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Background Prior research on cognitive and functional outcomes after coronary artery bypass graft (CABG) surgery has largely explored these two domains in isolation. In this study, we assess baseline depression and cognition as risk factors for decline in the Clinical Dementia Rating Sum-of-Boxes (CDR-SB) one month post-CABG surgery, which a combined measure of cognition and function. Design The Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study is a prospective observational cohort study. Setting A tertiary care, academic center. Participants Of a total study sample of 148 patients undergoing CABG surgery, 124 (83.8%) completed one-month follow-up assessment. Mean age was 66.3, 32 (25.8%) female, and 112 (90.3%) White. Measurements Cognition, function and depression were assessed on semi-structured clinical interviews. Cognitive and functional status were defined using CDR-SB; mild or major depression was defined by the Hamilton Depression Rating Scale. Additionally, neuropsychological battery was performed at baseline. Results CDR-SB decline occurred in 18 (14.5%) subjects. Older age, depression, baseline CDR-SB, and postoperative delirium were associated with one-month decline on univariate analysis. Older age (OR 1.1 [1.0-1.2]) and depression (OR 6.2 [1.1-35.0]) remained significant on multivariate regression. In separate models, baseline performance on visual Wechsler memory scale (delayed), Hopkins verbal learning test (immediate and delayed), controlled oral word fluency test, and Trails B predicted CDR-SB decline. Conclusion Roughly one in seven patients experienced CDR-SB decline one month after CABG surgery. Also, preoperative depression deserves recognition for being a predictor of CDR-SB decline one month post-CABG. This article is protected by copyright. All rights reserved.

OBJECTIVES: Although depression is a known risk factor for delirium after coronary artery bypass graft (CABG) surgery, it is unclear whether this risk is independent of delirium risk attributable to cognitive impairment or cerebrovascular disease. This study examines depression (mild or major), mild cognitive impairment (MCI) and cerebrovascular disease (defined as intracranial atherosclerosis) as post-CABG delirium risk factors. DESIGN: Prospective, observational cohort study. SETTING: Tertiary-care academic hospital. PARTICIPANTS: Subjects without dementia undergoing CABG surgery. MEASUREMENTS: Preoperative cognitive assessment included Clinical Dementia Rating and neuropsychological battery; depression was assessed using Depression Interview and Structured Hamilton. Baseline intracranial stenosis was evaluated by transcranial Doppler of bilateral middle cerebral arteries (MCA). Study psychiatrists assessed delirium on postoperative days 2–5 using the Confusion Assessment Method. RESULTS: Our analytic sample comprised 131 subjects—average age 65.8 (9.2) years, 27% female. MCI prevalence was 24%, preoperative depression 10%, lifetime depression 35%, and MCA stenosis (≥ 50%) 28%. Sixteen percent developed delirium. Multivariate analysis revealed that age, MCI (OR 5.1, 95% CI 1.3–20.1), and preoperative depression (OR 9.9, 95% CI 1.3–77.9)—but not lifetime depression—predicted delirium. MCA stenosis and its severity predicted delirium in univariate but not multivariate analysis. Right MCA stenosis severity predicted delirium severity, but left-sided stenosis severity did not. CONCLUSIONS: We establish that the risk of delirium attributable to depression extends beyond the potential moderating influence of cognitive impairment and cerebrovascular disease alone. Even mild depression and cognitive impairment before CABG deserve recognition for their effect on post-CABG cognitive health.

Objectives To summarize evidence on cognitive outcomes after heart valve surgery; secondary aim, to examine whether aortic and mitral valve surgery are associated with different cognitive outcomes. Design Preferred Reporting Items for Systematic Reviews and Meta‐Analyses systematic review and meta‐analysis. Setting Cardiac surgery. Participants Individuals undergoing heart valve surgery. Measurements We searched MEDLINE, EMBASE, and PsycINFO for peer‐reviewed reports of individuals undergoing heart valve surgery who underwent pre‐ and postoperative cognitive assessment. Our initial search returned 1,475 articles, of which 12 were included. Postoperative cognitive results were divided into those from 1 week to 1 month (early outcomes, npooled = 450) and from 2 to 6 months (intermediate outcomes; npooled = 722). No studies with longer‐term outcomes were identified. Results Subjects had moderate early cognitive decline from baseline (Becker mean gain effect size (ES)=−0.39 ± 0.27) that improved slightly by 2 to 6 months (ES=–0.25 ± 0.38). Individuals undergoing aortic valve surgery—who were older on average than those undergoing mitral valve surgery (68 vs 57)—had greater early cognitive decline than those undergoing mitral valve surgery (ES=–0.68 vs −0.12), but both cohorts had similar decline 2 to 6 months postoperatively (ES=–0.27 vs −0.20). Conclusions Heart valve surgery is associated with cognitive decline over the 6 months after surgery, but outcomes beyond 6 months are unclear. These findings highlight the cognitive vulnerability of this population, especially older adults with aortic stenosis. © 2018 American Geriatrics Society and Wiley Periodicals, Inc. J Am Geriatr Soc 66:2327–2334, 2018

Introduction Although depression is a putative risk factor for delirium after coronary artery bypass graft (CABG) surgery, it is unclear to what extent this risk is independent of cognitive impairment and cerebrovascular disease. This study concurrently examines depression (mild or major), mild cognitive impairment (MCI) and cerebrovascular disease (defined as intracranial atherosclerosis) as post-CABG delirium risk factors. Methods This prospective, observational cohort study recruited and assessed 131 subjects without dementia undergoing CABG surgery at a tertiary-care, academic hospital. Preoperative cognitive assessment included Clinical Dementia Rating and neuropsychological battery; depression was assessed using Depression Interview Structured Hamilton. Baseline intracranial stenosis was evaluated by transcranial Doppler of bilateral middle cerebral arteries (MCA). Study psychiatrists assessed delirium on postoperative days 2–5 using the Confusion Assessment Method. Results Average age of the study sample was 65.8 (SD: 9.2) years, and 27% were female. MCI prevalence was 24%, preoperative depression 10%, lifetime depression 35%, and MCA stenosis (≥ 50%) 28%. Sixteen percent developed delirium. Multivariate analysis revealed that age, MCI (OR 5.1, 95% CI 1.3–20.1), and preoperative depression (OR 9.9, 95% CI 1.3–77.9)—but not lifetime depression—predicted delirium. MCA stenosis and its severity predicted delirium in univariate but not multivariate analysis. Right MCA stenosis severity predicted delirium severity but left-sided stenosis severity did not. Conclusions Our findings indicate that the risk of delirium attributable to depression could extend beyond the potential moderating influence of cognitive impairment and cerebrovascular disease. Even mild depression and cognitive impairment before CABG appear to deserve recognition for their effect on post-CABG cognitive health. This research was funded by The NOAHS study (PI: HB Lee) is supported by R01 MH085740. Exploratory analysis of this study was supported by the CEDARTREE Program (K07 AG041835; PI: SK Inouye).

Background:Cognitive and functional impairment increase risk for post-coronary artery bypass graft (CABG) surgery delirium (PCD), but how much impairment is necessary to increase PCD risk remains unclear.Methods:The Neuropsychiatric Outcomes After Heart Surgery (NOAHS) study is a prospective, observational cohort study of participants undergoing elective CABG surgery. Pre-operative cognitive and functional status based on Clinical Dementia Rating (CDR) scale and neuropsychological battery are assessed. We defined mild cognitive impairment (MCI) based on either (1) CDR global score 0.5 (CDR-MCI) or (2) performance 1.5 SD below population means on any cognitive domain on neurocognitive battery (MCI-NC). Delirium was assessed daily post-operative day 2 through discharge using the confusion assessment method (CAM) and delirium index (DI). We investigate whether MCI – either definition – predicts delirium or delirium severity.Results:So far we have assessed 102 participants (mean age 65.1 ± 9; male: 75%) for PCD. Twenty six participants (25%) have MCI-CDR; 38 (62% of those completing neurocognitive testing) met MCI-NC criteria. Fourteen participants (14%) developed PCD. After adjusting for age, sex, comorbidity, and education, MCI-CDR, MMSE, and Lawton IADL score predicted PCD on logistic regression (OR: 5.6, 0.6, and 1.5, respectively); MCI-NC did not (OR [95% CI]: 11.8 [0.9, 151.4]). Using similarly adjusted linear regression, MCI-CDR, MCI-NC, CDR sum of boxes, MMSE, and Lawton IADL score predicted delirium severity (adjusted R2: 0.26, 0.13, 0.21, 0.18, and 0.32, respectively).Conclusions:MCI predicts post-operative delirium and delirium severity, but MCI definition alters these relationships. Cognitive and functional impairment independently predict post-operative delirium and delirium severity.

Background Disseminated nontuberculous mycobacterium infections have occurred following surgical procedures involving extracorporeal circulation; contaminated water from heater-cooler devices (HCDs) has been implicated as the source. The purpose of this review was to evaluate the public health concern and to educate physicians who care for this patient population. Methods The Food and Drug Administration Medical Device Reporting (MDR) database was queried for reports received between January 2010 and August 2016 for patient infections and device contaminations associated with the use of HCDs. Reports were reviewed for type of infection, patient demographics or outcome, reporting country, HCD manufacturer, and the time to event occurrence. Results A total of 339 MDR reports involving 99 facilities and 5 HCD manufacturers were found. MDR reports originated within (n = 154) and outside the United States (n = 185), and included 107 MDR reports describing patient infections involving at least 86 patients and 232 MDR reports describing HCD contamination without known patient infections. The MDR reports identified the surgical procedure in 94 reports and infection location in 83 reports. The time from surgical procedure using an HCD to infection diagnosis was calculable in 67 reports and was reported up to 60 months following the initial surgery. Nontuberculous mycobacterium was the most frequent organism identified, with M. chimaera being the predominate isolate. Conclusions Nontuberculous mycobacterium infections associated with HCDs used during cardiothoracic surgery may have a long latency period and may be lethal. Cardiothoracic surgeon awareness or involvement in this issue is critical in helping to mitigate this emerging public health concern.

Thoracic aortic mycotic aneurysms caused by Aspergillus fumigatus postoperatively are rare and devastating complications. These cases are usually attributed to intraoperative contamination of surgical equipment. We present a patient who had an ascending aortic mycotic aneurysm 20 weeks post aortic valve replacement. A high index of suspicion allowed for diagnosis and prompt treatment, although the patient presented in an unusual manner. Treatment included both medical and surgical therapy to minimize morbidity and mortality. Despite treatment our patient suffered long-lasting consequences due to the aggressive nature of the disease. Cases presented in the literature and this experience show that a high index of suspicion must be maintained in such patients regardless of immune status and postoperative interval, in order to avoid long-lasting sequelae.

Background The number of alternatives to intra-aortic balloon counterpulsation in the treatment of anticipated and established acute circulatory failure is growing. Despite the clinical importance and significant cost of short-term mechanical circulatory support (MCS) devices, the state of their present use has not been analyzed on a national scale. Objectives The purpose of this study was to characterize the demographics, treatment practices, survival rates, and cost of short-term MCS. Methods In this serial cross-sectional study, we analyzed all adult patients receiving short-term MCS in the United States from 2004 to 2011 by using the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project. Results From 2007 to 2011, use of percutaneous devices for short-term MCS increased by 1,511% compared with a 101% increase in nonpercutaneous devices. Mortality rates declined over this period (p for trend = 0.027) from 41.1% in 2004 to 2007 to 33.4% in 2008 to 2011. A similar trend was observed for the subset of patients with cardiogenic shock, decreasing from 51.6% to 43.1% (p for trend = 0.012). Hospital costs also declined over this period (p for trend = 0.011). Multivariable analysis revealed balloon pumps (odds ratio [OR]: 2.00; 95% confidence interval [CI]: 1.58 to 2.52), coagulopathy (OR: 2.35; 95% CI: 1.88 to 2.94), and cardiopulmonary resuscitation (OR: 3.50; 95% CI: 2.20 to 5.57) before short-term MCS were among the most significant predictors of mortality. Conclusions Use of short-term MCS in the United States has increased rapidly, whereas rates of in-hospital mortality have decreased. These changes have taken place in the context of declining hospital costs associated with short-term MCS.

Objective Integrated 6-year cardiothoracic surgical residency programs have recently been implemented in the United States. We report the results of the first published nationwide survey assessing the motivations, satisfaction, and ambitions of integrated 6-year residents. Methods A 63-question web-based survey was distributed to 83 residents enrolled in 21 Accreditation Council for Graduate Medical Education–accredited integrated 6-year programs in November 2013. There was an outstanding 69% response rate. Results The median age of integrated 6-year residents was 29 years with women comprising 24%. A clear majority had faculty mentorship (95%) and significant clinical exposure in medical school. Focused (100%) and abbreviated (74%) training curricula were identified as the top advantages of integrated 6-year programs; the format itself was a significant factor (46%) in career choice. Most integrated 6-year residents (95%) were satisfied with their program; 80.7% were satisfied with their operative experience thus far. Career plans skewed toward adult cardiac surgery (67%), followed by pediatric cardiac (24%) and general thoracic (9%) surgery; 49% were not particularly concerned about future employment, with 65% foreseeing an increase in opportunities. Specialized training (eg, aortic, heart failure, minimally invasive, congenital) was anticipated by 77%. Most integrated 6-year residents envision an academic career (94.7%). Conclusions This survey takes an important snapshot of the nascent integrated 6-year format. Mentorship and intense clinical exposure are critical in attracting applicants. Purported advantages of the format are holding true among integrated 6-year residents, with the majority satisfied with their programs. These early data indicate that this format holds significant promise in attracting and retaining highly qualified trainees to academic cardiothoracic surgery.

Malignant pericardial disease in the setting of lung cancer portends a grave prognosis. We present a case of malignant pericardial tamponade and subsequent complications. A 61-year-old man presented with acute pericardial tamponade after having undergone a video-assisted left upper lobe

BackgroundImmunologic incompatibility has implications for primary graft failure, rejection, and survival in heart transplantation. To our knowledge, this is the first large cohort study investigating the impact of ABO-compatible versus identical blood type matching on post heart transplantation survival.MethodsWe used a nationwide sample (2000-2010) within the United Network for Organ Sharing database. Stratification was between ABO-identical and ABO-compatible heart transplantations for univariate and multivariate analyses. The primary end point was graft failure from all causes. Posttransplant survival was compared between groups using Cox proportional hazard and logistic regression models.ResultsA total of 17,951 patients met inclusion criteria, and 2684 (approximately 15%) underwent ABO-compatible heart transplantation. ABO-compatible recipients were generally sicker than ABO-identical recipients before transplant because more were status 1A, in the intensive care unit, and receiving mechanical ventilatory support (P

Background The aim of this study was to evaluate nationwide outcomes of ventricular assist device (VAD) implantation in elderly patients in the United States. Methods Patients undergoing VAD implantation between 2003 and 2008 were identified in the Nationwide Inpatient Sample. The primary outcome was inpatient mortality following VAD implantation. Secondary outcomes included disposition following discharge and costs of care. After stratification based on primary versus postcardiotomy VAD support, outcomes were compared between controls aged 60–69 years and elderly patients aged ≥70 years. Results A total of 2787 patients aged 60–69 years and 1472 patients aged ≥70 years underwent VAD implantation during the study period. Unadjusted mortality rates were comparable between elderly and control patients in both primary support (35.7% vs. 32.1%, p = 0.61) and postcardiotomy support (58.1% vs. 56.1%, p = 0.70). Similarly, in risk-adjusted multivariable logistic regression analysis incorporating clinically relevant variables, age ≥70 did not exert an independent effect on inpatient mortality for either indication. Inpatient costs in the elderly were lower than controls in the primary support cohort, although costs per day were similar, with comparable overall costs between age groups in the postcardiotomy cohort. Elderly survivors were discharged to a facility more frequently than control survivors (primary: 49.9% vs. 29.6%, p = 0.007; postcardiotomy: 67.4% vs. 45.7%, p = 0.03). Conclusions This large-cohort population-based analysis provides a useful framework for inpatient prognosis and resource utilization in elderly patients undergoing VAD implantation. Although mortality rates and costs were found to be comparable between elderly patients and those aged 60–69 years, these rates were nonetheless significant. This combined with more frequent discharge-to-facility in elderly survivors underscores the importance of careful patient selection in this population. doi: 10.1111/jocs.12066 (J Card Surg 2013;28:183–189)

OBJECTIVE To evaluate the contribution of institutional volume and other unmeasured institutional factors beyond volume to the between-center variability in outcomes after orthotopic heart transplantation (OHT). BACKGROUND It is unclear if institutional factors beyond volume have a significant impact on OHT outcomes. METHODS The United Network for Organ Sharing registry was used to identify OHTs performed between 2000 and 2010. Separate mixed-effect logistic regression models were constructed, with the primary endpoint being post-OHT mortality. Model A included only individual centers, model B added validated recipient and donor risk indices as well as the year of transplantation, and model C added institutional volume as a continuous variable to model B. The reduction in between-center variability in mortality between models B and C was used to define the contribution of institutional volume. Kaplan-Meier survival curves were also compared after stratifying patients into equal-size tertiles based on center volume. RESULTS A total of 119 centers performed OHT in 19,156 patients. After adjusting for transplantation year and differences in recipient and donor risk, decreasing center volume was associated with an increased risk of 1-year mortality (P < 0.001). However, procedural volume only accounted for 16.7% of the variability in mortality between centers, and significant between-center variability persisted after adjusting for institutional volume (P

This study examined whether institutional volume impacts outcomes after orthotopic heart transplantation (OHT) utilizing marginal donors.Adult patients undergoing OHT with the use of marginal donors between 2000 and 2010 were identified in the United Network for Organ Sharing database. A previously derived and validated donor risk score (range, 1 to 15) was used to define marginal donors as those in the 90th percentile of risk (score≥7). Patients were stratified into equal-size tertiles based on overall institutional OHT volume. Posttransplant outcomes were compared between these center cohorts.A total of 3,176 OHTs utilizing marginal donors were identified. In Cox regression analysis, recipients undergoing OHT at low-volume centers were at significantly increased risk of 30-day (hazard ratio 1.82 [1.31 to 2.54], p0.001), 1-year (hazard ratio 1.40 [1.14 to 1.73], p=0.002), and 5-year posttransplant mortality (hazard ratio 1.29 [1.10 to 1.52], p=0.02). These findings persisted after adjusting for recipient risk, differences in donor risk score, and year of transplantation (each p0.05). In Kaplan-Meier analysis, there was a similar trend of decreasing 1-year survival with decreasing center volume: high (86.0%), intermediate (85.7%), and low (81.2%; log rank p=0.003). Drug-treated rejection within the first post-OHT year was more common in low-volume versus high-volume centers (34.3% versus 24.2%, p0.001). At an overall mean follow-up of 3.4±2.9 years, low-volume centers also had higher incidences of death due to malignancy (2.8% versus 1.3%, p=0.01) or infection (6.2% versus 4.1%, p=0.02).Consolidating the use of marginal donors to higher volume centers may be prudent in improving post-OHT outcomes in this higher risk patient subset.

Objectives Current robotic training approaches lack the criteria for automatically assessing and tracking (over time) technical skills separately from clinical proficiency. We describe the development and validation of a novel automated and objective framework for the assessment of training. Methods We are able to record all system variables (stereo instrument video, hand and instrument motion, buttons and pedal events) from the da Vinci surgical systems using a portable archival system integrated with the robotic surgical system. Data can be collected unsupervised, and the archival system does not change system operations in any way. Our open-ended multicenter protocol is collecting surgical skill benchmarking data from 24 trainees to surgical proficiency, subject only to their continued availability. Two independent experts performed structured (objective structured assessment of technical skills) assessments on longitudinal data from 8 novice and 4 expert surgeons to generate baseline data for training and to validate our computerized statistical analysis methods in identifying the ranges of operational and clinical skill measures. Results Objective differences in operational and technical skill between known experts and other subjects were quantified. The longitudinal learning curves and statistical analysis for trainee performance measures are reported. Graphic representations of the skills developed for feedback to the trainees are also included. Conclusions We describe an open-ended longitudinal study and automated motion recognition system capable of objectively differentiating between clinical and technical operational skills in robotic surgery. Our results have demonstrated a convergence of trainee skill parameters toward those derived from expert robotic surgeons during the course of our training protocol.

The aim of this study was to evaluate the impact of metabolic risk factors on mortality rates after orthotopic heart transplantation (OHT).Adult patients undergoing OHT between 1998 and 2008 were identified in the United Network for Organ Sharing registry. The impact of metabolic risk factors (hypertension, diabetes mellitus, and obesity) on mortality post-OHT was evaluated in a Cox proportional hazards regression analysis adjusted for other variables associated with survival in univariate analysis (exploratory p value0.2). Kaplan-Meier survival estimates were compared with the log-rank test.A total of 15,960 eligible patients underwent OHT during the study period. There were 6,368 (39.9%) patients with none of these risk factors, 6,138 (38.5%) with 1 risk factor, 2,811 (17.6%) with 2 risk factors, and 643 (4.0%) who had all 3 risk factors. After adjusting for other significant variables influencing survival, each individual risk factor independently increased the likelihood of mortality post-OHT (hypertension: HR 1.10 [1.03 to 1.17]; diabetes: HR 1.22[1.13 to 1.31]; obesity: HR 1.17 [1.10 to 1.26], each p0.01). There was an exponential trend of increasing mortality with the addition of each risk factor (r2=0.99, p0.001) such that patients with all 3 risk factors had a 63% increased mortality compared with those with no risk factors (HR 1.63 [1.42 to 1.88], p0.001). There was also a significant trend in declining 5-year survival rates with an increasing number of risk factors: 0 (74.7%), 1 (71.3%), 2 (68.2%), and 3 (63.1%) (p0.001).This large-cohort study demonstrates that an increasing number of metabolic risk factors in OHT recipients is associated with exponential increases in postoperative mortality rates.

The aim of this study was to identify recipient factors that are associated with a high risk of graft failure after heart retransplantation (HRT).The prospectively collected United Network for Organ Sharing registry was used to identify patients undergoing HRT among 24,477 patients who had undergone cardiac transplantation between 1997 and 2009. The primary outcome was graft failure within 1 year of HRT. The impact of 35 recipient variables on the primary outcome was tested in exploratory univariate logistic regression analysis. Those factors found to be significantly associated with graft failure were entered into a multivariable logistic regression model.A total of 671 patients underwent HRT during the study period. Overall, 302 (45%) grafts failed after HRT at a mean follow-up of 4.3±3.7 years. Three recipient factors were found to be associated with 1-year graft failure in the multivariate model: older age, increasing serum creatinine, and mechanical ventilation before HRT. Moreover, each decade increase in recipient age was associated with a 20% increase in odds of 1-year graft failure (odds ratio, 1.02; 95% confidence interval, 1.01 to 1.04; p=0.005). Similarly, each 1-mg/dL increase in serum creatinine increased odds of graft failure by 58% (odds ratio, 1.58; 95% confidence interval, 1.27 to 1.97; p0.001). Patients who were mechanically ventilated had a fourfold higher likelihood of 1-year graft failure (odds ratio, 4.32; 95% confidence interval, 2.28 to 8.18; p0.001).The risk of graft failure after HRT increases with an increasing number of significant recipient risk factors, namely older age, increasing serum creatinine, and mechanical ventilation. These risk factors should serve as relative contraindications to HRT, especially when present in combination, given the higher rate of graft failure in these patients.

This case-control study was conducted to identify factors predictive of 10-year survival after orthotopic heart transplantation (OHT).Prospectively collected data from the United Network for Organ Sharing registry were reviewed to identify adult patients undergoing OHT between 1987 and 1999 (N=22,385) who had survived 10 years. Controls were those who had died within 10 years of OHT. Factors associated with 10-year survival were identified with multivariate logistic regression analysis. Lowess smoothing plots were used to identify linear breakpoints in continuous variables, and splines were incorporated when appropriate.There were 9,404 ten-year survivors (42%; mean follow-up, 14.0±3.0 years) and 10,373 controls (46%) with a mean survival of 3.7±3.3 years post-OHT. Predictors of 10-year survival in the optimal multivariate model were age younger than 55 (odds ratio [OR], 1.24; 95% confidence interval [CI], 1.10 to 1.38; p0.001), white race (OR, 1.35; 95% CI, 1.17 to 1.56; p0.001), shorter ischemic time (OR, 1.11; 95% CI, 1.05 to 1.18; p0.001), younger donor age (OR, 1.01; 95% CI, 1.01 to 1.02; p0.001), annual center volume of 9 or more (OR, 1.31; 95% CI, 1.17 to 1.47; p0.001), mechanical ventilation (OR, 0.53; 95% CI, 0.36 to 0.78; p=0.001), and diabetes (OR, 0.67; 95% CI, 0.57 to 0.78; p0.001).Age younger than 55 years, annual center volume of 9 or more, white race, shorter ischemic time, and younger donor age improved the likelihood of 10-year survival after OHT. Mechanical ventilation and diabetes reduced this likelihood. These data should serve as a useful guide to long-term prognostication in adult OHT.

Background With increased use of robotic surgery in specialties including urology, development of training methods has also intensified. However, current approaches lack the ability to discriminate between operational and surgical skills. Methods An automated recording system was used to longitudinally (monthly) acquire instrument motion/telemetry and video for four basic surgical skills – suturing, manipulation, transection, and dissection. Statistical models were then developed to discriminate the human–machine skill differences between practicing expert surgeons and trainees. Results Data from six trainees and two experts was analyzed to validate the first ever statistical models of operational skills, and demonstrate classification with very high accuracy (91.7% for masters, and 88.2% for camera motion) and sensitivity. Conclusions The paper reports on a longitudinal study aimed at tracking robotic surgery trainees to proficiency, and methods capable of objectively assessing operational and technical skills that would be used in assessing trainee progress at the participating institutions. Copyright © 2011 John Wiley & Sons, Ltd.

ObjectivesThe purpose of this study was to determine whether acute renal injury develops more frequently in women than in men after cardiac surgery and whether this complication is associated with operative mortality in women.MethodsProspectively collected data were evaluated from 9461 patients undergoing coronary artery bypass graft surgery, cardiac valve surgery, or both (3080 women) and not receiving preoperative dialysis. The glomerular filtration rate was estimated by using the Modification of Diet in Renal Disease equations with the last plasma creatinine level before surgical intervention (baseline) and the highest level of the first postoperative week. The primary renal injury outcome was the composite end point of renal injury according to RIFLE criteria (estimated glomerular filtration rate decrease >50% from baseline value) or failure.ResultsThirty-day operative mortality and renal injury were more common in women than in men (5.9% vs 2.8%, P = .01; 5.1% vs 3.6%, P

Rising health and financial costs associated with iatrogenic errors have drawn increasing attention to the dexterity of surgeons. With the advent of new technologies, such as robotic surgical systems and medical simulators, researchers now have the tools to analyze surgical motion with the goal of differentiating the level of technical skill in surgeons. The review for this paper is obtained from a Google Scholar and PubMed search of the key words “objective surgical skill evaluation.” Only studies that included motion analysis were used. In this paper, we provide a clinical motivation for the importance of surgical skill evaluation. We review the current methods of tracking surgical motion and the available data-collection systems. We also survey current methods of surgical skill evaluation and show that most approaches fall into one of three methods: (1) structured human grading; (2) descriptive statistics; or (3) statistical language models of surgical motion. We discuss the need for an encompassing approach to model human skill through statistical models to allow for objective skill evaluation.

Background— Pulmonary hypertension (PH) secondary to left heart failure portends a poor prognosis and is a relative contraindication to heart transplantation at many centers. We tested the hypothesis that when PH persists after adequate left ventricle unloading via recent left ventricular assist device (LVAD) therapy, phosphodiesterase type 5A inhibition would decrease PH in this population. Methods and Results— We performed an open-label clinical trial using control patients not receiving therapy. Between 1999 and 2007, 138 consecutive patients undergoing cardiac transplantation evaluation with advanced left ventricular dysfunction, an elevated pulmonary capillary wedge pressure, and PH (defined by a pulmonary vascular resistance (PVR) >3 Woods Units), were treated with LVAD therapy. Fifty-eight of these patients reduced their pulmonary capillary wedge pressure to a value P P Conclusions— In patients with persistent PH after recent LVAD placement, phosphodiesterase type 5A inhibition in this open-label trial resulted in a significant decrease in PVR when compared with control patients.

Intervention planning is essential for successful Mitral Valve (MV) repair procedures. Finite-element models (FEM) of the MV could be used to achieve this goal, but the translation to the clinical domain is challenging. Many input parameters for the FEM models, such as tissue properties, are not known. In addition, only simplified MV geometry models can be extracted from non-invasive modalities such as echocardiography imaging, lacking major anatomical details such as the complex chordae topology. A traditional approach for FEM computation is to use a simplified model (also known as parachute model) of the chordae topology, which connects the papillary muscle tips to the free-edges and select basal points. Building on the existing parachute model a new and comprehensive MV model was developed that utilizes a novel chordae representation capable of approximating regional connectivity. In addition, a fully automated personalization approach was developed for the chordae rest length, removing the need for tedious manual parameter selection. Based on the MV model extracted during mid-diastole (open MV) the MV geometric configuration at peak systole (closed MV) was computed according to the FEM model. In this work the focus was placed on validating MV closure computation. The method is evaluated on ten in vitro ovine cases, where in addition to echocardiography imaging, high-resolution μCT imaging is available for accurate validation.

Cardiac sarcoidosis is a common and often fatal complication of systemic sarcoidosis. When present, cardiac sarcoid is generally a diffuse and patchy process involving predominantly the left ventricle. We report the case of a patient with known cardiac sarcoidosis who underwent cardiac transplantation for poorly controlled ventricular tachycardia and heart failure. His explanted heart had a previously undescribed distribution of sarcoidosis. This patient had complete, circumferential involvement of the right ventricle with near-total loss of right ventricular wall myocardium, and secondary marked dilation. The interventricular septum was predominantly involved along the right ventricle. The cardiac conducting system was also extensively involved, showing granulomatous disease. The left ventricular free wall was spared of any gross evidence of sarcoidosis. We present the unusual pathologic findings of the explanted heart and correlate the results with the patient's clinical data.

Objective Laser transmyocardial revascularization is an emerging therapy for intractable angina stemming from diffuse, small-vessel coronary disease not amenable to percutaneous coronary intervention or coronary bypass grafting. Presently, this therapy is delivered through a median sternotomy or left thoracotomy. In this pilot study, we sought to combine the advantages of a dexterous robotic surgical platform with a flexible fiberoptic laser to develop a minimally invasive approach toward transmyocardial revascularization. Methods A flexible fiberoptic holmium:yttrium-aluminum-garnet laser probe (CardioGenesis Corporation, Foothill Ranch, Calif), deployed with the da Vinci surgical robotic system (Intuitive Surgical, Sunnyvale, Calif), was used to create transmyocardial channels through all left ventricular wall regions in 5 canine subjects. The channels were localized, quantified, and histologically analyzed to assess distribution, dimensions, and transmurality. Results Transmyocardial channels were successfully created in all 6 defined left ventricular wall segments by using this minimally invasive approach without port repositioning, instrument exchange, or probe modifications. Gross pathologic and histologic analyses confirmed the uniform distribution of 1.0-mm transmural channels in all left ventricular regions. No direct pressure, topical hemostatic agents, or suture repairs were required for hemostasis. No significant hemodynamic instability or sustained arrhythmias were encountered at any time during the procedures. Conclusions We report the first use of a prototype flexible fiberoptic laser probe deployed by the da Vinci surgical robotic system to successfully perform totally endoscopic off-pump transmyocardial revascularization in a canine model, demonstrating the feasibility, precision, and safety of this approach. Refinement of this minimally invasive technique may reduce the morbidity of open-chest transmyocardial revascularization and facilitate its use as sole therapy or as an adjunct to percutaneous coronary interventions.

Objectives Direct haptic (force or tactile) feedback is not yet available in commercial robotic surgical systems. Previous work by our group and others suggests that haptic feedback might significantly enhance the execution of surgical tasks requiring fine suture manipulation, specifically those encountered in cardiothoracic surgery. We studied the effects of substituting direct haptic feedback with visual and auditory cues to provide the operating surgeon with a representation of the forces he or she is applying with robotic telemanipulators. Methods Using the robotic da Vinci surgical system (Intuitive Surgical, Inc, Sunnyvale, Calif), we compared applied forces during a standardized surgical knot-tying task under 4 different sensory-substitution scenarios: no feedback, auditory feedback, visual feedback, and combined auditory-visual feedback. Results The forces applied with these sensory-substitution modes more closely approximate suture tensions achieved under ideal haptic conditions (ie, hand ties) than forces applied without such sensory feedback. The consistency of applied forces during robot-assisted suture tying aided by visual feedback or combined auditory-visual feedback sensory substitution is superior to that achieved with hand ties. Robot-assisted ties aided with auditory feedback revealed levels of consistency that were generally equivalent or superior to those attained with hand ties. Visual feedback and auditory feedback improve the consistency of robotically applied forces. Conclusions Sensory substitution, in the form of visual feedback, auditory feedback, or both, confers quantifiable advantages in applied force accuracy and consistency during the performance of a simple surgical task.

Background The morbidity of lung transplantation is higher than other solid organ transplants. Little is known about the outcomes of patients who require pulmonary resection following lung transplantation. We reviewed our experience to evaluate and discern any variables affecting outcome of pulmonary resections performed following lung transplantation. Methods A retrospective review of the lung transplant database was performed. Data are presented as mean ± standard error (median). Results A total of 136 lung transplants (80 single lung transplants [SLT], 55 bilateral lung transplants [BLT], and 3 heart-lung transplants [HLT]) were performed from August 1995 to February 2002. Twelve pulmonary resections, 7 lobectomies, and 5 wedge resections were performed on 11 patients. The indication for lobectomy was infection in 5 of 7 lobectomies (3 fungal, 2 bacterial), mass in 1 of 7, and infarction in 1 of 7. The indication for wedge resection was native lung hyperinflation in 4 of 5 wedge resections and mass in 1 of 5. The native lung was resected in 3 of 7 lobectomies and 4 of 5 wedge resections. An allograft lobectomy was performed following 1 SLT and 3 BLT and a wedge resection was performed after 1 SLT. The mean time to pulmonary resection was 12.4 ± 3.9 (9.1) months. Survival postresection was 17.2 ± 5.8 (8.3) months and 5 of 11 patients are still alive. There were no bronchial stump leaks following lobectomy. Conclusions Major pulmonary resections can safely be performed following lung transplant. We recommend early intervention to optimize outcomes.

Recent studies have shown the benefits of extracorporeal membrane oxygenation (ECMO) in supporting adults with severe respiratory or cardiac failure refractory to conventional treatments. The purpose of this investigation was to analyze the usage of ECMO in adults to identify recent trends within the United States. The usage of ECMO, the survival rates, and the hospitalization costs from 2006 to 2011 were analyzed using the Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project. The rate of ECMO cases per million adult discharges increased 433% from 11.4 (95% confidence interval, 6.1-16.8) in 2006 to 60.9 (95% confidence interval, 28.1-93.7) in 2011 (p for trend = 0.001). There was a trend toward improved survival rates, but this was not statistically significant (p for trend = 0.14). The costs per day have not changed significantly (p for trend = 0.07) nor have the total costs per patient (p for trend = 0.87). In conclusion, there was a huge increase in the usage of ECMO in adults from 2006 to 2011 with a trend toward improved survival rates and no increase in hospitalization costs.

Extracorporeal membrane oxygenation (ECMO) has been used infrequently as a bridge to lung transplantation due to lack of consensus and data regarding the benefits of such a strategy. We present data from the United Network of Organ Sharing (UNOS) database on the outcomes of patients bridged to lung transplantation with ECMO. We used the UNOS database to analyze data between January 1, 2000 and December 31, 2011. During this time 14,263 lung transplants were performed, of which 143 (1.0%) were bridged using ECMO. Patients on ECMO as a bridge to lung transplantation were compared to those transplanted without prior ECMO support. Demographics, survival rates, complications, and rejection episodes were compared between the two groups. The 30-day, 6-month, 1-year, 3-year, and 5-year survival rates were 69%, 56%, 48%, 26%, and 11%, respectively, for the ECMO bridge group and 95%, 88%, 81%, 58%, and 38% respectively, for the control group (p ≤ 0.01). The ECMO group incurred higher rate of postoperative complications, including airway dehiscence (4% vs. 1%, p ≤ 0.01), stroke (3% vs. 2%, p ≤ 0.01), infection (56% vs. 42%, p ≤ 0.01), and pulmonary embolism (10% vs. 0.6%, p ≤ 0.01). The length of hospital stay was longer for the ECMO group (41 vs. 25 days, p ≤ 0.01), and they were treated for rejection more often (49% vs. 36%, p = 0.02). The use of ECMO as a bridge to lung transplantation is associated with significantly worse survival and more frequent postoperative complications. Therefore, we advocate very careful patient selection and cautious use of ECMO.

Objective The recently implemented integrated 6-year (I-6) format represents a significant change in cardiothoracic surgical residency training. We report the results of the first nationwide survey assessing I-6 program directors' impressions of this new format. Methods A 28-question web-based survey was distributed to program directors of all 24 Accreditation Council for Graduate Medical Education-accredited I-6 training programs in November 2013. The response rate was a robust 67%. Results Compared with graduates of traditional residencies, most I-6 program directors with enrolled residents believed that their graduates will be better trained (67%), be better prepared for new technological advances (67%), and have superior comprehension of cardiothoracic disease processes (83%). Just as with traditional program graduates, most respondents believed their I-6 graduates would be able to independently perform routine adult cardiac and general thoracic operations (75%) and were equivocal on whether additional specialty training (eg, minimally invasive, heart failure, aortic) was necessary. Most respondents did not believe that less general surgical training disadvantaged I-6 residents in terms of their career (83%); 67% of respondents would have chosen the I-6 format for themselves if given the choice. The greater challenges in training less mature and experienced trainees and vulnerability to attrition were noted as disadvantages of the I-6 format. Most respondents believed that I-6 programs represent a natural evolution toward improved residency training rather than a response to declining interest among medical school graduates. Conclusions High satisfaction rates with the I-6 format were prevalent among I-6 program directors. However, concerns with respect to training relatively less experienced, mature trainees were evident.

Since the initial conceptual description of prosthesis-patient mismatch by Rahimtoola in 1978, many studies have been published that have substantiated or called into question its clinical relevance among patients undergoing aortic valve replacement. Most of these studies have narrowly focused on seeking correlations among transprosthetic gradients, indexed effective orifice area, left ventricular (LV)mass regression, and postoperative survival. Conclusions have been inconsistent, suggesting that the determinants of survival after aortic valve replacement may be more complex than simple replacement of a stenotic native valve with a prosthetic that is often just less stenotic. With this notion as a backdrop, Helder and colleagues’ broader analysis of a wider array of factors that might affect LV mass regression prompts provocative questions pertaining to the relative impact of aortic valve replacement on survival, and the significant effects adjunctive therapeutics might exert. The authors quite reasonably analyzed each factor in the context of its effect on LV mass regression based on the well-established premise that LV hypertrophy (LVH) negatively affects postoperative survival after aortic valve replacement. Of most interest in this study were the findings that treatment with beta-blockers or calciumchannel blockers at discharge was independently associated with an increased probability of complete LV mass regression, whereas prosthesis-patient mismatch was not. These findings, coupled with the observation that there was no difference in 5-year survival rates or New York Heart Association functional status among patients with complete versus incomplete LV mass regression, suggest that the absolute extent of LVH reduction after aortic valve replacement may not affect survival rates or symptomatic status among patients undergoing aortic valve replacement as much as a physiologically meaningful and sustained reduction in ventricular afterload and wall stress afforded by the

Background: Chest radiography and echocardiography are standard techniques to evaluate possible extracardiac migration of pacemaker and defibrillator leads, but computed tomography (CT) scanning may be a helpful adjunct. Methods: Chest CT using a 64-detector helical scanner was performed in three cases of lead perforation where standard techniques did not yield a definitive diagnosis. In two patients, a cardiac CT protocol was followed, the primary indication for which was to assess the lead tip location. On one patient, persistent chest pain several days after the implant led to a chest CT to rule out a pulmonary embolism, and the extracardiac lead was found fortuitously. Results: In all cases, CT scan images resulted in a definitive diagnosis of extracardiac migration of pacemaker or defibrillator leads. One patient had an extracardiac atrial lead which was dysfunctional but not associated with symptoms. The risks of repositioning were felt to outweigh potential benefits in this patient with chronic obstructive pulmonary disease, and treatment was conservative. The other two patients had extracardiac ventricular leads and were symptomatic with pleuritic chest pain. These patients were treated by lead revision with no evidence of bleeding into the pericardial space. All patients did well and none have suffered any further complications. Conclusion: CT images aid in the diagnosis of lead perforation when other modalities are nondiagnostic. Recent advances in CT technology have been associated with increased use of this technique for evaluation of chest pain, analysis of which should now include location of intracardiac leads.

Background— The aim of this study was to derive and validate a risk score for rejection after orthotopic heart transplantation. Methods and Results— The United Network for Organ Sharing registry was used to identify patients undergoing orthotopic heart transplantation between 1998 and 2008. A total of 14 265 eligible patients were randomly divided into derivation (80%; n=11 412) and validation (20%; n=2853) cohorts. The primary outcome was drug-treated rejection within 1 year of orthotopic heart transplantation. Covariates found to be associated (exploratory univariate P R 2 , likelihood ratio test, and c index. A risk score was then generated through the use of relative magnitudes of the odds ratios from the derivation cohort, and its ability to predict rejection was tested independently in the validation cohort. A 13-point risk score incorporating 4 variables (age, race, sex, HLA matching) was created. The mean scores in the derivation and validation cohorts were 8.3±2.2 and 8.4±2.1, respectively. Predicted 1-year rejection rates based on the derivation cohort ranged from 16.2% (score=0) to 50.7% (score=13; P r 2 =0.96, P P Conclusions— This novel 13-point risk score is highly predictive of clinically significant rejection episodes within 1 year of orthotopic heart transplantation. It has potential utility in tailoring immunosuppressive regimens and in research stratification in orthotopic heart transplantation.

ObjectiveThe aim of the present study was to review nationwide outcomes of surgical embolectomy for acute pulmonary embolism.MethodsAdult patients undergoing surgical embolectomy for acute pulmonary embolism from 1999 to 2008 were identified in the weighted Nationwide Inpatient Sample. The primary endpoint was inpatient mortality. Multivariate logistic regression analysis incorporating significant univariate predictors (P

Patients with acute coronary syndromes who require emergency cardiac surgery present complex management challenges. The early administration of antiplatelet and antithrombotic drugs has improved overall survival for patients with acute myocardial infarction, but to achieve maximal benefit, these drugs are given before coronary anatomy is known and before the decision to perform percutaneous coronary interventions or surgical revascularization has been made. A major bleeding event secondary to these drugs is associated with a high rate of death in medically treated patients with acute coronary syndrome possibly because of subsequent withholding of antiplatelet and antithrombotic therapies that otherwise reduce the rate of death, stroke, or recurrent myocardial infarction. Whether the added risk of bleeding and blood transfusion in cardiac surgical patients receiving such potent antiplatelet or antithrombotic therapy before surgery specifically for acute coronary syndromes affects long-term mortality has not been clearly established. For patients who do proceed to surgery, strategies to minimize bleeding include stopping the anticoagulation therapy and considering platelet and/or coagulation factor transfusion and possibly recombinant-activated factor VIIa administration for refractory bleeding. Mechanical hemodynamic support has emerged as an important option for patients with acute coronary syndromes in cardiogenic shock. For these patients, perioperative considerations include maintaining appropriate anticoagulation, ensuring suitable device flow, and periodically verifying correct device placement. Data supporting the use of these devices are derived from small trials that did not address long-term postoperative outcomes. Future directions of research will seek to optimize the balance between reducing myocardial ischemic risk with antiplatelet and antithrombotics versus the higher rate perioperative bleeding by better risk stratifying surgical candidates and by assessing the effectiveness of newer reversible drugs. The effects of mechanical hemodynamic support on long-term patient outcomes need more stringent analysis.

This paper presents a method for the computation of 3D flow in 4D (3D spatial+time) Transesophageal Echocardiography (4D TEE). 4D echocardiography is the only modality that allows real-time 3D imaging of the heart, at rates that are sufficiently high to characterize the very fast motion of key anatomical structures, such as the mitral and aortic valves or the left ventricle. The method described in this paper relies on a recently introduced variational optical flow approach. We applied the method to estimate the velocity field of myocardium in the left heart. Real intraoperative 4D TEE data was used and the method yielded good quantitative and qualitative preliminary results. This method has many applications, including elastography, biomechanical modeling, and automated diagnostics.