiple interim procedures, including placement of bilateral pulmonary artery stents, prior to our repair. Results There was 1 early death secondary to fungal sepsis. Six patients were discharged from the hospital. There was 1 late, noncardiac death from aspiration pneumonia in a patient with a severe craniofacial defect. Follow-up echocardiograms in the intermediate term have demonstrated relief of pulmonary artery narrowing and unobstructed aortic flow. Conclusions Aortic extension is an option in children with pulmonary artery compression of structures in the aortopulmonary space after complex aortic reconstruction.

Objective Completion of the Fontan procedure is frequently performed by using an extracardiac conduit between the inferior vena cava and the pulmonary artery. Most centers use a polytetrafluoroethylene graft for the extracardiac conduit, and because re-endothelialization is unlikely, anticoagulation is used for a variable period. This study explores the use of an alternate large-caliber venous conduit. Methods The superior vena cava was replaced in 8 minipigs with either a polytetrafluoroethylene interposition graft (2 pigs) or a depopulated (acellular), cryopreserved superior vena caval homograft (6 pigs). After 6 months, the animals were killed, and the grafts were examined for patency and histology, including immunostaining. No anticoagulation was used. Results Polytetrafluoroethylene grafts have a cross-sectional luminal narrowing, ranging from 16% to 40%. Histology showed only partial intimal ingrowth, with excessive subendothelial fibrosis and early calcification. In contrast, the depopulated venous homografts showed minimal luminal narrowing, ranging from 2% to 9%. These grafts were completely repopulated by the recipient with an endothelial lining, which stained positively for factor VIII, and a subendothelial region appropriately recellularized by myofibroblasts, which stained positively for smooth muscle actin and procollagen. There was no evidence of an immune response to the venous homografts, as judged by staining for T-cell surface antigen, CD4, and CD8. Thrombus was not seen in any of the grafts. Conclusion Depopulated, cryopreserved vena caval homografts might be superior conduits for cavopulmonary connection during completion of the Fontan operation by using the extracardiac conduit technique.

Protection of the myocardium during beating heart operations is paramount. The goal of this study is to determine if regional topical hypothermia (RTH) preserves myocardial viability and function during periods of temporary coronary artery occlusion.Sixteen pigs were divided into two groups (RTH and control). Each group received 40 minutes of midleft anterior descending coronary occlusion followed by 3 hours of reperfusion. The RTH group (n = 10) received RTH and the control group (n = 6) received no cooling. Myocardial and core temperatures were measured with thermistors. Sonomicrometers and micromonameters were used to determine load independent indices of myocardial function. These indices were measured at base line, during coronary occlusion, and at 3 hours of reperfusion. The myocardium at risk and the infarct area were determined with monastral blue dye and triphenyl tetrazolium chloride staining.The mean myocardial temperature in the risk zone during coronary occlusion was significantly less in the RTH group (29.4 degrees C +/- 5.6 degrees C versus 35.7 degrees C +/- 1.1 degrees C, p0.05). After 40 minutes of coronary occlusion, both the RTH group and control had a significant reduction in regional elastance (9.38 +/- 3.54 and 11.05 +/- 1.67 mm Hg/mm) compared with base line measurements (14.70 +/- 2.42 and 16.80 +/- 4.79 mm Hg/mm), p0.05. However, after 3 hours of reperfusion, the elastance returned to base line levels in the RTH group (15.83 +/- 3.06 mm Hg/mm) but remained significantly depressed in the control group (9.97 +/- 3.63 mm Hg/mm, p0.04). Myocardial necrosis as a percentage of the risk zone was significantly less in the hypothermia group (25% +/- 2% versus 62% +/- 5%, p0.001).Regional topical hypothermia during isolated temporary coronary occlusion provides regional myocardial protection expressed as a return of function and decreased necrosis. Regional topical hypothermia may be clinically applicable to myocardial preservation during beating heart operations.

Background. The isolated perfused lung model is commonly used in small animals to study lung function after preservation and cold storage. Measurements of oxygenation, compliance, and capillary filtration coefficient (K f ) permit analysis of preservation solutions or modifications of these solutions. However, inter-investigator variability using different perfusates makes comparisons difficult. Whole blood perfusion more closely mimics the in vivo situation, but extracorporeal circulation may alter the physiologic integrity of the model. Paracorporeal support has been used, but this technique required mechanical ventilation of the support rodent and did not incorporate a method for determining K f . We evaluated a less-invasive technique, of providing cross-circulatory syngeneic support, maintaining the ability to compute K f . Methods. Angiocatheters were inserted into both femoral arteries and one femoral vein of the support rat. The venous cannula was connected to the pulmonary artery of the ex vivo lung block to provide inflow. Pulmonary effluent blood from the lung block was collected via a left atrial cannula and returned to the support rat via the femoral artery. A separate, height-adjustable column was included in the circuit for measurement of K f . Results. Each support rat was used to sequentially perfuse three double-lung blocks. The inflow sample to each lung block was analyzed for pH, pO 2 , pCO 2 , and hematocrit to follow alterations in support rat physiology. There were no statistical differences in the pH, pO 2 , or hematocrit. No significant differences were noted in the pO 2 of the pulmonary effluent blood or the K f ; analyzed to determine whether the sequence of reperfusion affected the pulmonary function assessment. Conclusions. The syngeneic support rat delivers constant pressure systemic venous blood at stable physiologic parameters to the ex vivo lung block. Recirculation of the perfusate through the support rat diminishes the need to pool blood from donors, detoxifies and deoxygenates pulmonary effluent blood, and permits examination of sequential lung blocks. This technique represents a hybrid model between isolated perfused and orthotopic transplant models, maintaining K f determination, a sensitive indicator of reperfusion injury. This technique could be applicable to reperfusion injury models of other organs (using arterial inflow instead) and may permit increased standardization among investigators.

Background . The optimal hemodynamic performance and potential growth of the pulmonary autograft has led to expanded indications for the Ross procedure. We reviewed our institutional experience to assess midterm results with the Ross operation. Methods . In a 7-year period (1992 to 1999), 111 patients with a median age of 15.7 years (range 2 days to 67 years), underwent the Ross procedure. Ninety-five patients had isolated aortic valve disease and 16 pediatric patients had a more complex left ventricular outflow tract obstruction. Results . There were 3 early (2.7%) and 3 late deaths over a median follow-up of 3.6 years (range 6 months to 7.6 years). Actuarial survival at 5 years was 94% ± 2%. In pediatric patients, the pulmonary autograft annulus enlarged from 14.7 ± 6.2 mm to 22 ± 6.3 mm. This growth followed the expected increase in pulmonary valve diameter based on body surface area. Eight reoperations were necessary for autograft insufficiency at a median interval of 14 months (range 2 days to 31 months). Freedom from replacement of the pulmonary autograft was 91% ± 3% at 5 years. Three patients developed important obstruction of the pulmonary homograft requiring reoperation at a median of 29 months (range 9 to 31 months). Conclusions . The Ross procedure can be performed with good midterm results. In pediatric patients, autograft growth has been appropriate. The potential for development of important autograft insufficiency suggests close follow-up through the intermediate and late term.

A 27-year-old male presented with a known history of congenital ventricular septal defect (VSD). A Gerbode-type defect was discovered intraoperatively that was originally misinterpreted as pulmonary hypertension. The case report will review the Gerbode defect and the transesophageal echocardiography findings. It is important, in patients with history of perimembranous VSD, to consider Gerbode-type defect when the tricuspid regurgitation jet velocity is high.

Background. Reperfusion injury with pulmonary edema continues to be a major complication after lung transplantation. Alveolar fluid homeostasis is regulated by Na + /K + -ATPase activity on the basolateral surface of alveolar epithelial cells. Intact Na + /K + -AT-Pase is essential to the resolution of pulmonary edema. We characterized the effects of cold ischemia and reperfusion on expression of Na + /K + -ATPase mRNA and protein. Methods. Baseline values for Na + /K + -ATPase mRNA and protein were determined from freshly harvested lungs with no cold storage time or reperfusion (group I). Group II lungs were analyzed after cold storage times of 12 or 24 hr without subsequent reperfusion. Group III lungs were analyzed after cold storage times of 12 or 24 hr with subsequent reperfusion. Lungs were flushed with either Euro-Collins (EC) or University of Wisconsin (UW) solution in each group. All samples were quantified for Na + /K + -ATPase mRNA and Na + /K + -ATPase protein. Physiological parameters including oxygenation and compliance were also measured. Results. There were no significant differences in the level of mRNA and protein for samples that were cold stored without reperfusion (group II). With reperfusion (group III) there was a significant increase in the level of the Na + /K + -ATPase mRNA after 12 hr of storage for both EC and UW. After 24 hr of storage and subsequent reperfusion, lungs flushed with EC had significantly decreased Na + /K + -ATPase protein and mRNA, although lungs preserved with UW maintained their increased levels of Na + /K + -ATPase protein and mRNA. Conclusions. Our data suggest that ischemia-reperfusion injury results in an initial up-regulation of Na + / K + -ATPase mRNA. With prolonged injury in lungs preserved with EC, the level of the mRNA decreased with a corresponding decrease in the Na + /K + -ATPase protein. The different response seen in EC versus UW may be explained by better preservation of pump function with UW than EC and correlates with improved physiological function in lungs preserved with UW solution.

Background . Ischemia-reperfusion injury involves free radical production, polymorphonuclear neutrophil chemotaxis/degranulation, and production of proteolytic enzymes, complement components, coagulation factors, and cytokines. Activated polymorphonuclear neutrophils, endothelial cells, and macrophages produce platelet activating factor, which further promotes these inflammatory reactions. The recently cloned plasma form of platelet activating factor-acetylhydrolase (PAF-AH) demonstrates antiinflammatory effects by degrading platelet activating factor. We evaluated the effects of PAF-AH in an isolated perfused rat lung model by adding it to the flush solutions or to the reperfusion blood. Methods . Rat lungs were isolated, flushed with Euro-Collins (EC) or University of Wisconsin (UW) solution, stored at 4°C for 6 or 12 hours, and reperfused using a cross-circulating syngeneic support rat. During reperfusion, oxygenation, compliance, and capillary filtration coefficient were calculated. There were four groups in the study; group I (control) had no PAF-AH added, group II had PAF-AH added to the flush solution, group III had PAF-AH added to reperfusion blood, and group IV had PAF-AH added to both flush solution and reperfusion blood. Results . After 6 hours of storage, oxygenation, compliance, and capillary filtration coefficient significantly improved for EC in group IV. For UW, oxygenation improved in group IV whereas compliance improved in groups II, III, and IV. After 12 hours of storage, compliance improved for EC in group IV and capillary filtration coefficient improved in groups III and IV. For UW, oxygenation and compliance improved in groups II and IV, whereas capillary filtration coefficient improved in group IV. Conclusions . Addition of PAF-AH to intracellular organ preservation solutions and to the blood reperfusate significantly improves postreperfusion oxygenation and compliance, and reduces lung capillary permeability.

Background: Despite the decreased incidence of acute rejection episodes and improvements in short and intermediate term graft survival with current immunosuppressive agents, there has been little progress in decreasing the morbidity and mortality from chronic rejection. This phenomenon may, in part, be related to the development of a humoral immune response with increases in anti-HLA antibodies, which presents as accelerated graft arteriopathy with intimal hyperplasia. Methods: Based on prior experimental work, a pilot, prospective, randomized study was performed in 23 primary cardiac transplant recipients to determine whether the addition of prophylactic photopheresis to a cyclosporine, azathioprine and prednisone regimen was safe and resulted in decreased levels of panel reactive antibodies (PRA) and transplant arteriopathy. Results: There was no difference between the two groups in regard to infection or acute rejection incidence. The photopheresis group had a significant reduction in PRA levels at two time points within the first 6 postoperative months. Coronary artery intimal thickness was significantly reduced in the photopheresis group at 1-yr (0.23 vs. 0.49 mm, p < 0.04) and 2-yr (0.28 vs. 0.46 mm, p < 0.02) follow-up compared with the control group. Conclusion: In this small pilot study, photopheresis is a safe, well-tolerated immunomodulatory technique that is capable of decreasing the severity of chronic rejection manifesting as post-transplant graft intimal hyperplasia.

Submitted May 6, 2011; Accepted August 3, 2011. The survival into adulthood of patients with unoperated complex congenital heart disease with anomalies often considered life threatening in infancy and childhood requires a complex interplay of “balanced” defects allowing for cardiovascular physiology compatible with long-term survival. We report on a series of three cases from our advanced imaging database of middle-aged adults presenting with multiple similar defects providing a hemodynamically balanced circulation. The constellation of defects seen in each of these patients included congenitally corrected transposition of the great arteries, a large nonrestrictive ventricular septal defect, valvular pulmonary stenosis, and in two cases anomalous coronary arteries. Cardiovascular computed tomographic angiography (CCTA) and cardiovascular magnetic resonance imaging (CMR) were important to the characterization of the multiple defects and their three-dimensional relationships in these cases. Treatment decisions in patients with this constellation of findings are challenging, given the limited data due to the rarity of survival of patients with these defects into middle adulthood and the paucity of data related to decisions and approaches to medical management, surgical correction, or transplantation.

Cardiovascular computed tomographic angiography (CCTA) provides an understanding of the three-dimensional (3D) coronary artery anatomy in relation to cardiovascular thoracic structures important to the surgical management of anomalous coronary arteries (ACAs). Although some ACA variants are not clinically significant, others can lead to ischemia/infarction, related acute ventricular dysfunction, ventricular arrhythmias, and sudden cardiac death. The CCTA is important to surgical decision making, as it provides noninvasive visualization of the coronary arteries with (1) assessment of origin, course, and termination of coronary artery anomalies in the context of 3D thoracic anatomy, (2) characterization of anatomy helpful for differentiation of benign versus hemodynamically significant variants, (3) identification of other cardiothoracic anomalies, and (4) detection of coronary artery disease. High-risk ACA anatomy in the appropriate clinical setting can require surgical intervention with decisions including minimally invasive versus open sternotomy approach, correction via reimplantation of a coronary artery, alteration of the ACA course without reimplantation, or bypass of an ACA. Given the rarity of ACA, there is limited data in the literature, and significant controversy related to the management issues. The management of ACA requires comprehensive clinical history, thorough assessment of cardiac function, and detailed anatomic imaging. Future studies will need to address the long-term outcome based on detailed assessment of original anatomy and surgical approach.

Background A dramatic transformation of cardiothoracic surgical education has evolved over the past few decades. Methods We begin by presenting recognized catalysts of this change, organized by whom they primarily affect: the trainees, the trainers, and the profession as a whole. Our trainees' prior training is different, and their current demographics and priorities have changed. There is less incentive to teach, with time-honored traditions of education inadequate to meet the needs of trainees. Concurrently, our profession has to adjust to new regulations, increasing financial constraints, and an expanding body of knowledge and technology. To address these issues requires developing new models of education and assessment that can thrive in today's environment. We discuss efforts in the United States and abroad, including new training paradigms ranging from restructuring existing models to novel approaches (eg, competency-based training). Training tools are being developed, such as online instruction, simulation-based learning, and regular student-centered assessments. Finally, models that recognize and reward teaching as a scholarly activity are being implemented. Conclusions Like the radical advances we have witnessed in surgical therapy, surgical education requires creative and perhaps disruptive changes if we are to continue to produce well-trained additions to our professional ranks.

This module includes a handbook of procedural skills created as part of a school-wide procedural skills curriculum held annually for all Year II medical students prior to the start of the clinical clerkships at the Keck School of Medicine of the University of Southern California. The Delphi method was used to determine which skills were the most important or applicable to all students regardless of specialty choice. The authors excluded skills that were already being taught in the curriculum. The handbook contains the objectives, indications, contraindications, general principles, and procedural steps for each skill. At the end of the 8-hour session, each student is asked to demonstrate the skill to one of the instructors. The instructor subjectively rates whether or not each learner completed the essential tasks of the skill in the correct sequence. A student who does not successfully demonstrate the skill is asked to attend another session. The curriculum was implemented in 2008 and it has been a success. Since that time there have been numerous requests from colleagues at other institutions for the handbook. The biggest challenge in implementing this curriculum is getting the students to practice and perform the skills during the required clerkships. Students have found this process burdensome and have asked for dedicated time to practice each skill. In response to this we have set up an additional animate skills lab adjacent to the student conference room and have educated residents and faculty about the importance of providing the students the opportunity to perform these skills.

The ability to competently place a central venous catheter is a skill that is expected of many residents-in-training. Although this is a requisite skill, there has been recent national attention given to the increased amount of central-line associated complications and its impact on patient outcomes and safety. Traditionally, the creation of procedural skills curricula have relied on the ability of experts to describe the procedure. This is problematic due to the fact that experts often omit essential information when trying to describe a task. There appears to be two reasons for this problem. First, as physicians gain expertise, their skills become automated and the steps of the skill blend together. Automated knowledge is achieved by years of practice and experience wherein the basic elements of the task are performed largely without conscious awareness. This causes experts to omit specific steps when trying to describe a procedure because this information is no longer accessible to conscious processes. Second, many physicians are not able to share the complex thought processes that accompany the behavioral execution of technical skills. Even physicians who make an attempt to “think-out-loud” during a procedure often omit essential information because their knowledge is automated. This situation causes problems in medical education because it forces learners to ‘fill in the blanks' by trial and error learning. A potential solution to this dilemma is the use of interview methods that capture the underlying knowledge and skills experts use to perform complex procedures. Known collectively as Cognitive-Task-Analysis (CTA), these techniques enable us to extract implicit and explicit knowledge from experts to inform procedural instruction. The attached CTA informed curriculum to teach and assess competency in central line placement was developed using CTA techniques. Six subject matter experts participated in a formal CTA. The results of each individual report were aggregated into one “Gold Standard” for Central Venous Catheter Placement. This information was used to create the attached Central Line Skills Module, Procedural Guide and Evaluation Checklist. This CTA informed skills module is an effort to overcome the difficulty accessing expert knowledge and presents a novel approach to retrieve the automated expertise of physicians and create comprehensive instructional materials. This curriculum was developed using a complete “Gold Standard” Cognitive-Task-Analysis report with the goal of capturing the automated knowledge of experts that is routinely omitted. We were asked to develop this curriculum by LAC+USC Medical Center administration due to the increasing numbers of CVC related complications. We implemented this curriculum for all residents at LAC+USC beginning in 2008. Since that time there has been a decrease in reported CVC complication rates.

INTRODUCTION: The number of women affected by valvular heart disease and the number of women with breast implants are both on the rise. Minimally invasive heart surgery using a limited thoracotomy offers many potential benefits including reduction in blood loss, shorter hospital stay, faster recovery time, decreased pain, and improved cosmesis. Minimally invasive heart surgery often requires access to the second, third, or fourth intercostal space of the anterior chest wall. The presence of a breast implant may interfere with the surgeon's ability to gain adequate exposure for entry to the appropriate intercostal space. We present a case series of 5 women with breast implants who successfully underwent minimally invasive cardiac valve surgery. METHODS: A retrospective review was conducted of all patients with breast implants who underwent minimally invasive cardiac valve surgery at the University of Southern California University Hospital. In each patient, an inframammary incision was performed, facilitating removal of the implant, performance of the cardiac operation, and reimplantation of the implant. RESULTS: Five women with breast implants who underwent minimally invasive cardiac valve surgery were identified; of these, 4 (80%) patients underwent repair of the mitral valve for mitral regurgitation, whereas 1 (20%) underwent an aortic valve replacement for aortic stenosis. Two patients underwent a concomitant maze procedure for atrial fibrillation during the same operation. The median follow-up time was 7.4 months, and the follow-up period ranged from 2 to 12 months. There were no significant postoperative complications such as infection, hematoma, or need for reoperation. CONCLUSIONS: Our series of 5 patients demonstrates that minimally invasive heart surgery performed through an inframammary incision can be safely performed in those with breast implants.