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Abstract Late gadolinium enhanced (LGE) cardiovascular magnetic resonance (CMR) has proven to be the gold standard for viability assessment. LGE CMR is also useful for identifying the nature of cardiac masses or lesions. We report a case of a rare primary cystic tumor of the atrioventricular node, in which CMR proved to be valuable.

Objectives: The Ross procedure has excellent outcomes in the pediatric population. Some series report age and anatomy dependent outcomes, but no comprehensive analysis stratified by these variables exists. We sought to describe the landscape of congenital heart disease (CHD) treated with the Ross procedure and identify the patients best served with this operation., Methods: Over 30 years, 317 pediatric patients underwent the Ross procedure. Patients were stratified into 4 age groups: neonates (<31days,n=21), infants (31days-1year,n=40), children (1-12years,n=165), and adolescents (13-18years,n=91), and 3 anatomical groups: isolated aortic valve (AV) disease (n=221), Shone's complex or multilevel LVOT obstruction (n=61), and complex CHD (n=35). Groups were compared across outcomes., Results: Neonates and infants had the highest rates of Shone's syndrome (p<0.001), complex CHD (p<0.001), concomitant root enlargement (p<0.001), and arch procedures (p<0.001). Operative mortality and morbidity were 14/317 (4.4%) and 44/317 (14%) respectively. Both were higher in neonates and infants (p<0.001,p<0.001), but lower for patients with isolated AV disease (p<0.001,p<0.001). 10-year survival and freedom from LVOT reintervention were 92% and 81% and were both significantly better in patients with isolated AV disease compared to those with complex CHD (p<0.001,p=0.005). In neonates and infants with isolated AV disease, operative mortality was 1/23 (4%), morbidity was 2/23 (9%), 10-year survival was 85.6%, and 10-year freedom from LVOT reintervention was 88.4%., Conclusions: Among pediatric patients, those with isolated AV disease are best served with the Ross procedure, regardless of age. Complex CHD is associated with lower survival and increased risk of LVOT reintervention., (Copyright © 2024. Published by Elsevier Inc.)

Background: Bioprosthetic surgical mitral valve replacement (SMVR) remains an important treatment option in the era of transcatheter valve interventions. We present 10-year clinical outcomes of Medicare beneficiaries undergoing SMVR with a contemporary low-profile mitral porcine valve., Methods: This is a single-arm observational study using Medicare fee-for-service claims data. De-identified patients undergoing SMVR with the Epic™ Mitral valve (Abbott, Minnesota, USA) in the United States between 1/1/2008-12/31/2019 were selected by ICD-9/10 procedure codes and then linked to a manufacturer device tracking database. All-cause mortality, heart failure (HF) re-hospitalization, and mitral valve reintervention (surgical or transcatheter valve-in-valve) were evaluated at 10-years using the Kaplan Meier method., Results: Among 75,739 Medicare beneficiaries undergoing SMVR during the study period, 14,015 were implanted with the Epic™ Mitral valve, of which 76.5% (10,720) had underlying HF. Mean age was 74±8 years. Survival at 10-years in patients without preoperative HF was 40.4% (95% CI 37.4%-43.4%) compared to 25.4% (95% CI 23.8%-27.0%) for patients with HF (p < 0.001). The 10-year freedom from HF rehospitalization was 51.3% (95% CI 49.4%-53.1%). Freedom from mitral valve reintervention was 91.4% (95% CI 89.7%-92.7%) at 10 years., Conclusions: This real-world nationwide study of Medicare beneficiaries receiving the Epic™ Mitral valve demonstrates >90% freedom from all-cause valve reintervention and >50% freedom from HF rehospitalization at 10-years post-implant. Long-term survival and HF rehospitalization in this population with mitral valve disease undergoing SMVR was found to be impacted by underlying HF., (Copyright © 2024. Published by Elsevier Inc.)

Repair of concomitant aortic and mitral valvular disease with involvement of the aortomitral curtain requires a technically complex operation colloquially termed the commando procedure. Surgical outcomes of this procedure are not well described. The objective of this study was to examine outcomes of the commando procedure at our center. We identified all patients undergoing concomitant aortic and mitral valve replacements from 2004-2021. Of 363 patients, 41 underwent reconstruction of the aortomitral curtain. Survival analysis and multivariable modeling were used to examine outcomes and risk factors for mortality. The median age was 52 (IQR 44-71) years. Preoperatively, 4 of 41 (9.8%) patients had renal failure, and 10 of 41 (24.4%) had a stroke. The most common surgical indication was endocarditis in 25 of 41 (61.0%) patients. 25 of 41 (61.0%) patients underwent redo sternotomy, and 23 of 41 (56.1%) had previous prosthetic valves. Operative mortality was 14 of 41 (34.1%), and 8 of 41 (9.5%) patients received a permanent pacemaker. Survival at 1, 3, and 5 years was 55.4% (95% confidence interval (CI), 40.6-75.5%), 50.3% (35.0-72.3%), and 37.7% (19.3-73.9%) respectively. Cox proportional hazards regression identified previous sternotomy (HR 4.76, 95% CI 1.21-18.73), and female gender (HR 1.39, 95% CI 1.17-13.82) as risk factors for mortality. Patients undergoing reconstruction of the aortomitral curtain represent a high-risk population with complex surgical indications. Due to high perioperative morbidity and mortality, this procedure should be performed only when necessary. Despite a high up front morbidity burden, outcomes remain favorable for patients who survive the initial hospitalization., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Valve-sparing repair (VSR) of tetralogy of Fallot (TOF) tends to result in higher residual right ventricular outflow tract (RVOT) gradients. We evaluated the progression and clinical implications of RVOT gradients following VSR of TOF. Demographic, clinical, and operative data were retrospectively collected from consecutive TOF patients who underwent VSR at our institution between 01/2010 and 06/2021. RVOT gradient, pulmonary valve annulus (PVA) diameter and Boston Z-scores were recorded from serial echocardiograms. Data are presented as median and interquartile range or number and percentage. A total of 156 children (boys 92, 59%) underwent VSR at 6.5 (4.9-8.4) months of age and 6.6 kg (5.6- 7.7) weight. There was 1 (0.6%) operative mortality. The remaining 155 patients were followed for 69.4 months (4-106.2). RVOT gradient was 2.4m/s (1.7-2.9) at discharge. It transiently increased, then declined and stabilized during follow-up. PVA Z-score was -1.7 (-3.1 to 0.5) at discharge and 'grew' to -0.8 (-1.7 to 0.4) at last follow-up. Freedom from RVOT re-intervention was 97%, 94% and 91% at 1, 5 and 10-year follow-up. Among 67 (43%) patients with PVA Z-score < -2, a similar RVOT gradient pattern was observed and freedom from RVOT re-intervention was 97%, 95% and 95% at 1, 5 and 8-year follow-up. Following VSR of TOF, RVOT gradients transiently increase and then fall as PVA growth catches up, resulting in durable intermediate outcomes. Patients with PVA Z-score < -2 demonstrated a similar pattern of hemodynamics in the RVOT and excellent freedom from reintervention., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: We sought to evaluate whether the anatomic and physiologic stratification system (ACAP score), released as part of the American College of Cardiology/American Heart Association updated guidelines for management of adult congenital heart disease (ACHD) in 2018, better estimated mortality and morbidity after cardiac operations for ACHD., Methods: The ACAP score was determined for 318 patients (age ≥18 years) with ACHD undergoing heart surgery at our institution between December 2001 and August 2019. The primary end point was perioperative mortality. The secondary aim was to evaluate the performance of the ACAP, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) Congenital Heart Surgery Mortality Categories, and ACHS mortality scores/categories at predicting a composite adverse outcome of perioperative mortality, prolonged ventilation, and renal failure requiring replacement therapy. Logistic regression models were built to estimate mortality and the composite outcome using anatomic and physiologic components independently and together. Receiver operating characteristic curves were created, and area under the curves were compared using the Delong test., Results: The median age was 37 years (interquartile range, 26.3-50.0 years). There were 9 perioperative mortalities (2.8%). With respect to perioperative mortality, the area under the curve using the anatomic component only was 0.74, which improved to 0.81 after including physiologic severity (P = .05). When physiologic severity was added to the model for the composite outcome, the discriminatory abilities of the ACHS mortality score and the STAT categories increased significantly to 0.83 (95% CI, 0.75-0.91; P = .02) and 0.82 (95% CI, 0.73-0.90; P = .04), comparable to the predictive power of ACAP., Conclusions: Physiologic severity augments ability to predict mortality and morbidity after cardiac surgery for ACHD. There is need for more robust ACHD-specific risk models., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Pulmonary arterioplasty (PA plasty) at bidirectional cavopulmonary anastomosis (BDCA) is associated with increased morbidity, but outcomes to final stage palliation are unknown. We sought to determine the influence of PA plasty on pulmonary artery growth and hemodyamics at Fontan., Methods: We retrospectively reviewed clinical data and outcomes for BDCA patients from 2006 to 2018. PA plasty was categorized by extent (type 1-4), as previously described. Outcomes included pulmonary artery reintervention and mortality before final palliation., Results: Five hundred eighty-eight patients underwent BDCA. One hundred seventy-nine patients (30.0%) underwent concomitant PA plasty. Five hundred seventy (97%) patients (169 [94%] PA plasty) survived to BDCA discharge. One hundred forty out of 570 survivors (25%) required PA/Glenn reintervention before final stage palliation (59 out of 169 [35%]) PA plasty; 81 out of 401 (20%) non-PA plasty; P  < .001). Twelve-, 24-, and 36-month freedom from reintervention after BDCA was 80% (95% CI, 74-86%), 75% (95% CI, 69-82%), and 64% (95% CI, 57-73%) for PA plasty, and 95% (95% CI, 93-97%), 91% (95% CI, 88-94%), and 81% (95% CI, 76-85%) for non-PA plasty ( P  < .001). Prefinal stage mortality was 37 (6.3%) (14 out of 169 PA plasty; 23 out of 401 non-PA plasty; P  = .4). Five hundred four (144 PA plasty and 360 non-PA plasty) patients reached final stage palliation (471 Fontan, 26 1.5-ventricle, and 7 2-ventricular repair). Pre-Fontan PA pressure and pulmonary vascular resistance were 10 mm Hg (range, 9-12 mm Hg) and 1.6 mm Hg (range, 1.3-1.9 mm Hg) in PA plasty and 10 mm Hg (range, 8-12 mm Hg) and 1.5 mm Hg (range, 1.3-1.9 mm Hg) in non-PA plasty patients, respectively ( P  = .29, .6). Fontan hospital mortality, length of stay, and morbidity were similar., Conclusions: PA plasty at BDCA does not confer additional mortality risk leading to final palliation. Despite increased pulmonary artery reintervention, there was reliable pulmonary artery growth and favorable pulmonary hemodynamics at final stage palliation., Competing Interests: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2024 The Author(s).)

Objective: The Ross procedure is an important tool that offers autologous tissue repair for severe left ventricular outflow tract (LVOT) pathology. Previous reports show that risk of mortality is highest among neonates and infants. We analyzed our institutional experience within this patient cohort to identify factors that most affect clinical outcome., Methods: A retrospective chart review identified all Ross operations in neonates and infants at our institution over 27 years. The entire study population was analyzed to determine risk factors for mortality and define outcomes for survival and reintervention., Results: Fifty-eight patients underwent a Ross operation at a median age of 63 (range, 9-156) days. Eighteen (31%) were neonates. Eleven (19%) patients died before hospital discharge. Multiple regression analysis of the entire cohort identified young age (hazard ratio [HR], 1.037; P = .0045), Shone complex (HR, 17.637; P = .009), and interrupted aortic arch with ventricular septal defect (HR, 16.01; P = .031) as independent predictors of in-hospital mortality. Receiver operating characteristic analysis (area under the curve, 0.752) indicated age younger than 84 days to be the inflection point at which mortality risk increases. Of the 47 survivors, there were 2 late deaths with a mean follow-up of 6.7 (range, 2.1-13.1) years. Three patients (6%) required LVOT reintervention at 3, 8, and 17.5 years, respectively, and 26 (55%) underwent right ventricular outflow tract reintervention at a median of 6 (range, 2.5-10.3) years., Conclusions: Ross procedure is effective in children less than one year of age with left sided obstructive disease isolated to the aortic valve and/or aortic arch. Patients less than 3 months of age with Shone or IAA/VSD are at higher risk for morbidity and mortality. Survivors experience excellent intermediate-term freedom from LVOT reintervention., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The study objective was to evaluate the surgical outcomes of mitral valve repair in the era of percutaneous technology., Methods: We retrospectively reviewed 452 patients who underwent mitral valve repair for degenerative disease between 2010 and 2021. Survival, mitral valve reoperation, and mitral regurgitation recurrence were assessed using Cox regression, dichotomized for those aged more than or less than 60 years., Results: Median age in years (interquartile range) was 52 (47-57) in the younger cohort and 67 (63-73) in the older cohort ( P  < .0001). Preoperative comorbidities and leaflet pathology were comparable between groups. After adjustment for sex, prior sternotomy, diabetes, atrial fibrillation, and type of leaflet repair, age 60 years or more was not associated with increased mortality (hazard ratio, 6.96, 95% confidence interval, 0.85-56.8, P  = .07). Considering death as a competing outcome, cumulative incidence of mitral valve reoperation at 1, 3, and 5 years was 0.9%, 1.4%, and 1.8% in the younger cohort, respectively, and 2.7%, 4.0%, and 5.1% in the older cohort, respectively (subhazard ratio, 2.95, 95% confidence interval, 0.84-10.4, P  = .09). Cumulative incidence of mitral regurgitation recurrence with moderate-severe or greater mitral regurgitation at 1, 3, and 5 years was 1.4%, 3.6%, and 5.1%, and 2.7%, 3.5%, and 4.7% in the younger and older cohorts, respectively (subhazard ratio, 0.85, 95% confidence interval, 0.29-2.50, P  = .76). Subgroup analysis focusing on isolated mitral valve repairs (n = 388) showed equivalent results with respect to mortality (hazard ratio, 5.31, 95% confidence interval, 0.64-44.0, P  = .12), mitral valve reoperation (subhazard ratio, 4.04, 95% confidence interval, 0.89-18.4, P  = .07), and mitral regurgitation recurrence (subhazard ratio, 0.98, 95% confidence interval, 0.30-3.15, P  = .97)., Conclusions: Mitral valve repair outcomes continue to be excellent, even in low-risk patients aged more than 60 years., (© 2022 The Author(s).)

Background: The objective of this study was to identify trainee knowledge gaps in reimbursement and compensation, determine the perceived importance of understanding these topics, and to explore if the Thoracic Surgery Curriculum needs additional educational material., Methods: The Thoracic Surgical Residents Association Executive Committee selected the research proposal and distributed an anonymous electronic survey to 531 Accreditation Council for Graduate Medical Education cardiothoracic surgery trainees. Standard descriptive statistics and regression analyses were performed., Results: One hundred fourteen responses were collected (response rate, 21.5%). Most trainees understood little to none about how attending surgeons are reimbursed (n = 74, 69%). Most trainees reported knowing little or nothing about pay-for-performance compensation (n = 73, 67%), bundled care (n = 82, 75%), or value-based reimbursement (n = 84, 77%). Approximately 20% of trainees were accurate in estimating surgeon reimbursement for 3 common cardiothoracic surgery procedures to within 20% of the true reimbursement value, whereas approximately 30% were accurate to within 50% of the true reimbursement value. No respondent characteristics were found to be associated with a more or less accurate reimbursement response. Additionally 81% of trainees (n = 87) responded that by the conclusion of training, understanding surgeon reimbursement is very important or extremely important and 90% of trainees (n = 95) either somewhat agreed or strongly agreed with including these topics in the Thoracic Surgical Curriculum., Conclusions: Despite acknowledging the importance of understanding physician compensation and reimbursement, cardiothoracic surgery trainees do not understand how the current models work. This study exemplifies the need for a succinct curriculum in this domain for trainees nationwide., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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 < .001) and decrease in death/deterioration (sdHR: 0.55, p = .011) on the waitlist with no effect on 1-year post-HT survival (p = .8). The exception status of patients undergoing HT was predominantly seen in the POST era (29%, 293/1006); only four patients in the PRE era. Exception requests in the POST era did not alter patient outcomes., Conclusions: In patients bridged to heart transplant with an IABP, policy change is associated with decreased rates of death/deterioration and increased rates of heart transplantation on the waitlist without affecting 1-year post-transplant survival. While exception status use has markedly increased post-PC, it is not associated with patient outcomes., (© 2021 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Objective: Most of all congenital cardiac surgical programs participate in public outcomes reporting. The primary end point is transparency. In this era, academic programs with surgical residents face the challenge of producing outstanding results while allowing residents to learn by doing. We sought to understand the effect of education on our surgical outcomes., Methods: We collected data for all American Board of Thoracic Surgery index cases done at our institution over a 10-year period. We identified 3406 cases and categorized them into 2 groups according to primary surgeon: attending (2269) versus resident (1137). In a multivariable logistic regression model we examined the effect of operating surgeon on in-hospital mortality, major morbidity, and length of stay. We used propensity score matching subsequently to balance differences between cohorts, and multivariable logistic regression was repeated., Results: Using the entire cohort, multivariable logistic regression model adjusted for age, sex, weight, lack of preoperative comorbidity, presence of preoperative respiratory failure, The Society of Thoracic Surgeons--European Association for Cardio-Thoracic Surgery category, and need for deep hypothermic circulatory arrest, showed a higher odds of survival in the resident cohort (odds ratio, 1.484; 95% confidence interval, 0.998-2.206; P = .05). Propensity score matching identified 1137 pairs of attending and resident cases with well-balanced preoperative variables. Logistic regression modeling using the matched cohort showed equivalent 30-day mortality, 30-day major morbidity, and length of stay., Conclusions: There was no difference in mortality, major morbidity, or length of stay when similar cases were compared that were operated on by attendings versus those by a resident. Effectively educating congenital heart surgeons without compromising an operation's quality requires thoughtful approach, including case selection and graded responsibility., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

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. The 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 was strongly associated with overall mortality (hazard ratio [HR], 25.0 and 9.9; 95% confidence intervals [CIs], 1.18-52.8 and 1.28-76.5; p-value .04 and .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 = .024) and diagnosed late were more likely to be female (OR, 8.75; 95% CI, 2.0-38.4; p = .004) and require an urgent DSWI procedure (OR, 9.25; 95% CI, 1.86-45.9; p = .007). Both early diagnosis of DSWI and initial attempted medial management were strongly associated with mortality (HR, 7.48; 95% CI, 1.38-40.4; p = .019 and HR, 7.76; 95% CI, 1.67-35.9; p = .009, respectively)., Conclusions: Early aggressive surgical therapy for DSWI after cardiac surgery results in excellent outcomes. Those diagnosed with DSWI early and who have failed initial medical management have increased mortality., (© 2021 Wiley Periodicals LLC.)

Introduction: Intercostal cryo nerve block has been shown to enhance pulmonary function recovery and pain management in post-thoracotomy procedures. However, its benefit have never been demonstrated in minimal invasive thoracotomy heart valve surgery (Mini-HVS). The purpose of the study was to determine whether intraoperative intercostal cryo nerve block in conjunction with standard of care (collectively referred to hereafter as CryoNB) provided superior analgesic efficacy in patients undergoing Mini-HVS compared to standard-of-care (SOC)., Methods: FROST was a prospective, 3:1 randomized (CryoNB vs. SOC), multicenter trial in patients undergoing Mini-HVS. The primary endpoint was the 48-h postoperative forced expiratory volume in 1 s (FEV1) result. Secondary endpoints were visual analog scale (VAS) scores for pain at the surgical site and general pain, intensive care unit and hospital length-of-stay, total opioid consumption, and allodynia at 6 months postoperatively., Results: A total of 84 patients were randomized to the two arms of the trial CryoNB (n = 65) and SOC (n = 19). Baseline Society of Thoracic Surgeons Predictive Risk of Mortality (STS PROM) score, ejection fraction, and FEV1 were similar between cohorts. A higher 48-h postoperative FEV1 result was demonstrated in the CryoNB cohort versus the SOC cohort (1.20 ± 0.46 vs. 0.93 ± 0.43 L; P = 0.02, one-sided two-sample t test). Surgical site VAS scores were similar between the CryoNB and SOC cohorts at all postoperative timepoints evaluated, but VAS scores not related to the surgical site were lower in the SOC group at 72, 94, and 120 h postoperatively. The SOC cohort had a 13% higher opioid consumption than the CryoNB cohort. One of 64 CryoNB patients reported allodynia that did not require pain medication at 10 months., Conclusions: The results of FROST demonstrated that intercostal CryoNB provided enhanced FEV1 score at 48 h postoperatively with optimized analgesic effectiveness versus SOC. Future larger prospective randomized trials are warranted to determine whether intercostal CryoNB has an opioid-sparing effect in patients undergoing Mini-HVS., Trial Registration: Clinicaltrials.gov identifier: NCT02922153., (© 2021. The Author(s).)

Background: Debate continues in regard to the optimal surgical approach to the mitral valve for degenerative disease., Methods: Between February 2004 and July 2015, 363 patients underwent mitral valve repair for degenerative mitral valve disease via either sternotomy (sternotomy, n = 109) or small right anterior thoracotomy (minimally invasive, n = 259). Survival, need for mitral valve reoperation, and progression of mitral regurgitation more than two grades were compared between cohorts using time-based statistical methods and inverse probability weighting., Results: Survival at 1, 5, and 10 years were 99.2, 98.3, and 96.8 for the sternotomy group and 98.1, 94.9, and 94.9 for the minimally invasive group (hazard ratio: 0.39, 95% confidence interval [CI] 0.11-1.30, p = .14). The cumulative incidence of need for mitral valve reoperation with death as a competing outcome at 1, 3, and 5 years were 2.7%, 2.7%, and 2.7% in the sternotomy cohort and 1.5%, 3.3%, and 4.1% for the minimally invasive group (subhazard ratio (SHR) 1.17, 95% CI: 0.33-4.20, p = .81). Cumulative incidence of progression of mitral regurgitation more than two grades with death as a competing outcome at 1, 3, and 5 years were 5.5%, 14.4%, and 44.5% for the sternotomy cohort and 4.2%, 9.7%, and 20.5% for the minimally invasive cohort (SHR: 0.67, 95% CI: 0.28-1.63, p = .38). Inverse probability weighted time-based analyses based on preoperative cohort assignment also demonstrated equivalent outcomes between surgical approaches., Conclusions: Minimally invasive and sternotomy mitral valve repair in patients with degenerative mitral valve disease is associated with equivalent survival and repair durability., (© 2021 Wiley Periodicals LLC.)

Background: Increased attention has been dedicated to gender inequity at scientific meetings. This study evaluated the gender distribution of session leaders at cardiothoracic surgery national and regional meetings., Methods: This is a descriptive study of the gender of peer-selected session leaders at 4 cardiothoracic surgery organizations' annual meetings from 2015 to 2019. Session leaders included moderators, panelists, and invited discussants. Data from publicly available programs were used to generate a list of session leaders and organization leaders. The primary outcome measure was the proportion of female session leaders at annual meetings. Descriptive analyses were performed, including the Cochran-Armitage trend test for linear trends of proportions., Results: A total of 679 sessions over 20 meetings were examined. Of the 3662 session leaders, 480 (13.1%) were women. The proportion of total female session leaders trended positively over time from 9.6% (56 of 581) in 2015 to 15.9% (169 of 1060) in 2019 (P = .001). Among specialty topic sessions, female session leaders were distributed as follows: adult cardiac, 6.9% (81 of 1172); congenital cardiac, 10.8% (47 of 437); and thoracic, 23.2% (155 of 668). The proportion of female session leaders trended significantly only for thoracic sessions (20.6% [21 of 102] in 2015 to 29.2% [58 of 199] in 2019; P = .02). More than one-half of the sessions (57.4%; 390 of 679) featured all-male session leadership., Conclusions: Women remain underrepresented in leadership roles at cardiothoracic surgery organizational meetings. This may deter female applicants and has implications for female surgeons' career trajectories; therefore, attention must be given to the potential for unconscious bias in leadership in cardiothoracic surgery., (Copyright © 2021. Published by Elsevier Inc.)

Background: In patients with interrupted aortic arch and ventricular septal defect (VSD) with a small left ventricular outflow tract (LVOT), either aortopulmonary amalgamation or a Ross-Konno type procedure can be performed to create stable systemic outflow. We sought to analyze factors associated with these different surgical approaches., Methods: We retrospectively identified patients who underwent surgical repair for interrupted aortic arch/VSD at our institution between 1998 and 2017. Of these, 43 patients had a small, native LVOT that was unsuitable for systemic outflow. Patient data were retrospectively collected for this cohort and analyzed., Results: Aortopulmonary amalgamation was performed at 7 days (interquartile range [IQR], 5-10) in 30 patients (group I). Within group I a primary Yasui repair with ventricular septation was performed in 3 patients and a Norwood-type repair in the other 27. Of these 27, 19 underwent subsequent biventricular conversion at 9 months (IQR, 7-11). In contrast 13 patients underwent a Ross procedure at 12 days (IQR, 6-27) (group II). Compared with group I, group II patients had a smaller VSD (3.5 vs 5.1 mm, P < .001) that was more often remote from the semilunar valves (38% vs 13%, P = .02). Operative mortality occurred in 1 group I patient (4%) at the time of biventricular conversion and 2 group II patients (15%) during the Ross procedure. After a 5.2-year (IQR, 3.2-7.4) follow-up there were 2 additional mortalities in each group, all unrelated to cardiac disease., Conclusions: When native LVOT in interrupted aortic arch/VSD is unsuitable for systemic outflow, size and location of the VSD can be used to tailor the surgical approach to establish biventricular circulation with favorable intermediate-term outcomes., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Congenital heart disease (CHD) frequently occurs in conjunction with extracardiac developmental anomalies, including cleft malformations. The clinical impact of concomitant cleft disease on the surgical management of CHD has not been studied. We evaluated cardiac surgical outcomes in patients with concomitant CHD and cleft lip and/or palate (CL/P)., Methods: Patients with CHD + CL/P managed at our institution between January 2004 and December 2018 were included. Demographic, operative, and follow-up data were retrospectively collected and analyzed using SAS 9.4. Chi-square tests were used for categorical variables and t test or Wilcoxon rank sum tests for continuous variables. Significance of P < .05 was used., Results: There were 127 patients with CHD + CL/P; 63 (50%) were boys. Compared to the general CHD population, patients with CHD + CL/P demonstrated an enrichment of atrial septal defects (10.5% vs 34%), tetralogy of Fallot/double outlet right ventricle (6.4% vs 15.7%), arch defects (4.5% vs 10.2%), truncus arteriosus (1.2% vs 3.1%), and total anomalous pulmonary venous return (1.0% vs 2.4%). Of 63 patients who underwent CHD repair, 58 (92%) did so prior to CL/P repair at 21.5 (6-114) days of age. Compared to CHD lesion-matched patients undergoing cardiac surgical repair at our institution, patients with CL/P had a 2- to 3.7-fold longer intensive care stay, 1.8- to 2.6-fold longer hospital stay, and 6- to 13.5-fold increase in major morbidity, without a significant difference in mortality., Conclusions: Cardiac outflow tract defects are particularly overrepresented in CL/P patients. The presence of CL/P increases the complexity of postoperative care after CHD surgery, without a significant impact on mortality.

The management of aortic valve disease in the pediatric population is complex and requires an individualized approach and opportune application of techniques focused on each individual patient's specific anatomy, pathology, and clinical presentation. Though some patients may require variations in the approach to management, the ultimate goal should be to perform a Ross procedure when aortic valve replacement is indicated., (Copyright © 2021. Published by Elsevier Inc.)

Background: Phrenic nerve injury is a known cause of morbidity after single ventricle palliation. Previous studies have shown that hemidiaphragm plication improves short-term outcomes. The effect of plication on the outcomes of subsequent stages of single ventricle palliation is unknown., Methods: From 1997 to 2015, 1146 patients underwent surgical management of single ventricle physiology at our institution. We reviewed the records of 30 patients who had undergone diaphragm plication for phrenic nerve injury before Fontan completion. Each patient was compared with 2 propensity-matched controls identified from patients who underwent the Glenn or Fontan procedure during the same period without diaphragm plication. Propensity matching was achieved for each test subject using the nearest neighbor algorithm. Data are presented as the median and quartiles or numbers and percentages., Results: The cohort included 18 boys (60%). Of the 30 patients, 19 (63%) had undergone plication after first-stage palliation. Of these, 13 have undergone completion Fontan, 5 were awaiting Fontan at the last follow-up, and 1 had died. An additional 11 patients had undergone plication after Glenn and proceeded to Fontan completion. Thus, 24 patients with diaphragm plication have undergone Fontan completion. No difference was found in pulmonary pressure or resistance between the plicated patients and their propensity-matched controls. Both groups had comparable chest tube output and hospital lengths of stay. Equal proportions of patients in both groups required pulmonary vasodilator therapy and/or supplemental oxygen at hospital discharge., Conclusions: Prior diaphragm plication does not adversely affect Fontan completion in children with single ventricle physiology. The hospital course during subsequent stages of palliation for plicated patients was no different than that of matched controls., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: A penetrating injury to the "cardiac box" is thought to be predictive of an injury to the heart; however, there is very little evidence available to support this association. This study aims to evaluate the relationship between penetrating trauma to the cardiac box and a clinically significant injury., Methods: All patients presenting to a Level I trauma center from January 2009 to June 2015 who sustained a penetrating injury isolated to the thorax were retrospectively identified. Patients were categorized according to the location of injury: within or outside the historical cardiac box. Patients with concurrent injuries both inside and outside the cardiac box were excluded. Clinical demographics, injuries, procedures, and outcomes were compared., Results: During this 7-year period, 330 patients (92% male; median age, 28 years) sustained penetrating injuries isolated to the thorax: 138 (42%) within the cardiac box and 192 (58%) outside the cardiac box. By mechanism, 105 (76%) were stab wounds (SW) and 33 (24%) were gunshot wounds (GSW) inside the cardiac box, and 125 (65%) SW and 67 (35%) GSW outside the cardiac box. The overall rate of thoracotomy or sternotomy (35/138 [25.4%] vs. 15/192 [7.8%], p < 0.001) and the incidence of cardiac injury (18/138 [13%] vs. 5/192 [2.6%], p < 0.001) were significantly higher in patients with penetrating trauma within the cardiac box. This was, however, dependent on mechanism with SW demonstrating a higher incidence of cardiac injury (15/105 [14.3%] vs. 3/125 [2.4%], p = 0.001) and GSW showing no significant difference (3/33 [9.1%] vs. 2/67 [3%], p = 0.328]. There was no difference in overall mortality (9/138 [6.5%] vs. 6/192 [3.1%], p = 0.144)., Conclusion: The role of the cardiac box in the clinical evaluation of a patient with a penetrating injury to the thorax has remained unclear. In this analysis, mechanism is important. Stab wounds to the cardiac box were associated with a higher risk of cardiac injury. However, for GSW, injury to the cardiac box was not associated with a higher incidence of injury. The diagnostic interaction between clinical examination and ultrasound, for the diagnosis of clinically significant cardiac injuries, warrants further investigation., Level of Evidence: Prognostic study, Level IV, Therapeutic V.

A subset of neonates with single ventricle (SV) physiology has antegrade pulmonary blood flow that is deemed unlikely to be reliable until Glenn. We have used systemic to pulmonary shunt (SPS) with pulmonary artery banding (PAB) to optimize pulmonary blood flow while maintaining reserve antegrade flow. We hypothesize that this is an effective strategy that can be accomplished without the routine need for cardiopulmonary bypass. We retrospectively reviewed the records of 60 neonates who underwent combined SPS + PAB between 2004 and 2015. Data are presented as median with quartiles. Children were 8 (4-19) days old at surgery and included 38 (63%) boys. Atresia or severe stenosis of the subpulmonary atrioventricular (AV) valve associated with pulmonary blood flow across a bulboventricular foramen was present in 37 (62%). In 20 (33%), heterotaxy-associated unbalanced AV canal with pulmonary stenosis with or without anomalous pulmonary venous drainage was present. First-stage palliation was accomplished without cardiopulmonary bypass in 44 patients (73%). There were 7 (12%) hospital deaths, 4 among the 20 (20%) with heterotaxy. Fifty-three children were followed for a median 5.1 (1.8-8.2) years. Three early reinterventions were required after initial palliation (1 PAB adjustment, 2 SPS balloon angioplasties). Five additional heterotaxy patients experienced late mortality during follow-up. There were no early or emergent Glenn. Thirty-nine patients have reached Fontan circulation with a median pre-Fontan PA pressure of 14 (12-18) mm Hg. One patient converted to biventricular physiology and the remaining await completion Fontan. Heterotaxy was the only independent predictor of mortality (hazard ratio 10 (2.3-44, P < 0.001). In SV patients with unreliable antegrade PA flow, SPS + PAB is an effective first-stage palliation. SV patients with heterotaxy are at increased risk for mortality., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Re-expansion pulmonary oedema following the drainage of pleural fluid is rare. We report a patient with 1 lung who developed life-threatening re-expansion pulmonary oedema following thoracentesis and was rescued with venovenous (VV) extracorporeal membrane oxygenation (ECMO), surviving to discharge 28 days later. An aggressive early rescue therapy with VV ECMO should be pursued for all types of acute lung injury regardless of patient age, comorbidities or transplant candidacy, given the likelihood of native lung recovery following ECMO support., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Coarctation of the aorta can be associated with hypoplasia of the proximal transverse aortic arch. One approach to manage this condition is via left thoracotomy and extended end-to-end anastomosis with the expectation that the proximal arch will grow over time. Our preferred approach is to augment the aorta via midline sternotomy. We hypothesized that this approach is safe, durable, and allows reliable growth of the aorta., Methods: We identified the records of patients with biventricular anatomy who had coarctation of the aorta, hypoplasia of the proximal transverse arch, and no other cardiac lesion that would mandate cardiopulmonary bypass use and midline sternotomy. The records of 62 such patients operated on between 2005 and 2016 were retrospectively reviewed. Patient demographics, clinical variables and outcome data were collected and analyzed using SAS 9.4. Data are presented as median (interquartile range [IQR])., Results: Sixty-two patients (23 girls [37%]) underwent repair at 10 (IQR, 5 to 21) days of life. Forty-nine (79%) patients were on prostaglandin infusion to maintain ductal patency. Fifteen (24%) patients presented in shock with end organ dysfunction, 17 (27%) were on inotropes, and 26 (42%) were mechanically ventilated. The proximal transverse arch was 41% (IQR, 34% to 47%) of the size of ascending aorta as measured by echocardiography (z-score, -5 [IQR, -5.8 to -4.3]). Following median sternotomy, repair was carried out on cardiopulmonary bypass (41 [IQR, 37 to 47] minutes). The arch was reconstructed with (n = 26 [42%]) or without (n = 36 [58%]) coarctectomy usually using homograft patch aortoplasty (n = 58 [94%]). In all but 2 patients, repair was undertaken with circulatory arrest (27 [IQR, 22 to 31] minutes). Patients were extubated 4 (IQR, 3 to 5) days later and discharged home in 12 (IQR, 8 to 18) days. There was no mortality, and 8 morbidity events (3 recurrent nerve injury, 2 chylothorax, 1 phrenic nerve injury, 1 seizure, and 1 superficial wound infection) in 7 (11%) patients. All patients are alive at 41 (IQR, 11 to 64) months of follow-up. Reintervention was required in 6 (10%) patients (5 catheter based and 3 surgical) for recurrent distal coarctation. Reintervention-free survival at 1, 3, and 5 years was 87%. Only 1 child was currently on antihypertensive therapy, and all were in New York Heart Association functional class I symptoms. At last echocardiogram, the proximal transverse arch was 97% (IQR, 84% to 103%) of the diameter of the ascending aorta (z-score, 0.8 (IQR, 0.3 to 1.3]), ejection fraction was 70% (IQR, 60% to 76%), and only 2 patients had significant left ventricular hypertrophy., Conclusions: Arch augmentation via median sternotomy is a safe and effective procedure that can be accomplished with low morbidity and mortality. The reconstructed arch retains excellent growth potential resulting in a very favorable physiologic outcome., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Ebstein anomaly (EA) encompasses a broad spectrum of morphology and clinical presentation. Those who are symptomatic early in infancy are generally at highest risk, but there are limited data regarding multicentric practice patterns and outcomes. We analyzed multiinstitutional data concerning operations and outcomes in neonates and infants with EA., Methods: Index operations reported in The Society of Thoracic Surgeons Congenital Heart Surgery Database (2010 to 2016) were potentially eligible for inclusion. Analysis was limited to patients with diagnosis of EA and less than 1 year of age at time of surgery (neonates ≤30 days, infants 31 to 365 days)., Results: The study population included 255 neonates and 239 infants (at 95 centers). Among neonates, median age at operation was 7 days (interquartile range, 4 to 13 days) and the majority required preoperative ventilation (61.6%, n = 157). The most common primary operation performed among neonates was Ebstein repair (39.6%, n = 101), followed by systemic-to-pulmonary shunt (20.4%, n = 52) and tricuspid valve closure (9.4%, n = 24). Overall neonatal operative mortality was 27.4% (n = 70), with composite morbidity-mortality of 51.4% (n = 48). For infants, median age at operation was 179 days (interquartile range, 108-234 days); the most common primary operation for infants was superior cavopulmonary anastomosis (38.1%, n = 91) followed by Ebstein repair (15.5%, n = 37). Overall operative mortality for infants was 9.2% (n = 22) with composite morbidity-mortality of 20.1% (48)., Conclusions: Symptomatic EA in early infancy is very high risk and a variety of operative procedures were performed. A dedicated prospective study is required to more fully understand optimal selection of treatment pathways to guide a systematic approach to operative management., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Delayed sternal closure (DSC) is often employed to optimize hemodynamics following pediatric cardiac surgery. Prior reports have suggested that DSC may be associated with increased morbidity. We sought to analyze the impact of a liberal policy of DSC on surgical outcomes at our center., Methods: We retrospectively evaluated the clinical course of 1,000 consecutive patients between July 2005 and June 2015 whose sternum was electively left open following pediatric cardiac surgery. Data are presented as mean and standard error (parametric) or median and quartiles (nonparametric). Receiver-operating characteristic curve analysis was undertaken to identify significant points of inflection. A p less than 0.05 was considered significant., Results: An a priori decision to leave the sternum open is made when complex surgery, especially in neonates and usually involving circulatory arrest, is expected to result in postoperative hemodynamic instability. Age at index surgery for the 1,000 patients was 7 (interquartile range [IQR], 3 to 19) days and weight 3.3 (IQR, 2.8 to 3.7) kg. There were 816 (82%) neonates and 569 (57%) boys. Index operations included 332 (33%) Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category 5, 483 (48%) STAT category 4, and 185 (19%) STAT category 3 procedures. A total of 103 (10%) patients required postoperative extracorporeal support. Following hemodynamic recovery, DSC was undertaken 3 (IQR, 2 to 4) days postoperatively and in 98.3% patients was performed in the intensive care unit. Overall, mortality was 6.3% and major Society of Thoracic Surgeons morbidity was 21.6%. There were 42 (4.2%) positive mediastinal surveillance cultures at the time of DSC, with the most common organism being coagulase-negative staphylococcus. Fifty-nine (5.9%) clinical sternal and mediastinal wound infections and a total of 117 infectious complications were encountered in 94 patients. Using Society of Thoracic Surgeons database outcome as benchmark, mortality and length of stay in our patients were comparable when analyzed by STAT categories or for the 2 most common index procedures (eg, Norwood and arterial switch operations). Receiver-operating characteristic curve analysis showed that 5 days of open sternum had a weak, but statistically significant, correlation with incidence of infectious complications (area under the curve, 0.56; p = 0.002). The need for DSC 5 or more days after the index procedure was observed in 177 (18%) patients and was not associated with increased wound infection. It was, however, independently associated on multiple regression analysis with major morbidity (odds ratio, 1.7; 95% confidence interval, 1.2 to 2.5; p = 0.002) and, in the subset of 897 patients who did not require extracorporeal support, with increased mortality (odds ratio, 2.2; 95% confidence interval, 1.3 to 3.6; p = 0.003)., Conclusions: A liberal policy of DSC does not adversely affect surgical outcomes, including infectious complications and length of stay. We submit that need for DSC should not, by itself, be considered a source of morbidity., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Bidirectional cavopulmonary anastomosis (BDCA) can be accomplished with low morbidity and mortality. The impact of concomitant pulmonary arterioplasty (PAplasty) is not known. We hypothesized that the need for and extent of PAplasty adversely affect BDCA outcomes., Methods: Patients who underwent BDCA at our institution between 2006 and 2014 were included. Patient demographics, operative characteristics, mortality, and morbidity were analyzed. Serious physiologic adverse event following Glenn (GAE) was defined as need for extracorporeal support, BDCA takedown or percutaneous intervention during same admission, hospital length of stay 1 SD or more from mean, or need for supplemental oxygen at discharge. PAplasty was categorized according to extent. Data were analyzed using SAS 9.4 (SAS Institute, Cary, NC)., Results: A total of 424 patients (231 boys, 54%) underwent BDCA for single ventricle physiology at a median of 7 (5.5 to 8.9) months of age and 6.5 (5.7 to 7.7) kg weight. A total of 112 (26%) patients required PAplasty: 23 were patch closures of the divided distal PA (type 1), 45 were central PA augmentations (type 2), 23 extended to the hilum on 1-branch PA (type 3), and 21 were bilateral hilum to hilum augmentation (type 4). Patients who required PAplasty tended to be significantly younger and more likely to have single right ventricles. There was no difference in PA pressure or resistance between patients who did and did not require PAplasty. Major Society of Thoracic Surgeons morbidity (13% vs 6%; p = 0.001), GAE (45% vs 34%; p = 0.04), and in-hospital mortality (5.4% vs 1.9%; p = 0.03) were higher in patients who required PAplasty compared with those who did not. Among the operative variables evaluated, need for PAplasty (hazard ratio [HR], 1.6; p = 0.03) independently predicted hospital mortality. Need for circulatory arrest (HR, 4; p = 0.005) and PAplasty (HR, 2.4; p = 0.0006) were independent predictors of Society of Thoracic Surgeons morbidity and need for PAplasty independently predicted GAE (HR, 1.8; p = 0.03)., Conclusions: The need for PAplasty at BDCA is an independent predictor of mortality and morbidity. It is important to consider this variable when developing outcome metrics for BDCA., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)