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To compare perioperative and midterm outcomes in thoracic and thoraco-abdominal aortic aneurysm (TAA and TAAA) repair using hypothermic circulatory arrest (HCA) or aortic clamping (AC) with mild hypothermia.From 2012 to 2021 there were 180 open repairs of a TAA or TAAA, of which 90 (50%) were done with HCA and 90 (50%) with aortic clamping with mild hypothermia. The indications for HCA were arch aneurysm, TAA from chronic aortic dissection, and inability to clamp the aorta for proximal anastomosis.Compared to AC, the HCA group had less prior descending aorta replacement/repair (9.1% vs. 32%, p = 0.0001). Intraoperatively, the HCA group had more TAAs (70% vs. 20%, p 0.0001) while the AC group had more TAAAs (80% vs. 30%, p 0.0001). HCA group had longer cardiopulmonary bypass times (242 vs. 181 min, p 0.0001) but shorter cross-clamp time (39 vs. 120 min, p 0.0001) and lower temperatures (18°C vs. 34°C, p 0.0001). Postoperatively, the HCA group had longer intubation times (31 vs. 26 h, p = 0.002), but all other postoperative outcomes including paralysis (2.2% vs. 8.9%, p = 0.08), and operative mortality (4.4% vs. 2.2%, p = 0.68) were similar between HCA and AC groups. Patient age was an independent risk factor for postoperative paralysis (OR 1.07, p = 0.03) while HCA was not significant (OR 0.37, p = 0.21). Five-year survival was similar between HCA and AC groups (85% vs. 80%, p = 0.36).Postoperative outcomes and midterm survival were acceptable in thoracic and thoracoabdominal aneurysm patients after HCA or AC. Both HCA and AC with mild hypothermia were valid approaches in TAA/A repair.

Persistent racial disparities in lung cancer incidence, treatment, and survival are well documented. Given the importance of surgical resection for lung cancer treatment, racial disparities in surgical quality were investigated using a statewide quality collaborative.This retrospective study used data from the Michigan Society of Cardiothoracic Surgeons General Thoracic database, which includes data gathered for the Society of Thoracic Surgeons General Thoracic Surgery Database at 17 institutions in Michigan. Adult patients undergoing resection for lung cancer between 2015 and 2021 were included. Propensity score-weighting methodology was used to assess differences in surgical quality, including extent of resection, adequate lymph node evaluation, 30-day mortality, and 30-day readmission rate between white and black patients.The cohort included 5073 patients comprising 357 (7%) black and 4716 (93%) white patients. The black patients had significantly higher unadjusted rates of wedge resection than the white patients, but after propensity score-weighting for clinical factors, wedge resection did not differ from lobectomy (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.78-1.49; P = 0.67). The black patients had fewer lymph nodes collected (incidence rate ratio [IRR], 0.77; 95% CI, 0.73-0.81; P0.0001) and lymph node stations sampled (IRR, 0.89; 95% CI, 0.84-0.94; P0.0001). The black patients did not differ from the white patients in terms of mortality (OR, 0.65; 95% CI, 0.19-2.34; P = 0.55) or readmission (OR, 0.79; 95 % CI, 0.49-1.27; P = 0.32). The black patients had longer hospital stays (OR, 1.08; 95% CI, 1.02-1.14; P = 0.01).In a statewide quality collaborative that included high-volume centers, black patients received a less extensive lymph node evaluation, with fewer non-anatomic wedge resections performed, and a more limited lymph node evaluation with lobectomy.

BACKGROUND: There is little evidence on managing the proximal aorta of 4.0-4.5 cm during aortic valve replacement (AVR) in bicuspid aortic valve (BAV) patients. METHODS: A total of 431 patients between 1993-2019 underwent either an isolated AVR, AVR + concomitant ascending aorta replacement, or aortic root replacement. We divided patients into native root dilation [4.0-4.5 cm, n=121] vs. root control groups [

To determine the progression of aortic root in acute type A aortic dissection (ATAAD) patients after aortic root repair (ARr) or replacement (ARR) based on long-term follow-up imaging studies.From 1996 to 2019, 732 patients had ATAAD repair at our institution. Six hundred and seven of these patients had either ARr, (n = 383) or ARR (n = 224). Eighty-one patients were excluded due to a lack of postoperative imaging. Three hundred and thirty-two patients were included in the repair group and 194 patients in the replacement group for long-term follow-up imaging study.Compared to the ARR group, the ARr group was significantly older (60 years vs. 55 years) and had more patients with hypertension (79% vs. 63%) but less male patients (63% vs. 79%) and connective tissue disorder (1.8% vs 8%). The ARr group had more zone two arch replacement (22% vs. 11%), similar HCA time (35 min vs. 31 min), shorter cardiopulmonary bypass time (203 min vs. 266 min), aortic cross-clamp time (128 min vs. 214 min), and fewer concomitant coronary artery bypass (3.9% vs. 8.9%). The root growth rate over 12 years was similar between the repair and replacement group (0.20 mm/year vs. 0.18 mm/year, p = .75). Both the repair and replacement group had similar 15-year cumulative incidence of reoperation (6.9% vs. 5.9%; p = .67), operative mortality (7.8% vs. 8.5%; p = .78), and 15-year survival (51% vs. 52%; p = .40).There was minimal growth of the aortic root after root repair or replacement for ATAAD patients. Both aortic root repair and replacement were acceptable techniques for ATAAD surgery in select patients.

Background: This study aims to determine the long-term outcomes and rate of reoperation among BAV patients with aortic diameter of 5–5.5cm who underwent immediate surgical repair versus surveillance. Methods: A total of 148 BAV patients with aortic aneurysm measuring 5–5.5cm were identified between 1993 to 2019. Patients were categorized into two groups: immediately operated (n=89), versus watched group (n=59) i.e., monitored until either symptomatic, aortic diameter ≥ 5.5 cm or operated at surgeons’ discretion/patient preference. Results: Compared to the immediately operated group the watched group had significantly lower proportion of proximal aorta replacement (86% vs 100%). The mean size of proximal thoracic aorta at initial encounter, including aortic root, ascending, and arch, for the watched group was 52.1 ± 1.62mm and 52.6 ± 1.81mm in the immediately operated group, p=0.06. There was no significant difference in 10-year survival between the watched group 94% (95% CI: 79%, 99%) vs immediately operated group 96.5% (95% CI: 86%, 99%), p=0.90. Initial operation rate for the watched group during 10-year follow-up was 85%. The operative mortality in both groups was 0%. The 10-year reoperation rate between groups was similar: 3.5% (95% CI: 0.9%, 9.1%) in the immediately operated group vs 7.7% (95% CI: 2.4%, 17.1%) in the patients who eventually had surgery in the watched group, p= 0.30. Conclusions Our study showed that the rate of reoperation was similar between groups and survival outcomes were acceptable in observed asymptomatic BAV patients without significant family history and with proximal aortic diameter of 5–5.5cm.

Neomedia has been frequently used for aortic root repair in acute type A aortic dissection. We aimed to determine the efficacy and necessity of neomedia during acute type A aortic dissection root repair.From January 2010 to February 2021, 308 patients with acute type A aortic dissection underwent aortic root repair with neomedia (n = 132) or without neomedia (n = 176). Of these, 121 matched pairs were identified using propensity score matching based on age, sex, coronary artery disease, preoperative renal failure, acute stroke, prior cardiac surgery, cardiogenic shock, coronary malperfusion, preoperative cardiopulmonary resuscitation, and severe aortic insufficiency.After matching, the preoperative demographics and comorbidities were well balanced in both groups. Compared with the neomedia group, the no neomedia group had less hemiarch (57% vs 69%, P = .05) and more zone 1 arch replacements (12% vs 4.1%, P = .03), shorter hypothermic circulatory arrest time (28 vs 36 minutes, P .001), and shorter crossclamp time (120 vs 131 minutes, P = .02). Postoperative outcomes were similar, and the odds ratio by univariable logistic model of no neomedia for operative mortality was 0.83 (P = .76). Aortic root growth over 11 years (0.11 vs 0.16 mm/year, P = .66), 5-year freedom from greater than mild aortic insufficiency (84% vs 85%, P = .80), reoperation for root pathology (1 patient in each group), and 8-year survival (80% [95% confidence interval, 69-97] vs 71% [95% confidence interval, 55-82], P = .26) were similar between the neomedia and no neomedia groups.In patients with acute type A aortic dissection, aortic root repair with or without neomedia was equally safe and effective. Neomedia use could be avoided in acute type A aortic dissection repair.

The objective of this study was to evaluate outcomes of nonsurgically managed acute type A aortic dissection (ATAAD) in the contemporary era.From January 1996 to December 2021, 999 patients presented with ATAAD at our institution, of whom 839 patients underwent open aortic repair (surgical cohort) whereas 148 patients were managed nonoperatively (nonsurgical cohort) because of severe comorbidities, organ failure from malperfusion syndrome, and patients' wishes. Data were obtained from chart review, the Society of Thoracic Surgeons warehouse, the national death index, and Michigan death index database.The combined in-hospital + 30-day mortality rate was 9 times higher in the nonsurgical cohort compared with the surgical cohort (70% vs 7.9%). In the nonsurgical cohort, compared with the first decade (1996-2010), patients during the second decade (2011-2021) had a lower in-hospital+30-day mortality rate (58% vs 87%; P.001); lower incidence of aortic rupture (8% vs 21%; P=.008), and a higher 3-year survival rate (29% vs 13%; P=.005). Within the nonsurgical cohort, compared with patients without malperfusion syndrome, the patients with malperfusion syndrome had similar in-hospital + 30-day mortality but a greater incidence of aortic rupture (21% vs 6.1%, P=.01) with an odds ratio of 4.2 (P=.03); compared with classic type A dissection, the patients with intramural hematoma had a lower in-hospital+30-day mortality rate (52% vs 72%, P=.02) with an odds ratio of 0.36 (P=.02).Surgery remained the mainstream treatment for ATAAD. Nonsurgical management still had a role for those who were not surgical candidates because of comorbidities or malperfusion syndrome, especially in those with acute type A intramural hematoma.

Clostridium difficile is an important cause of nosocomial infection in the pediatric population. The purpose of this study is to estimate the impact of Clostridium difficile infection complicating pediatric acute appendicitis. This study utilizes the combined 2009 and 2012 Kids’ Inpatient Database. Statistical analysis is weighted and was done using Survey Sampling and Analysis procedures in SAS 9.4. We identified 176,934 cases with appendicitis and 0.2% (n = 358) had a concurrent diagnosis of C. difficile. The proportion of cases with C. difficile in perforated appendicitis was greater than in the non-perforated cases (0.39% vs. 0.06%; p

This study assesses impact of COVID-19 testing delay on perioperative outcomes of Acute Type A Aortic Dissection (ATAAD) repair at a single institution.From January 2010 - May 2021, 539 ATAAD patients underwent open aortic repair at our institution. Sixty-five of these patients had open aortic repair during COVID (March 2020 - May 2021) and 474 patients were pre-COVID (January 2010 - February 2020).Compared to the pre-COVID group, patients During-COVID had a higher proportion of previous myocardial ischemia [9/65 (14%) vs 28/474 (5.9%), p=0.03], chronic obstructive pulmonary disease [14/65 (22%) vs 55/474 (12%), p=0.02], and renal malperfusion syndrome [11/65 (17%) vs 30/474 (6.4%), p=0.01]. There was no significant difference in surgical outcomes between groups, including operative mortality (7.6% vs 9.2%, p=0.64). The median admission-to-Operating Room (OR) time was 107 minutes in the During-COVID group compared to 87 minutes in pre-COVID group, p=0.88. During COVID, the median admission-to-OR time was significantly longer in the Waiting group compared to the No-waiting group (209 min vs 75min, p=0.0009). Only one patient had positive COVID test. There were no aortic ruptures while awaiting COVID testing results. There was a total of 6 reported deaths in the During-COVID group: 1 patient died post-surgery due to ARDS caused by COVID, and others due to ischemic stroke (3 patients) and organ failure (2 patients).Perioperative outcomes of ATAAD patients were similar during-COVID compared to pre-COVID. Waiting for COVID testing results did not significantly affect the perioperative outcomes among ATAAD patients after repair.

To assess the outcomes of emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair in patients with acute type A aortic dissection with lower extremity (LE) malperfusion syndrome (MPS); that is, necrosis and dysfunction of the lower extremity.From 1996 to 2019, among 760 consecutive acute type A aortic dissection patients 512 patients had no malperfusion syndrome (Non-MPS), whereas 26 patients had LE-MPS with/without renal MPS and underwent endovascular fenestration/stenting, open aortic repair, or both. Patients with coronary, cerebral, mesenteric, and celiac MPS, or managed with thoracic endovascular aortic repair, were excluded (n = 222). All patients with LE-MPS underwent upfront endovascular fenestration/stenting except 1 patient (with signs of rupture) who initially underwent emergency open aortic repair.Among the LE-MPS patients, 17 (65%) had LE pain, 15 (58%) had abnormal motor function with 8 (31%) having paralysis, 10 (38%) had LE pallor, 17 (65%) had LE paresthesia, and 20 (77%) had LE pulselessness. Of the 25 patients undergoing upfront endovascular fenestration/stenting, 16 went on to open aortic repair, 3 survived to discharge without aortic repair, and 6 died before aortic repair (3-aortic rupture and 3-organ failure). In-hospital mortality among all patients was significantly higher in the LE-MPS group (31% vs 6.3%;In acute type A aortic dissection, LE-MPS was associated with high in-hospital mortality. Emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair may be a reasonable approach.

Clostridium difficile is an important cause of nosocomial infection in the pediatric population. The purpose of this study is to estimate the impact of Clostridium difficile infection complicating pediatric acute appendicitis.This study utilizes the combined 2009 and 2012 Kids' Inpatient Database. Statistical analysis is weighted and was done using Survey Sampling and Analysis procedures in SAS 9.4.We identified 176,934 cases with appendicitis and 0.2% (n = 358) had a concurrent diagnosis of C. difficile. The proportion of cases with C. difficile in perforated appendicitis was greater than in the non-perforated cases (0.39% vs. 0.06%; p .01). Multivariate analysis showed that perforated appendicitis (OR 5.22), and anemia (OR 4.95) were independent predictors of C. difficile infection (p .001). Adjusted for perforated appendicitis, cases with C. difficile had 4.78 days longer length of stay (LOS) and higher total charges of $29,887 (all p 0.0001) compared to non-C. difficile cases.C. difficile infection is a rare, but impactful complication of pediatric appendicitis and is associated with greater disease severity. Proper antibiotic stewardship could minimize the risk of C. difficile in pediatric appendicitis.

OBJECTIVES: This study aimed to determine how acute type A aortic dissection (ATAAD) impacts patients’ quality of life. METHODS: The 36-Item Short Form Survey (SF-36) was used to measure quality of life. The eight SF-36 scales were aggregated into a two-factor summary: physical and mental component summary scales (PCS and MCS). 114 patients were included in the ATAAD group and 81 patients in the aortic valve replacement (AVR) group. All patients underwent surgery between June 2007 and December 2018. Surveys were completed after the operation. RESULTS: The mean scaled score of the ATAAD group decreased significantly in all eight domains of the SF-36 survey after aortic dissection repair except mental health. Also, the post-surgery PCS score was significantly lower than the pre-surgery score (39 vs 49; p

Background: Meckel's diverticulum (MD) is a true diverticulum in the small intestine due to an incomplete obliteration of the vitelline duct. It is commonly located within two feet from the ileocecal valve and occurs in approximately two percent of the population before the age of two years. Meckel's diverticulum is often clinically silent but when symptomatic (4%), it could present with gastrointestinal bleeding, bowel obstruction, perforation or diverticulitis. Case: A 1900g male infant was born at 31 weeks and six days. He was placed on CPAP for poor respiratory effort, and was transported to our intensive care unit immediately after delivery. By day of life three, he had failed to pass meconium and developed signs of intestinal perforation prompting surgical exploration. A perforated Meckel's diverticulum was discovered and he underwent a small bowel resection with primary anastomosis. Histopathology study of resected bowel showed a small intestine with focal mural necrosis and perforation, and marked serositis with abundant acute on chronic inflammation. We present a case of a neonatal symptomatic MD in a preterm infant with failure to pass meconium without obstruction on imaging, and an extensive literature review on this topic in the last 40 years. Conclusion: The literature review and our case show that it can be safe to perform primary anastomosis after resection for perforated MD in the neonatal population, even in those of low birth weight. Keywords: Neonate, Meckel's diverticulum, Intestinal perforation

A common approach to ablating along the posterior wall of the left atrium in atrial fibrillation ablation is to use low power with longer duration for durable lesions and reducing thermal injury. We hypothesize that similar lesions can be safely obtained at high power with low open-irrigation flow and low duration. Twenty-two porcine ventricles were placed in a tissue bath with circulating 0.45% NaCl at a maintained temperature of 37 °C. Bipolar radiofrequency ablation (RFA) with a 4-mm-tip irrigated, force-sensing catheter was performed with various combinations of irrigation, power, and duration at 20g of contact force. Fiber optic temperature probes were placed at depths of 3 mm and 5 mm. Temperature was measured during and 30 s after each ablation. Two hundred sixty-eight lesions were made. At a fixed power and flow rate, lesion surface diameter, maximum lesion width, and lesion depth all increased with longer ablation duration. At fixed duration and irrigation flow rate, increased power led to increased lesion dimensions. At a lower flow rate (2 ml/min), surface lesion diameter and maximum width were significantly larger compared to a higher flow rate (17 ml/min), but lesion depth was not significantly different. The maximum temperature and the rate of temperature rise at a depth of 5 mm with different power settings and ablation durations were lower as compared to a depth of 3 mm at both flow rates (2 ml/min and 17 ml/min). Effective lesions can be performed with high-power and short-ablation durations, thereby reducing RFA procedure time. Higher power, shorter duration lesions result in adequate temperature for myocardial lesion formation at 3 mm, but do not result in excessive temperature at 5 mm depth, potentially reducing the risk of collateral injury. Compared to higher irrigation flow rate, larger surface lesions and comparable maximum lesion width are achieved with lower irrigation flow rate, thus resulting in better lesion contiguity.

Sickle cell disease (SCD) is an autosomal recessive disease not specific to one race. This study aims to assess knowledge about the inheritance pattern of sickle cell disease among college students in the Metropolitan Detroit area. An electronic survey was administered to undergraduate students at Oakland University, and first through fourth year medical students at Oakland University William Beaumont School of Medicine (OUWB). The primary analysis compared knowledge of sickle cell disease inheritance pattern between different demographic categories. A total of 146 Oakland University (27.4%) and OUWB (72.6%) students responded to the survey. The average age of the respondents was 24.27 ± 4.09. The majority of respondents were female (61%) and white (72.6%). In total, three (3) respondents - 1 white, 1 Asian and 1 African American, reported knowing that they have sickle cell disease/trait. In addition, one (1) white female respondent reported having an infant carrying the sickle cell trait. Most respondents (95.9%) knew that sickle cell disease/trait is genetically inherited, but a majority believed that it is associated only with African-Americans (67.8%). Respondents who were college graduates were more likely to correctly identify SCD inheritance patterns (98% compared to 85% of undergraduates; p = 0.002) and less likely to correctly answer the question "Who gets the disease?" (24% compared to 63%; p 0.001). Most respondents (75%) think people should know if they have sickle cell trait/disease before marriage. The result shows that most respondents believe sickle cell disease is specific to African-Americans. However, because it is equally possible for all races to inherit this disease, knowing one's status could help prevent sickle cell-related deaths during rigorous exercises and enable individuals of reproductive age to make informed reproductive decisions in order to decrease sickle cell disease prevalence, and its associated financial and psychosocial burdens.