Global Makeup of Cardiothoracic Surgeons as Represented by Our Major Societies and Associations.

BACKGROUND: Prior efforts to capture the cardiothoracic surgery community rely on survey data with potentially biased or low response rates. Our goal is to better understand our community by assessing the membership directories from The Society of Thoracic Surgeons (STS), American Association for Thoracic Surgery (AATS), European Association for Cardio-Thoracic Surgery (EACTS), and Asian Society for Cardiovascular and Thoracic Surgery (ASCVTS). METHODS: Membership data were obtained from membership directories. Data for STS and EACTS were supplemented by the associations from their internal databases. The inclusion criterion was active membership; trainees and wholly incomplete profiles were excluded. RESULTS: A total of 12 053 membership profiles were included (STS, 6365; EACTS, 3661; AATS, 1495; ASCVTS, 532). Membership is 7% female overall (EACTS, 9%; STS, 6%; AATS, 5%; ASCVTS, 3%), with a median age of 57 years (STS, 60 years; EACTS, 52 years). All societies had a broad scope of practice including members who practiced both adult cardiac and thoracic (20% overall), but most members practiced adult cardiac (31% overall; ASCVTS, 48%; AATS, 36%; EACTS, 30%; STS, 28%) and were in the late stage of their careers. CONCLUSIONS: We present the makeup of our 4 major societies. We are global with a diversity of careers but concerning factors that require immediate attention. The future of our specialty depends on our ability to evolve, to promote the specialty, to attract trainees, and to include and promote female surgeons. It is crucial that we wake up to these issues, change the narrative, and create action on both individual and leadership levels.

Improved survival after lung transplantation for adults requiring preoperative invasive mechanical ventilation: A national cohort study.

OBJECTIVE: Early survival after lung transplantation has improved in the last decade. Mechanically ventilated recipients are known to be at greater risk for early post-transplant mortality. We hypothesized that post-transplant survival in mechanically ventilated recipients has improved over time. METHODS: Using a national registry, we compared hazard of death at 30 days, 4 and 14 months, 3 and 5 years, and overall for adults on mechanical ventilation who underwent lung or heart-lung transplantation from May 4, 2011, to April 4, 2018 (modern group) with those undergoing transplantation from May 4, 2005, to May 3, 2011 (early group). We quantified the impact of mechanical ventilation on survival using population-attributable fractions. We also compared mechanically ventilated recipients with nonmechanically ventilated recipients. RESULTS: Mechanically ventilated recipients from the modern group had lower hazard of death than recipients in the early group at all time-points, lowest at 30-days post-transplant (hazard ratio, 0.04; 95% confidence interval, 0.02-0.08). In the modern period, mechanically ventilated recipients had greater hazard of death than nonmechanically ventilated recipients at 30 days' post-transplant (9.53; 4.57-19.86). For mechanically ventilated recipients, the population attributable fraction was lower in the modern group compared to the earlier group (0.6% vs 5.7%). CONCLUSIONS: While mechanically ventilated recipients remain at high risk, survival in this patient population has improved over time. This may reflect improvements in perioperative recipient management.

Elevated donor plasminogen activator inhibitor-1 levels and the risk of primary graft dysfunction.

Primary graft dysfunction (PGD) following lung transplantation is associated with elevated recipient plasma levels of plasminogen activator inhibitor-1 (PAI-1) and the receptor for advanced glycation end products (RAGE). However, the significance of these biomarkers in the donor plasma is uncertain. We hypothesized that elevated donor plasma levels of PAI-1 and RAGE would be associated with recipient PGD. We carried out a prospective unmatched case-control study of double-lung transplant recipients between May 2014 and September 2015. We compared donor plasma levels of PAI-1 and RAGE using rank-sum tests and t tests, in 12 recipients who developed PGD grade 2 or 3 within 72 hours postoperatively with 13 recipients who did not. Recipients who developed PGD had higher donor plasma levels of PAI-1 than recipients who did not (median 2.7 ng/mL vs 1.4; P = .03). Recipients with PGD also had numerically higher donor plasma levels of RAGE than recipients without PGD, although this difference did not achieve statistical significance (median 1061 pg/mL vs 679; P = .12). Systemic inflammatory responses in the donor, as reflected by elevated plasma levels of PAI-1, may contribute to the risk of developing PGD. Rapid biomarker assessment of easily available plasma samples may assist in donor lung selection and risk stratification.

Efficacy of Evolving Early-Extubation Strategy on Early Postoperative Functional Recovery in Pediatric Open-Heart Surgery: A Matched Case-Control Study.

There has been a paradigm shift toward "fast-track" management with early extubation (EE) in cardiac surgery. Our retrospective, matched case-control study wishes to define the benefits of EE in pediatric congenital heart surgery. We examined 50 consecutive pediatric cardiac surgery patients extubated in the operating room (February 2009 to July 2009) against a control group of delayed-extubation patients. No significant differences were found in preoperative variables except heart failure medication. Significant intraoperative variables included the following: blood products (363 vs 487 mL, P = .023), morphine (62% vs 6%, P < .0001), and inotropes (16% vs 60%, P < .0001) given. Postoperatively significant differences included hospital stay and lower inotrope scores in the early-extubation group (14.89 vs 31.68, P < .0001). The reintubation rate was not significant. EE patients have equivalent hemodynamic profiles shown by a decreased necessity for inotropic support. We conclude that EE is feasible in low-/medium-risk pediatric congenital heart surgery patients.

Primary sutureless repair for infants with mixed total anomalous pulmonary venous drainage.

BACKGROUND: Mixed type total anomalous pulmonary venous drainage (TAPVD) poses technical challenges and high mortality owing to diminutive size and remote location of the pulmonary vein (PV) confluences. We hypothesized that primary application of sutureless repair may better incorporate small and remote confluences, thereby minimizing PV stenosis and improving outcomes. METHODS: Twenty-two consecutive infants (1985 to 2009; median age 27 days; body weight 3.7 kg) with mixed type TAPVD were retrospectively reviewed. Survival and reintervention were compared between the sutureless group (n = 8) and the conventional group (n = 14). Predictors for death and reintervention were identified by an univariate analysis using a chi(2) test. RESULTS: No differences were noted on preoperative and intraoperative variables between the groups. There were 5 early deaths in the conventional group and no deaths in the sutureless group (p = 0.05). There were trends toward improved survival (100% versus 57% at 1 year, p = 0.07) and freedom from reintervention (100% versus 67% at 1 year, p = 0.09) in the sutureless group. The univariate analysis showed that preoperative PV obstruction (p = 0.05), conventional repair (p = 0.05), palliative surgery (p = 0.001), and residual PV obstruction (p = 0.002) were the risk factors for death. Preoperative PV obstruction, palliative surgery, and residual PV obstruction were the predictors for reintervention (p < 0.05 for all). CONCLUSIONS: The primary sutureless repair for the patients with mixed type TAPVD appeared to be safe and effective, resulting in no mortality and reintervention. There were nonsignificant trends toward improving survival and reintervention in the sutureless group. The patients who had sutureless repair and partially unrepaired PV revealed reasonable early and medium-term physiologic tolerance without need for reinterventions.

Early extubation after pediatric cardiac surgery: systematic review, meta-analysis, and evidence-based recommendations.

OBJECTIVE: To derive evidence-based recommendations regarding early extubation strategy after congenital cardiac surgery. OUTCOMES: Incidence of total mortality, morbidity, reintubation, length, and costs of intensive care unit and hospital stay. EVIDENCE: Medline, Embase, and the Cochrane-controlled trial register on the Cochrane library were searched from the earliest achievable date of each database to present. No language restrictions were applied. Retrieved reprints were evaluated according to a priori inclusion criteria, and those included were critically appraised using established internal validity criteria. BENEFITS AND HARMS: Early extubation (in the operating room or ≤6 hours after surgery) was associated with a lower early mortality. There was a trend toward lower ICU and hospital length of stays, lower hospital costs, and less respiratory morbidity. There was no difference in the rate of reintubation in those extubated early versus late. CONCLUSION: Early extubation appears safe and is associated with reduction in length of ICU and hospital stay without adverse effects on mortality or morbidity. However, studies to date are poor, heterogeneous, and not suitable to determine a causal effect. Therefore, there is need for a well-designed randomized clinical trial to demonstrate the potential significant benefits of early extubation.