Cardiac Surgery Exposure in General Surgery Residency-A Survey of General Surgery Residency Program Directors.

BACKGROUND: Little is known regarding how much exposure general surgery residents have to cardiac surgery, despite cardiothoracic (CT) surgery being an offered postresidency fellowship and career. Exposure to a subspecialty is important in shaping residents' interests and career decisions. METHODS: A survey was sent to all general surgery program directors via the Association of Program Directors in Surgery examining cardiac surgery exposure during training. The survey examined the presence of operative rotations in cardiac surgery and cardiac critical care, portions of cases residents were permitted to perform, cardiac surgery mentorship and education, and perceived biases in applying to cardiac surgery. Differences between programs with and without cardiothoracic training programs were analyzed. RESULTS: In total, 44% (102/230) of program directors responded to the survey. Residents were involved in operative cardiac and cardiac ICU rotations in 61 programs (69.8%) and 39 programs (38.2%), respectively. Twenty programs (19.6%) had a dedicated cardiothoracic surgery training program and these programs had significantly more graduates who aspired to be cardiac surgeons (M = 2.75, SD = 2.47) compared to hospitals with no CT programs (M = 1.43, SD = 1.41; p = 0.031). 35.3% of program directors reported resident concern over family life. CONCLUSIONS: There is a notable heterogeneity in general surgery resident exposure to cardiac surgery, cardiac ICU, and cardiac surgery mentorship. Increased exposure, mentorship and mitigating resident concern over the impact of social factors on cardiac surgical careers should be key areas of focus to ensure continued encouragement of future trainees and surgeons.

Cardiac surgical simulation program during general surgery residency increases resident physician exposure to cardiac surgery and technical expertise.

Objective: The changing surgical education landscape in surgical training pathways greatly diminished cardiac surgical knowledge, interest, and skills among general surgery trainees. To address this issue, our department developed a cardiac surgery simulation program. Methods: All simulation sessions lasted at least 2 hours and occurred during resident physician protected education time. Participants were postgraduate year 2 through 5 general surgery residents assisted by staff and led by cardiac surgery faculty. Five of the 6 sessions were porcine heart wet labs simulating coronary anastomoses, surgical aortic valve replacement, mitral valve repair and replacement, and left ventricular assist device implantation. The transcatheter aortic valve replacement session was designed as a video simulation and a manikin for wire manipulation and implantation. At the end of each lab, all participants were surveyed about their experiences. Results: An average of 10 resident physicians participated in each session (range, 8-13), for a total of 120 simulation hours. One hundred percent of residents surveyed agreed that the labs improved knowledge and understanding of the disease process, improved understanding of cardiac surgical principles, and helped acquire skills for surgical residency and treatment. Factors that residents cited for increased attendance rate included protected education time, hands-on experience, and a high faculty-to-resident ratio. Conclusions: This program successfully demonstrates that cardiac surgery training and simulation can be integrated into general surgery residency programs, despite the lack of cardiac surgery requirements. Additional metrics for future study includes technical grades on resident physicians' performance to further assess the value of this program.

SAVE score with lactate modification predicts in-hospital mortality in patients with ongoing cardiac arrest during VA-ECMO cannulation.

The survival after veno-arterial extracorporeal membrane oxygenation score and its lactate modification predict in-hospital mortality in patients based on pre-extracorporeal membrane oxygenation variables. Cardiac arrest history is a significant variable in these scores; however, patients with ongoing cardiac arrest during cannulation were excluded from these models. The goal of this study is to validate the survival after veno-arterial extracorporeal membrane oxygenation score with a lactate modification among patients with ongoing cardiac arrest. In our study, the survival after veno-arterial extracorporeal membrane oxygenation score predicted mortality in all patients, but did so with higher discrimination among ongoing cardiac arrest patients with a lactate modification.

Survival and Outcomes After Cardiac Arrest With VA-ECMO Rescue Therapy.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) use in patients with cardiac arrest is increasing. Utilization remains variable between centers using ECMO as a rescue therapy or early protocolized extracorporeal cardiopulmonary resuscitation. METHODS: Single-center, retrospective evaluation of cardiac arrest with cardiopulmonary resuscitation and rescue ECMO support from 2011 through 2019. Study objectives included survival, non-neurologic, and neurologic outcomes; validation of the SAVE and modified SAVE (mSAVE) scores for survival and favorable neurologic outcome; and predictive factor identification in cardiac arrest with ECMO rescue therapy. RESULTS: Eighty-nine patients were included. In-hospital survival was 38.2% and median CPC score was 2. Survivors had lower BMI (27.9 ±â€Š4.2 kg/m2 vs. 32.3 ±â€Š7.5 kg/m2, P = 0.003), less obesity (BMI ≥ 30 kg/m2) (26.5% vs. 49.1%, P = 0.035), shorter CPR duration (35.5 ±â€Š31.7 m vs. 58.0 ±â€Š49.5 m, P = 0.019), more tracheostomy (38.2% vs. 7.3%, P < 0.001), and less renal replacement therapy (RRT) (17.6% vs. 38.2%, P = 0.031). Patients with a favorable neurologic outcome had lower body weight (86.2 ±â€Š17.9 kg vs. 98.1 ±â€Š19.4 kg, P = 0.010), lower BMI (28.1 ±â€Š4.5 kg/m2 vs. 33.9 ±â€Š7.9 kg/m2, P < 0.001), and less obesity (29.7% vs. 56.3%, P = 0.026). mSAVE score predicted in-hospital survival (OR 1.11; 95%CI 1.03-1.19; P = 0.004) and favorable neurologic outcome (OR 1.11; 1.03-1.20; P = 0.009). Multivariate analysis for in-hospital survival included mSAVE, BMI, CPR-time, tracheostomy, and RRT (c-statistic: 0.864). Favorable neurologic outcome included mSAVE and BMI (c-statistic: 0.805). CONCLUSIONS: mSAVE, BMI, RRT, and tracheostomy are predictors of in-hospital survival and mSAVE and BMI are predictors of favorable neurologic outcome in cardiac arrest with ECMO rescue therapy.

Explantation of an Infected TEVAR With an Extra-Anatomic Arch Reconstruction Along the Right Heart.

This case represents the disease progression and workup of an infected thoracic endovascular aortic repair (TEVAR) graft that initially manifested as an aortic arch pseudoaneurysm. The patient underwent a 2-stage operation to resect the infected TEVAR and to reconstruct flow via an extra-anatomic aortic bypass paralleling the right heart. This is one of the few documented cases of TEVAR explantation with an extra-anatomic aortic bypass to re-establish flow.

Middle Aortic Syndrome in a Child-Bearing Age Patient.

We report a rare case of a 30-year-old female who had a long-standing history of middle aortic syndrome that was being managed nonsurgically. She presented with hypertension and buttock pain with plans to become pregnant. She underwent an aortoiliac bypass.

Medical Management of Three Patients with an Acute Type A Aortic Dissection: Case Series and a Review of the Literature.

The model of surgery first and always for Type A aortic dissections has continued to evolve. During the last three decades, various studies have demonstrated that in select patients, surgery should be delayed or avoided. This case series examines three cases in which patients were medically treated. Furthermore, we review the literature and when surgery should be delayed for acute Type A aortic dissections.