Resection of a Giant Cardiac Lymphovenous Malformation Involving the Right Atrioventricular Groove.

Lymphovenous malformations of the heart are rare, and optimal management is uncertain. We present a case of a 39-year-old gentleman with a giant symptomatic lymphovenous malformation involving the right atrium, ventricle, and coronary artery. Radical resection was performed with replacement of the tricuspid valve and bovine pericardial reconstruction of the atrium and ventricle. Additional coronary artery bypass grafting was performed to the acute marginal and distal right coronary artery. Radical resection for this benign process is feasible and may be considered given the possibility of recurrence seen with lymphatic malformations of other parts of the body.

Creation and Global Deployment of a Mobile, Application-Based Cognitive Simulator for Cardiac Surgical Procedures.

Several modern learning frameworks (eg, cognitive apprenticeship, anchored instruction, and situated cognition) posit the utility of nontraditional methods for effective experiential learning. Thus, development of novel educational tools emphasizing the cognitive framework of operative sequences may be of benefit to surgical trainees. We propose the development and global deployment of an effective, mobile cognitive cardiac surgical simulator. In methods, 16 preclinical medical students were assessed. Overall, 4 separate surgical modules (sternotomy, cannulation, decannulation, and sternal closure) were created utilizing the Touch Surgery (London, UK) platform. Modules were made available to download free of charge for use on mobile devices. Usage data were collected over a 6-month period. Educational efficacy of the modules was evaluated by randomizing a cohort of medical students to either module usage or traditional, reading-based self-study, followed by a multiple-choice learning assessment tool. In results, downloads of the simulator achieved global penetrance, with highest usage in the USA, Brazil, Italy, UK, and India. Overall, 5368 unique users conducted a total of 1971 hours of simulation. Evaluation of the medical student cohort revealed significantly higher assessment scores in those randomized to module use versus traditional reading (75% ± 9% vs 61% ± 7%, respectively; P < 0.05). In conclusion, this study represents the first effort to create a mobile, interactive cognitive simulator for cardiac surgery. Simulators of this type may be effective for the training and assessment of surgical students. We investigated whether an interactive, mobile-computing-based cognitive task simulator for cardiac surgery could be developed, deployed, and validated. Our findings suggest that such simulators may be a useful learning tool.

Inheriting the Learner's View: A Google Glass-Based Wearable Computing Platform for Improving Surgical Trainee Performance.

BACKGROUND: It is speculated that, in operative environments, real-time visualization of the trainee's viewpoint by the instructor may improve performance and teaching efficacy. We hypothesized that introduction of a wearable surgical visualization system allowing the instructor to visualize otherwise "blind" areas in the operative field could improve trainee performance in a simulated operative setting. METHODS: A total of 11 surgery residents (4 in general surgery training and 7 in an integrated 6-year cardiothoracic surgery program) participated in the study. Google (Mountain View, CA) Glass hardware running proprietary software from CrowdOptic (San Francisco, CA) was utilized for creation of the wearable surgical visualization system. Both the learner and trainer wore the system, and video was streamed from the learner's system in real time to the trainer, who directed the learner to place needles in a simulated operative field. Subjects placed a total of 5 needles in each of 4 quadrants. A composite error score was calculated based on the accuracy of needle placement in relation to the intended needle trajectories as described by the trainer. Time to task completion (TTC) was also measured and participants completed an exit questionnaire. RESULTS: All residents completed the protocol tasks and the survey. Introduction of the wearable surgical visualization system did not affect mean time to task completion (278 ± 50 vs. 282 ± 69 seconds, p = NS). However, mean composite error score fell significantly once the wearable system was deployed (18 ± 5 vs. 15 ± 4, p < 0.05), demonstrating improved accuracy of needle placement. Most of the participants deemed the device unobtrusive, easy to operate, and useful for communication and instruction. CONCLUSIONS: This study suggests that wearable surgical visualization systems allowing for adoption of the learner's perspective may be a useful educational adjunct in the training of surgeons. Further evaluations of the efficacy of wearable technology in the operating room environment are warranted.

Thoracoscopic Resection of a Symptomatic, Congenital Rib Synostosis.

We describe a rare case of a 20-year-old man with a 1½-year history of a symptomatic congenital bridging rib synostosis. A minimally invasive surgical solution was provided, with resolution of symptoms.

Integrated thoracic residency program applicants: the best and the brightest?

BACKGROUND: Comparative data are lacking on the numbers and nature of applicants to North American 6-year integrated thoracic residency and traditional thoracic fellowship programs. METHODS: Candidates applying within the first 3 months of the application cycles to the integrated and traditional thoracic surgery residency programs starting in 2011 at Mount Sinai Medical Center, New York, were reviewed. RESULTS: The overall ratio of applicants to positions was 27:1 for the traditional program and 131:1 for the integrated program. There was no significant difference in the proportion of female applicants (22% vs 16%, p = 0.57). Almost half of integrated program applicants were final-year medical students, 20% of whom attended institutions with integrated programs. Traditional program applicants on average had 4 years surgery residency experience compared with the average of 3 years reported by the 46% of applicants to the integrated program who had postgraduate clinical experience. More than half of integrated program applicants were overseas graduates. Shortlisted integrated applicants had significantly greater United States Medical Licensing Examination scores and peer reviewed publications than shortlisted traditional applicants and were more likely to hold higher degrees and national research funding. CONCLUSIONS: Much of the dramatic increase in the number of applicants to North American integrated thoracic residency programs has been driven by experienced international graduates. The caliber of applicants is strong, but efforts are needed to increase the appeal of thoracic surgery training to North American medical students if the goals of integrated programs are to be realized.

Extending the use of the pacing pulmonary artery catheter for safe minimally invasive cardiac surgery.

OBJECTIVE: In this study, the therapeutic use of pacing pulmonary artery catheters in association with minimally invasive cardiac surgery was evaluated. DESIGN: A retrospective study. SETTINGS: A single institutional university hospital. PARTICIPANTS: Two hundred twenty-four consecutive patients undergoing minimally invasive cardiac surgery through a small (5-cm) right anterolateral thoracotomy using fibrillatory arrest without aortic cross-clamping. MEASUREMENTS AND MAIN RESULTS: Two hundred eighteen patients underwent mitral valve surgery (97%) alone or in combination with other procedures. Six patients underwent other cardiac operations. In all patients, the pacing pulmonary artery catheter was used intraoperatively to induce ventricular fibrillation during the cooling period, and in the postoperative period it also was used in 37 (17%) patients who needed to be paced, mainly for bradyarrhythmias (51%). There were no complications related to the insertion of the catheters. Six (3%) patients experienced a loss of pacing capture, and 2 (1%) experienced another complication requiring the surgical removal of the catheter. Seven (3%) patients needed postoperative implantation of a permanent pacemaker. CONCLUSIONS: In combination with minimally invasive cardiac surgery, pacing pulmonary artery catheters were therapeutically useful to induce ventricular fibrillatory arrest intraoperatively and for obtaining pacing capability in the postoperative period. Their use was associated with a low number of complications.

Idiopathic mitral valve disease in a patient presenting with Axenfeld-Rieger syndrome.

A 33-year-old, previously healthy male presented with respiratory distress and underwent intubation. A physical examination revealed a holosystolic murmur and pupillary abnormalities. Echocardiography revealed a flail anterior mitral valve leaflet with ruptured chordae and severe mitral regurgitation. The patient underwent urgent mitral valve replacement and tolerated the procedure well. The mitral valve leaflet was myxomatous and calcified -- an unusual find in such a patient. An ophthalmology consultation was obtained and the patient diagnosed with Axenfeld-Rieger syndrome, a disorder of the anterior ocular chamber that has been associated with cardiac malformations. The present case report adds to the body of literature which suggests a correlation between Axenfeld-Rieger syndrome and valvular abnormalities. Hence, it is believed prudent that patients with Axenfeld-Rieger syndrome should undergo echocardiographic screenings for valvular abnormalities.

Quantitative analysis of EGFRvIII cellular signaling networks reveals a combinatorial therapeutic strategy for glioblastoma.

Glioblastoma multiforme (GBM) is the most aggressive brain tumor in adults and remains incurable despite multimodal intensive treatment regimens. EGFRvIII is a truncated extracellular mutant of the EGF receptor (EGFR) commonly found in GBMs that confers enhanced tumorigenic behavior. To gain a molecular understanding of the mechanisms by which EGFRvIII acts, we have performed a large-scale analysis of EGFRvIII-activated phosphotyrosine-mediated signaling pathways and thereby have identified and quantified 99 phosphorylation sites on 69 proteins. Distinct signaling responses were observed as a function of titrated EGFRvIII receptor levels with the phosphatidylinositol 3-kinase pathway being dominant over the MAPK and STAT3 pathways at a high level of EGFRvIII expression. Within this data set, the activating phosphorylation site on the c-Met receptor was found to be highly responsive to EGFRvIII levels, indicating cross-activation of the c-Met receptor tyrosine kinase by EGFRvIII. To determine the significance of this finding, we devised a combined treatment regimen that used a c-Met kinase inhibitor and either an EGFR kinase inhibitor or cisplatin. This regimen resulted in enhanced cytotoxicity of EGFRvIII-expressing cells compared with treatment with either compound alone. These results suggest that the clinical use of c-Met kinase inhibitors in combination with either EGFR inhibitors or standard chemotherapeutics might represent a previously undescribed therapeutic approach to overcome the observed chemoresistance in patients with GBMs expressing EGFRvIII.