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OBJECTIVES: Percutaneous pulmonary artery cannulas, used as inflow for left ventricular venting or as outflow for right ventricular mechanical circulatory support, are easily and rapidly deployable with transesophageal and fluoroscopic guidance. METHODS: We chose to review our institutional and technical experience with all right atrium to pulmonary artery cannulations. RESULTS: Based on the review, we describe 6 right atrium to pulmonary artery cannulation strategies. They are divided into total right ventricular assist support, partial right ventricular assist support, and left ventricular venting. A single limb cannula or a dual lumen cannula can be used for right ventricular support. CONCLUSIONS: In the right ventricular assist device configuration, percutaneous cannulation may prove beneficial in cases of isolated right ventricular failure. Conversely, pulmonary artery cannulation can be used for left ventricular venting as drainage to a cardiopulmonary bypass or extracorporeal membrane oxygenation circuit. This article can be used as a reference for the technical aspects of cannulation, decision-making in patient selection, and management of patients in these clinical scenarios.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a bridge to cardiac transplantation. As the 2018 United Network for Organ Sharing (UNOS) heart allocation policy change elevated waitlist status for patients receiving mechanical circulatory support (MCS), we aimed to determine if a center's annual heart transplant volume was associated with ECMO-support duration and posttransplant outcomes.Adults heart transplant candidates between January 1, 2011, and December 31, 2021, were isolated in the UNOS database. VA-ECMO use was identified at the time of listing for transplant. Average annual transplant volume was calculated by the center, with stratification as high (≥20 cardiac transplants, high volume center [HVC]) or low (20 cardiac transplants, low volume center [LVC]) volume centers. Results are reported as mean (interquartile range) or n (%).In total, 543 patients at HVCs and 275 at LVCs were listed for transplant supported with VA-ECMO. Those listed at HVCs were more likely to be supported by intra-aortic balloon pump (103 [19%] vs. 32 [11.6%], p = .008) and inotropes (267 [49.2%] vs. 106 [38.5%], p = .004) at time of listing. Patients at HVCs received ECMO support for 6 [4-9] days, compared to 8 [4-15] days at low-volume centers (p = .030), and but were cannulated a similar time before listing (2 [1-5] vs. 3 [1-7] days, p = .517). There were no differences in rates of transplant (p = .2126), waitlist mortality (p = .8645), delisting due to clinical deterioration (p = .8419), or recovery (p = .1773) between groups. Among transplanted patients, there were no differences in support duration (6 [4-8] vs. 6 [4-10], p = .187), or time from registration to transplant (5 [2-20] vs. 7 [3-22] days, p = .560). Posttransplant survival did not vary (p = .293).LVCs can successfully bridge patients to transplant with VA-ECMO and achieve comparable outcomes to HVCs.

Background The relationship between low oxygen delivery (DO2) on cardiopulmonary bypass and morbidity and mortality following cardiac surgery remains unexamined. Methods We reviewed patients undergoing Society of Thoracic Surgeons index procedures from March 2019 to July 2020, coincident with implementation of a new electronic perfusion record that provides for continuous recording of DO2 and flow parameters. Continuous perfusion variables were analyzed using area-over-the-curve (AOC) calculations below predefined thresholds (DO2 24 hours, stroke, sternal wound infection, and reoperation). Results Eight hundred thirty-four patients were included; 42.7% (356) underwent isolated coronary artery bypass grafting (CABG), whereas 57.3% underwent nonisolated CABG (eg, valvular or combined CABG/valvular operations). DO2 24 hours (P = .04), an effect again most pronounced in nonisolated-CABG cases (P = .002), as well as acute kidney injury Conclusions Low DO2 on bypass may be associated with morbidity/mortality following cardiac surgery, particularly in patients undergoing nonisolated CABG. These results underscore the importance of goal-directed perfusion strategies.

Continuous-flow left ventricular assist devices (CF-LVAD) have been shown to enhance reverse remodeling and myocardial recovery in certain patients allowing for device removal. We sought to analyze the characteristics and describe outcomes of patients who underwent CF-LVAD explantation at a large academic center. We retrospectively identified all patients who underwent CF-LVAD explants due to recovery from 2006 to 2019. Patient baseline characteristics and data on pre- and postexplant evaluation were collected and analyzed. Of 421 patients who underwent CF-LVAD implantation, 13 underwent explantation (3.1%). Twelve HeartMate II and one HeartWare LVAD were explanted. All patients had nonischemic cardiomyopathy. Median time from heart failure diagnosis to LVAD implant was 12 months (interquartile range [IQR], 2-44) and the median time supported on LVAD was 22 months (IQR, 11-28). Two patients died within 30 days of explant. Three additional patients died during the follow-up period and all were noted to be nonadherent to medical therapy. After a mean follow-up duration of 5 years, overall survival was 52%. Mean pre-explant ejection fraction was 49%, which decreased at most recent follow-up to 32%. Mean pre-explant left ventricular internal diameter in diastole (LVIDD) was 4.37 cm and increased to 5.52 cm at most recent follow-up. Continuous-flow left ventricular assist device explantation is feasible and safe in select patients.

Combined heart-liver transplantation (CHLT) is indicated for patients with concomitant end-stage heart and liver disease or patients with amyloid heart disease where liver transplantation mitigates progression. Limited data suggest that the liver allograft provides immunoprotection for heart and kidney allografts in combined transplantation from the same donor. We hypothesized that CHLT reduces the incidence of acute cellular rejection (ACR) and the development of de novo donor-specific antibodies (DSAs) compared with heart-alone transplantation (HA). We conducted a retrospective analysis of 32 CHLT and 280 HA recipients in a single-center experience. The primary outcome was incidence of ACR based on protocol and for-cause myocardial biopsy. Rejection was graded by the International Society of Heart and Lung Transplantation guidelines with Grade 2R and higher considered significant. Secondary outcomes included the development of new DSAs, cardiac function, and patient and cardiac graft survival rates. Of CHLT patients, 9.7% had ACR compared with 45.3% of HA patients (p 0.01). Mean pretransplant calculated panel reactive antibody (cPRA) levels were similar between groups (CHLT 9.4% vs. HA 9.5%; p = 0.97). Among patients who underwent testing, 26.9% of the CHLT and 16.7% of HA developed DSA (p = 0.19). Despite the difference in ACR, patient and cardiac graft survival rates were similar at 5 years (CHLT 82.1% vs. HA 80.9% [p = 0.73]; CHLT 82.1% vs. HA 80.9% [p = 0.73]). CHLT reduced the incidence of ACR in the cardiac allograft, suggesting that the liver offers immunoprotection against cellular mechanisms of rejection without significant impacts on patient and cardiac graft survival rates. CHLT did not reduce the incidence of de novo DSA, possibly portending similar long-term survival among cardiac allografts in CHLT and HA.

BACKGROUND: We hypothesized that long-term clinical and echocardiographic recovery of the impaired ventricle from pressure (aortic stenosis [AS]) and volume (aortic regurgitation [AR]) overload would be different after aortic valve replacement (AVR). METHODS: We compared the results of AVR in patients with a preoperative ejection fraction (EF) of 0.35 or less due to AS, AR, or mixed disease. We constructed a mixed-effects model of EF and left ventricular (LV) end-diastolic diameter (LVEDD) to understand ventricular recovery over the short- (in-hospital), intermediate- (3–6 months), and longer- (>24 months) terms. We sought to identify factors associated with clinical and echocardiographic recovery using multivariable analysis. RESULTS: Between July 2011 and 2017, 136 patients with a preoperative EF of 0.35 or less and severe AS (n = 83), severe AR (n = 18), or mixed AS and AR (n = 35) underwent AVR. There were 2 (1.5%) early deaths in the AS group. Survival at 1, 2, and 5 years did not differ between groups. Baseline EF did not differ between the groups but improved with markedly different trajectory and time course in the AS, AR, and mixed groups over time. LVEDD regressed in all patient cohorts, following a different pattern for AS and AR. Baseline EF and LVEDD predicted the long-term fate of the LV but did not determine survival. We identify factors associated with long-term survival. CONCLUSIONS: The pattern of LV recovery appears to be early in AS and delayed in AR. Baseline clinical factors, rather than echocardiographic status of the LV, appear to determine late survival.

Background Although recruiting highly qualified, diverse applicants into cardiothoracic surgery remains a national priority, their characteristics remain unknown. This study aims to describe current and future applicants in cardiothoracic surgery. Methods Aspiring cardiothoracic surgeons (students interested in matriculating in a North American training program) were voluntarily enrolled in the study through Twitter and email outreach. A 33-question survey evaluated their backgrounds, research experiences, attitudes, and interests within cardiothoracic surgery. Standard descriptive statistics were used. Results There were 111 participants, 40 of whom were female (36.0%) and 27 of whom identified as an underrepresented minority (24.3%). Of the total, 63 belonged to an institution with a cardiothoracic surgery training program (56.8%). A total of 91 students envisioned having a mostly operative career (82.0%) and 75 envisioned pursuing educational roles (67.6%). The most popular surgical specialties were heart transplantation (50.5%) and aortic surgery (47.8%). Participants selected having a high-intensity operative environment (81.2%) and an innovative academic environment (58.8%) as the most attractive qualities. Perceived lack of work–life balance (46%) and toxic training or work environment (28%) were the greatest deterrents. Finances during the application process were perceived as a potential barrier by 41 students (36.9%). Approximately 75% of students (83 of 111) had faculty as mentors; 46.8% (56 of 111) thought that cardiothoracic surgery faculty were approachable but had limited time for mentorship. Conclusions This survey study characterized a nationally selected pool of aspiring cardiothoracic surgeons using social media. Future studies involving larger and more diverse cohorts are warranted to find areas for improvement in recruitment, retention, and diversity.

ImportanceWhether people from racial and ethnic minority groups experience disparities in access to minimally invasive mitral valve surgery (MIMVS) is not known.ObjectiveTo investigate racial and ethnic disparities in the utilization of MIMVS.Design, Setting, and ParticipantsThis cross-sectional study used data from the Society of Thoracic Surgeons Database for patients who underwent mitral valve surgery between 2014 and 2019. Statistical analysis was performed from January 24 to August 11, 2022.ExposuresPatients were categorized as non-Hispanic White, non-Hispanic Black, and Hispanic individuals.Main Outcomes and MeasuresThe association between MIMVS (vs full sternotomy) and race and ethnicity were evaluated using logistic regression.ResultsAmong the 103 753 patients undergoing mitral valve surgery (mean [SD] age, 62 [13] years; 47 886 female individuals [46.2%]), 10 404 (10.0%) were non-Hispanic Black individuals, 89 013 (85.8%) were non-Hispanic White individuals, and 4336 (4.2%) were Hispanic individuals. Non-Hispanic Black individuals were more likely to have Medicaid insurance (odds ratio [OR], 2.21; 95% CI, 1.64-2.98; P P P P = .74). Patients with commercial insurance had 2.35-fold higher odds of undergoing MIMVS (OR, 2.35; 95% CI, 2.06-2.68; P P P = .04) and were more likely to die or experience a major complication (aOR, 1.25; 95% CI, 1.16-1.35; P Conclusions and RelevanceIn this cross-sectional study, non-Hispanic Black patients were less likely to undergo MIMVS and more likely to die or experience a major complication than non-Hispanic White patients. These findings suggest that efforts to reduce inequity in cardiovascular medicine may need to include increasing access to private insurance and high-volume surgeons.

OBJECTIVES In 2018, the United Network for Organ Sharing modified their heart allocation policy to reduce waitlist mortality and prioritize patients with the greatest acuity. Considering declining rates of combined heart-lung transplantation, this study sought to investigate the impact of the new allocation system on waitlist and post-transplant outcomes of patients listed for combined heart-lung transplantation. METHODS Adult patients listed for combined heart-lung transplant between 2012 and 2021 were included. Patients were stratified according to listing era. Competing risk regression was used to assess waitlist outcomes. Cox proportional hazards regression was used to establish risk factors for post-transplant mortality. RESULTS A total of 511 patients were included, of whom 295 (57.8%) were listed in era 1 and 216 (42.2%) in era 2. Era 2 was associated with increased likelihood of transplant (adjusted standard hazard ratio (aSHR): 1.60 [1.23–2.07]; P CONCLUSIONS The allocation policy change has led to improvements in waitlist outcomes in patients listed for heart-lung transplantation. Despite increased ischaemic times and use of ECMO, early post-transplant survival was equivalent.

BackgroundWe sought to describe trends in extracorporeal membrane oxygenation (ECMO) use, and define the impact on PGD incidence and early mortality in lung transplantation.MethodsPatients were enrolled from August 2011 to June 2018 at 10 transplant centers in the multi-center Lung Transplant Outcomes Group prospective cohort study. PGD was defined as Grade 3 at 48 or 72 hours, based on the 2016 PGD ISHLT guidelines. Logistic regression and survival models were used to contrast between group effects for event (i.e., PGD and Death) and time-to-event (i.e., death, extubation, discharge) outcomes respectively. Both modeling frameworks accommodate the inclusion of potential confounders.ResultsA total of 1,528 subjects were enrolled with a 25.7% incidence of PGD. Annual PGD incidence (14.3%-38.2%, p=.0002), median LAS (38.0-47.7 p=.009) and the use of ECMO salvage for PGD (5.7%-20.9%, p=.007) increased over the course of the study. PGD was associated with increased 1 year mortality (OR 1.7 [95% C.I. 1.2, 2.3], p=.0001). Bridging strategies were not associated with increased mortality compared to non-bridged patients (p=.66); however, salvage ECMO for PGD was significantly associated with increased mortality (OR 1.9 [1.3, 2.7], p=.0007). Restricted mean survival time comparison at 1-year demonstrated 84.1 days lost in venoarterial salvaged recipients with PGD when compared to those without PGD (ratio 1.3 [1.1, 1.5]) and 27.2 days for venovenous with PGD (ratio 1.1 [1.0, 1.4]).ConclusionsPGD incidence continues to rise in modern transplant practice paralleled by significant increases in recipient severity of illness. Bridging strategies have increased but did not affect PGD incidence or mortality. PGD remains highly associated with mortality and is increasingly treated with salvage ECMO.

OBJECTIVE: To assess the effect of intraoperative cryoablation on postoperative patient-reported pain, opioid use, and clinical outcomes in lung transplantation. METHODS: We performed a single-center retrospective cohort study of adult lung transplant recipients from August 2017 to September 2018. We compared outcomes of patients who received intraoperative cryoablation of the intercostal nerves with those who did not. Primary outcomes were postoperative patient-reported pain scores and opioid use. Secondary outcomes included postoperative sedation and agitation levels and perioperative outcomes. Data were abstracted from patients' electronic health records. RESULTS: Of the 102 patients transplanted, 45 received intraoperative cryoablation (intervention group) and 57 received the standard of care, which did not include intercostal or serratus blocks or immediate postoperative epidural placement (control group). The intervention group had significantly lower median and maximum postoperative pain scores at days 3 and 7 and significantly lower oral opioid use at days 3, 7, and 14 compared with the control group. Chronic opioid use at 3 and 6 months' posttransplant was lower in the intervention group. Differences in perioperative outcomes, including length of mechanical ventilation, sedation and agitation levels, and hospital stay, were not clinically meaningful. Survival at 30 days and 1 year was superior in the intervention compared with the control group. CONCLUSIONS: Findings suggest that use of intraoperative cryoablation is an effective approach for treating pain and reducing opioid use in patients who undergo lung transplant, but a randomized study across multiple institutions is needed to confirm these findings.

In recent years, the Thoracic Surgery Match (TSM) has become increasingly competitive. The purpose of this study was to compare recent trends in application and match rates in the TSM by training pathway.This was a retrospective cohort study of all applicants to Integrated and Independent pathways for Thoracic Surgery training (2008-2021). Chi square tests were used to elucidate temporal trends and make comparisons by training pathway.Accreditation Council for Graduate Medical Education (ACGME)-accredited Thoracic Surgery training programs in the United States.1500 Independent and 1242 Integrated pathway applicants for Thoracic Surgery training.From 2008 to 2021, the annual match rate decreased from 91% to 71% in the Independent pathway (p0.001). This was driven by a decrease in the number of training positions (130-101, 22% decrease) and increase in number of applicants (96-140, 46% increase). In the Integrated pathway, the annual match rate increased from 33% to 35% (p0.001) as did the number of training positions (3 to 46, 1430% increase) and applicants (9-129, 1333% increase). During each year, match rates in the Independent pathway exceeded those in the Integrated pathway (p0.001). U.S. Allopathic graduates had higher match rates than non-U.S. Allopathic graduates for both Integrated and Independent training pathways. The percentage of applicants in the Independent pathway matching at one of their top 3 choices decreased from 73% to 40% (p0.001). The percentage of Independent thoracic surgery training positions that went unmatched decreased from 28% to 2% (p0.001). This percentage was stable at an average of 1% in the Integrated pathway (p0.05).The TSM has become increasingly competitive for Independent pathway applicants and remains ultracompetitive for Integrated pathway applicants. More research is needed to understand disparities in match rates by Thoracic Surgery training pathway.

Cardiogenic shock represents a very challenging patient population due to the undifferentiated pathologies presenting as cardiogenic shock, difficult decision-making, prognostication, and ever-expanding support options. The role of cardiac surgeons on this team is evolving. The implementation of a shock team is associated with improved outcomes in patients with cardiogenic shock. Early deployment of mechanical circulatory support devices may allow an opportunity to rescue these patients. Cardiothoracic surgeons are a critical component of the shock team who can deploy timely mechanical support and surgical intervention in selected patients for optimal outcomes.

Program directors are tasked with selecting whom they think will be the best fit for residency and the next leaders of the field. While numerical metrics have played a vital role in this process, recent changes to student evaluation are reducing the availability of these metrics. This poses unique challenges for both applicants and program directors. Here we discuss how this will likely shift the focus on other parts of the application and the consequences (good and bad) of doing so.

Purpose: We sought to assess the relationship of intraoperative perfusion parameters while on cardiopulmonary bypass, including oxygen delivery (DO2), to the need for ECMO following orthotopic heart transplantation (OHT). Methods: We included all adult (>18 years old) OHTs performed at our institution since implementation of an electronic perfusion record (March 2019-February 2020). Multi-organ transplants were excluded. The primary outcome was the need for immediate venoarterial ECMO in the OR following OHT. Univariable statistics were computed across demographic, clinical, operative, and perfusion variables, including oxygen delivery (DO2) measured each minute. Results: Fifty-three OHT were included with a median age of 54 years (interquartile range, 45-61). The primary outcome occurred in eight patients (15.1%). A significantly greater proportion of patients requiring ECMO had ischemic cardiomyopathy (50.0% (4/8) vs. 15.6% (7/45), p = 0.02) and had preoperative ventricular assist devices (37.5% (3/8) vs. 8.9% (4/45), p = 0.03). Median bypass times were longer in the ECMO group (217 vs. 147 minutes, p = 0.001). Phenylephrine doses were nonsignificantly higher in ECMO patients (4.1 vs. 1.9 mg, p = 0.10). No significant differences were observed in single-point median DO2 (275 vs. 294 mL O2/min/m2 BSA, p = 0.17) and nadir DO2 (226 vs. 222, p = 0.94), but increasing time and depth of DO2 below a threshold of 300 mL O2/min/m2 BSA (i.e. area over the DO2 curve (AOC) but below threshold) was significantly associated with the need for postoperative ECMO (p = 0.04). Conclusion: This is the first study to examine the relationship of perfusion parameters, including oxygen delivery, to outcomes following heart transplantation. We note that DO2 2 differences in patients who require post-OHT ECMO reflect vasoplegia, or a more causative relationship which might be leveraged to improve outcomes.

Despite advancing technology, right heart failure after left ventricular assist device implantation remains a significant source of morbidity and mortality. With the UNOS allocation policy change, a larger proportion of patients proceeding to LVAD are destination therapy and consist of an overall sicker population. Thus, a comprehensive understanding of right heart failure is critical for ensuring the ongoing success of durable LVADs. The purpose of this review is to describe the effect of LVAD implantation on right heart function, review the diagnostic and predictive criteria related to right heart failure, and discuss the current evidence for management and treatment of post-LVAD right heart failure.

Right ventricular assist devices (RVADs) can be used in patients with acute right heart failure. A novel device that has recently been deployed is the right atrium to pulmonary artery (RA-PA) dual lumen single cannula (DLSC). One of the limitations is that it occupies a large proportion of the right ventricular outflow tract and PA; therefore, standard continuous hemodynamic monitoring with a pulmonary artery catheter is commonly not used. Serial echocardiography is pivotal for device deployment, monitoring device position, assessing RV readiness for decannulation, and surveilling for short-term complications. We performed a retrospective case series of 24 patients with RA-PA DLSC RVAD assessing echocardiographic RV progression and vasoactive infusion requirements. The overall survival was 66.6%. The average vasoactive infusion score at the time of cannulation was 24.9 ± 43.9, at decannulation in survivors 4.6 ± 4.9 vs. 25.4 ± 21.5 in nonsurvivors, and 2.7 ± 4.9 at 48 hours post decannulation. On echocardiography, the average visual estimate of RV systolic function encoded (0 = none and 5 = severe) in survivors was 3.9 ± 1.2, 2.8 ± 1.6, 2.5 ± 1.7, and 2.8 ± 1.9, respectively, and in nonsurvivors 3.8 ± 1.6 and 3.4 ± 1.8, respectively. This demonstrated an RV systolic function improvement over time in survivors as opposed to nonsurvivors. This was also demonstrated in RV size visual estimate, respectively. Quantitatively, at the pre-defined four timepoints, the RV:LV, tricuspid annular plane systolic excursion, and fractional area change all improve over time and there is statistically significant difference in survivors versus nonsurvivors. In this study, we describe a cohort of patients treated with RA-PA DLSC RVAD. We illustrate the critical nature of echocardiographic measures to rate the progression of RV function, improvement in vasoactive infusion requirements, and ventilator parameters with the RA-PA DLSC.

In 2018, a United Network for Organ Sharing (UNOS) policy change increased prioritization of patients bridged with temporary mechanical circulatory support devices, such as venoarterial ECMO, for cardiac transplantation. Considering increased waitlist acuity, we sought to characterize whether this was associated with an increased risk for development of postoperative acute renal failure requiring dialysis (AKI-D) and risk of death after transplantation.Dialysis-naive adults receiving single-organ heart transplant between November 2009 and February 2020 were stratified by receipt of AKI-D. Era 1 and era 2 were defined by the periods of UNOS allocation before and after policy change, respectively. Multivariable logistic regression was performed to determine risk factors for AKI-D. Rates of AKI-D were compared by propensity score-matched cohorts. Survival was compared by Kaplan-Meier analysis.A total of 20 698 patients were included. Venoarterial ECMO use significantly increased in era 2 (5.6% vs 0.58%; P.01). Overall prevalence of AKI-D was greater in era 2 (13.5% vs 10.2%; P.01). Use of preoperative ECMO, intra-aortic balloon pump, and ventilators and longer ischemia times were identified as independent risk factors for development of AKI-D. Five- and 10-year survival rates were significantly decreased for patients with AKI-D. There was no short-term survival difference of patients with AKI-D between era 2 and the more contemporary era 1.Patients in whom AKI-D develops after transplantation have significantly worse short- and long-term outcomes. Preoperative use of ECMO, preoperative ventilator support, and longer ischemia times are risk factors for development of AKI-D, and their prevalence has increased since the allocation policy change.

In patients with preoperative atrial fibrillation (AF) undergoing aortic valve replacement, the addition of surgical ablation to surgical aortic valve replacement (SAVR-SA) is efficacious and a Class I guideline. We hypothesized that this subgroup may benefit from SAVR-SA compared to transcatheter aortic valve replacement (TAVR) alone.Medicare beneficiaries with persistent non-valvular AF who underwent SAVR-SA or TAVR alone between 2012 and 2018 were included. Patients with high-risk surgical comorbidities were excluded. Groups were matched using inverse probability weighting. The primary outcome was all-cause mortality. Secondary outcomes were stroke, transient ischemic attack, permanent pacemaker implantation, bleeding, rehospitalization for atrial arrhythmias, and rehospitalization for heart failure. Kaplan-Meier estimates and Cox proportional-hazards regression were used to compare outcomes. Outcomes were adjusted for variables with a standardized mean difference greater than 0.1.Of 439,492 patients who underwent aortic valve replacement, 2591 underwent SAVR-SA and 1494 underwent TAVR alone. Weighting resulted in adequately matched groups. Compared to TAVR alone, SAVR-SA was associated with a significant reduction in all-cause mortality (HR 0.65, 95% CI 0.53-0.79), permanent pacemaker implantation (HR 0.62, 95% CI 0.44-0.87), bleeding (HR 0.63, 95% CI 0.39-1.00), and rehospitalization for heart failure (HR 0.49 (0.36-0.65). There was no difference in the incidence of stroke (HR 1.07, 95% CI 0.74-1.54), transient ischemic attack (HR 1.05, 95% CI 0.75-1.47), or rehospitalization for atrial arrhythmia.Select patients with persistent non-valvular AF may benefit from SAVR-SA compared to TAVR alone.

A significant decrease in emergency presentations of acute cardiac conditions has been observed during the COVID-19 pandemic. We aimed to understand perceptions that influence people's decisions whether to present to the emergency department (ED) with symptoms related to acute cardiovascular events to inform necessary medical communication.We recruited users of Amazon Mechanical Turk (Seattle, WA) to participate in a survey to elucidate perceptions of COVID-19 risk associated with a visit to the ED. A conjoint analysis was designed based on commonly reported factors associated with people's decisions to present to the ED during the pandemic to calculate preference utilities.After exclusions, 1003 participants completed the survey between 12/5/2020 and 12/6/2020. Participants ranked the perceived risk of contracting COVID-19 at the ED as one of the highest, only second to that at bars and restaurants. Only 68% (685/1003) were willing to present to the ED immediately with severe chest pain. Fear of further transmitting the virus to loved ones was the most frequently cited reason for not presenting. Conjoint analysis demonstrated severe chest pain to be the dominant factor in the decision to present to the ED.The risk of contracting COVID-19 while presenting to the ED for a life-threatening cardiovascular symptom is overestimated and is strongly affected by social factors.

Case Presentation: A 29-year-old male with LVH diagnosed in childhood was admitted with acute HF. TTE showed LVEF 5-10% and LV thrombi for which he was anticoagulated. He received inappropriate ICD shocks due to T wave oversensing, leading to cardiogenic shock requiring VA-ECMO support. Serum lactate peaked at 17 mmol/L due to cardiac and metabolic decompensation. He underwent heart transplantation (HT) on hospital day (HD) 8 and tolerated standard immunosuppression. First endomyocardial biopsy showed acute cellular rejection requiring pulse steroids. He was discharged on HD 33. Trio whole exome and mitochondrial genome sequencing revealed biallelic variants in complement component 1Q subcomponent-binding protein ( C1QBP ), due to a maternally inherited likely pathogenic variant c.612C>G (p.F204L in exon 5) and an apparently de novo deletion of 17p13.2, spanning exons 4-6 of C1QBP and exon 6 of the RPAIN gene. Mitochondrial genome sequencing of the explanted heart revealed multiple large-scale mitochondrial DNA deletions at 33% heteroplasmy. Discussion: C1QBP variants are associated with mitochondrial and multi-organ dysfunction. Only 12 patients exhibiting biallelic C1QBP variants are reported. Four died in the peripartum period due to fetal hydrops or HF; 5 exhibited early-onset cardiomyopathy (CM); 3 others had late-onset ophthalmoplegia without CM. The p.F204L variant has been reported in 1 patient with compound C1QBP p.F204L/p.C186S heterozygosity who died from hydrops fetalis and a second with p.F204L homozygosity with late-onset ophthalmoplegia and skeletal myopathy without CM. Differences in the size, heteroplasmy, and tissue distribution of mitochondrial genome secondary deletions may explain variability in disease onset and progression. We present the first patient with biallelic pathogenic C1QBP gene variants with mitochondrial CM to undergo HT and highlight the diagnosis and management of an exceptionally uncommon genetic disorder.

Our group has previously described how dedicated practice outside the operating room can improve surgical technique and enhance intraoperative performance. We have also recently developed a "do-it-yourself" simulator made from inexpensive, easily obtainable materials to practice a variety of operative scenarios in cardiac surgery. This video tutorial demonstrates our Coronary Anastomosis Module, which is designed for practice of both distal and proximal coronary anastomoses.

It is unknown whether some donor specific antibodies (DSA) can be crossed at the time of lung transplant without desensitization or augmented induction immunosuppression. This study assessed whether crossing low-level pre-transplant DSA (defined as mean fluorescence intensity (MFI) 1000-6000) without augmented immunosuppression is associated with worse retransplant-free or chronic lung allograft dysfunction (CLAD)-free survival. Of the 458 included recipients, low-level pre-transplant DSA was crossed in 39 (8.6%) patients. The median follow-up time was 2.2 years. There were 15 (38.5%) patients with Class I DSA and 24 (61.5%) with Class II DSA. There was no difference in adjusted overall retransplant-free survival between recipients where pre-transplant DSA was and was not crossed (HR: 0.98 (95% CI = 0.49-1.99), p = 0.96). There was also no difference in CLAD-free survival (HR: 0.71 (95% CI = 0.38-1.33), p = 0.28). There was no difference in Grade 3 PGD at 72 hours (OR: 1.13 (95% CI = 0.52-2.48), p = 0.75) or definite or probable AMR (HR: 2.22 (95% CI = 0.64-7.61), p = 0.21). Lung transplantation in the presence of low-level DSA without planned augmented immunosuppression is not associated with worse overall or CLAD-free survival among recipients with intermediate-term follow-up. This article is protected by copyright. All rights reserved.

Background Valve-sparing aortic root replacement (VSARR) is an increasingly popular alternative to traditional aortic root replacement for aortic root aneurysm disease with a normal aortic valve. We evaluated the early and midterm outcomes of VSARR—reimplantation technique (VSARR-RT) done at a single institution over a decade. Materials and Methods We performed a retrospective study of all patients who underwent VSARR-RT between January 2004 and July 2014. Results A total of 85 patients underwent VSARR-RT. Median time to latest echocardiographic follow-up was 4 years (range: 15–72 months). Total observation time was 491 patient years. Mean age was 44.6 ± 14.3 years, and 13 (15%) were women. Thirty-nine (46%) patients had a connective tissue disorder and 6 (7%) had a bicuspid aortic valve. Thirty-three (39%) patients underwent concomitant procedures, including coronary artery bypass grafting (n = 9, 11%), mitral valve repair (n = 8, 9%), and aortic hemi-arch replacement (n = 7, 8%). There were no operative deaths or in-house mortality and no postoperative strokes. Kaplan-Meier analysis demonstrated survival of 99% (95% confidence interval [CI]: 97–100%) at 2 years and 98% (95% CI: 97–100%) at 8 years. Freedom from reoperation was 95.8% (95% CI: 91.2–100%) at 8 years. Freedom from endocarditis was 100% at 8 years. At the last echocardiographic follow-up, 95% of patients were free of severe aortic regurgitation (AR) and 82% free of moderate AR. Of the four patients who had severe AR, three underwent reoperations and received prosthetic valves and one is being clinically monitored. Conclusion This study reports early and midterm outcomes after VSARR-RT at our institution, including those patients who underwent a VSARR-RT procedure combined with other procedures. Further follow-up remains necessary to determine long-term outcomes.

Subacute groin complications associated with extracorporeal membrane oxygenation (ECMO) cannulation are well recognized, yet their effects on clinical outcomes remain unknown. This single-center, retrospective study reviewed all patients receiving venoarterial ECMO from 01/2017 to 02/2020. Cohorts analyzed included transplanted patients (TPs) and non-transplanted patients (N-TPs) who did or did not develop ECMO-related subacute groin complications. Standard descriptive statistics were used for comparisons. Logistic regressions identified associated risk factors. Overall, 82/367 (22.3%) ECMO patients developed subacute groin complications, including 25/82 (30.5%) seromas/lymphoceles, 32/82 (39.0%) hematomas, 18/82 (22.0%) infections, and 7/82 (8.5%) non-specified collections. Of these, 20/82 (24.4%) underwent surgical interventions, most of which were muscle flaps (14/20, 70.0%). TPs had a higher incidence of subacute groin complications than N-TPs (14/28, 50.0% vs. 68/339, 20.1%, P = 0.001). Seromas/lymphoceles more often developed in TPs than N-TPs (10/14, 71.4% vs. 15/68, 22.1%, P = 0.001). Most patients with subacute groin complications survived to discharge (60/68, 88.2%). N-TPs who developed subacute groin complications had longer post-ECMO lengths of stay than those who did not (34 days, IQR 16-53 days vs. 17 days, IQR 8-34 days, P 0.001). Post-ECMO length of stay was also longer among patients who underwent related surgical interventions compared to those who did not (50 days, IQR 35-67 days vs. 29 days, IQR 16-49 days, P = 0.007). Transplantation was the strongest risk factor for developing subacute groin complications (OR 3.91, CI

Objective To assess societal preferences regarding allocation of extracorporeal membrane oxygenation (ECMO) as a rescue option for select patients with coronavirus disease 2019 (COVID-19). Design Cross-sectional survey of a nationally representative sample. Setting Amazon Mechanical Turk platform. Participants In total, responses from 1,041 members of Amazon Mechanical Turk crowd-sourcing platform were included. Participants were 37.9 ± 12.6 years old, generally white (65%), and college-educated (66.1%). Many reported working in a healthcare setting (22.5%) and having a friend or family member who was admitted to the hospital (43.8%) or died from COVID-19 (29.9%). Measurements and Main Results Although most reported an unwillingness to stay on ECMO for >one week without signs of recovery, participants were highly supportive of ECMO utilization as a life-preserving technique on a policy level. The majority (96.7%) advocated for continued use of ECMO to treat COVID patients during periods of resource scarcity but would prioritize those with highest likelihood of recovery (50%) followed by those who were sickest regardless of survival chances (31.7%). Patients >40 years old were more likely to prefer distributing ECMO on a first-come first-served basis (21.5% v 13.3%, p Conclusion Even though participants expressed hesitation regarding ECMO in personal circumstances, they were uniformly in support of using ECMO to treat COVID patients at a policy level for others who might need it, even in the setting of severe scarcity.

Background The COVID‐19 pandemic has disrupted all aspects of healthcare, including cardiothoracic surgery (CTS). We sought to determine the pandemic's impact on CTS trainees' educational experiences. Methods A survey was developed and distributed to members of the Thoracic Surgery Residents Association and other international CTS trainees. Trainees were asked to evaluate their cumulative experiences and share their overall perceptions of how CTS training had been impacted during the earliest months of the COVID‐19 pandemic (i.e., since March 01, 2020). Surveys were distributed and responses were recorded June 25–August 05, 2020. In total, 748 surveys were distributed and 166 responses were received (overall response rate 22.2%). Of these, 126 of 166 responses (75.9%) met inclusion criteria for final analysis. Results Final responses analyzed included 45 of 126 (35.7%) United States (US) and 81 of 126 (64.3%) international trainees, including 101 of 126 (80.2%) senior and 25 of 126 (19.8%) junior trainees. Most respondents (76/126, 43.2%) lost over 1 week in the hospital due to the pandemic. Juniors (12/25, 48.0%) were more likely than seniors (20/101, 19.8%) to be reassigned to COVID‐19‐specific units (p, Cardiothoracic surgery trainees in the United States and abroad have been significantly impacted by the COVID‐19 pandemic in the form of lost time in the hospital, decreased operative volumes, and frequent reassignment to COVID‐19‐specific care settings