The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation.

The Society of Thoracic Surgeons 2023 Clinical Practice Guidelines for the Surgical Treatment of Atrial Fibrillation incorporate the most recent evidence for surgical ablation and left atrial appendage occlusion in different clinical scenarios. Substantial new evidence regarding the risks and benefits of surgical left atrial appendage occlusion and the long-term benefits of surgical ablation has been produced in the last 5 years. Compared with the 2017 clinical practice guideline, the current update has an emphasis on surgical ablation in first-time, nonemergent cardiac surgery and its long-term benefits, an extension of the recommendation to perform surgical ablation in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery, and a new class I recommendation for left atrial appendage occlusion in all patients with atrial fibrillation undergoing first-time, nonemergent cardiac surgery. Further guidance is provided for patients with structural heart disease and atrial fibrillation being considered for transcatheter valve repair or replacement, as well as patients in need of isolated left atrial appendage management who are not candidates for surgical ablation. The importance of a multidisciplinary team assessment, treatment planning, and long-term follow-up are reiterated in this clinical practice guideline with a class I recommendation, along with the other recommendations from the 2017 guidelines that remained unchanged in their class of recommendation and level of evidence.

Program characteristics of cardiothoracic surgery departments versus divisions.

BACKGROUND: The organizational structure of cardiothoracic surgery practices varies among different programs throughout the United States (U.S.). We aimed to investigate the characteristics of the top ranked programs within the specialty and the surgeons practicing within each. METHODS: The top 50 hospitals for adult cardiology and heart surgery were identified using the US News and World Report 2019-20 ranking. There were 590 hospitals reported on, with 50 top rated programs. Data was collected from each hospital's website, analyses conducted using SAS 9.4 with statistical significance set at p ≤ 0.05. RESULTS: When comparing cardiothoracic surgery program organizational structures, 21 of the top 50 ranked programs were departments and 24 were divisions within their respective Department of Surgery. Mean number of surgeons was 11 with no statistical difference when analyzed by division versus department. Overall, 9% of practicing cardiothoracic surgeons were female. Between programs that are a department versus division, general thoracic surgery was included in 58% of divisions and 52% of departments (p = ns). Among programs that were departments, approximately 6% of surgeons had attained a Ph.D., while in divisions approximately 4% of surgeons had attained a Ph.D. CONCLUSIONS: The top 50 Cardiothoracic Surgery programs in the U.S. have approximately the same number of surgeons within the group and are organized similarly. This study group had a slightly higher percentage of female surgeons than has previously been noted in cardiothoracic surgery, with general thoracic surgery trending toward higher gender diversity. The presence of physician scientists was low, though similar amongst the study groups.

Initial Experiences with the MitraClip G4: Review of the Novel Device Features.

OBJECTIVE: Percutaneous edge-to-edge mitral valve repair is an evolving procedure with increasing indications for use. The MitraClip™ G4 is the newest device with 4 device options, each with distinct characteristics. While the NTR and XTR clips have been in use, the G4 adds 2 new wider clips with additional features, the NTW and XTW. METHODS: We reviewed 26 cases employing the MitraClip G4 at our institution from November 2019 to March 2020. RESULTS: The NTR, XTR, NTW, and XTW clips were used in 3 (11.5%), 0 (0.0%), 16 (61.5%), and 11 (42.3%) cases, respectively. Median mitral regurgitation grade was reduced from 4+ to 1+, though 7 (27%) cases had 2+ residual mitral regurgitation. CONCLUSIONS: The new G4 device includes simplified instructions for use, the option of a wider clip, controlled gripper actuation, and potential left atrial pressure monitoring. The newest MitraClip G4 device allows for potential improved treatment options for patients with mitral regurgitation.

Incremental value of three-dimensional transesophageal echocardiography over the two-dimensional technique in the assessment of a partially detached MitraClip.

We describe an elderly male patient with two MitraClip devices, one fixed and the other detached, in whom live/real-time three-dimensional echocardiography (3DTEE) provided incremental value and additional information compared to two-dimensional transesophageal echocardiography (2DTEE). 3DTEE offered the ability to comprehensively assess the mitral valve (MV) utilizing full volume and multiplanar reconstruction (MPR) modes. 3DTEE proved useful in assessing the position of the properly attached and the partially detached MitraClip, including assessment of orifice size and degree of mitral regurgitation (MR). In addition, trapping of MV chordae by both clips was noted in the 3DTEE image dataset and confirmed at the time of surgery. Chordal trapping was not detected by 2DTEE. 3DTEE proved useful in more accurately estimating the severity of residual MR with the MitraClips in place since the regurgitant jet vena contracta (VC) could be viewed en face and VC area measured by planimetry in the correct imaging plane as compared to limited linear images from 2DTEE.

Left Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement Following Left Pneumonectomy.

We report the case of a 59-year-old man referred for aortic valve replacement for severe, symptomatic aortic insufficiency who underwent a minimally invasive left anterior thoracotomy aortic valve replacement. This approach was facilitated by his history of a left pneumonectomy for lung cancer 7 years prior to presentation, which resulted in a significant left mediastinal shift. The cannulation strategy and exposure were analogous to what would be expected from a standard right anterior thoracotomy minimally invasive aortic valve replacement. The minimally invasive approach allowed for early extubation and mobilization in a patient with moderate baseline pulmonary dysfunction.

Robotic mitral valve repair in a type B hemophiliac.

Hemophilia B is a rare X-linked recessive disorder that places surgical patients at an increased risk of bleeding. Patients with hemophilia are now achieving near-normal life expectancies and therefore the number of these patients requiring cardiac surgery due to the development of age-related cardiovascular disease may increase. We present the case of a young male with hemophilia B who was diagnosed with severe symptomatic mitral regurgitation and underwent successful robotic mitral valve repair. To our knowledge, this is the first report of a patient with hemophilia B who underwent robotic mitral valve repair.

Severe re-expansion pulmonary edema after conventional cardiac surgery: Identification and management.

Re-expansion Pulmonary Edema (REPE) is a recognized but rare complication of lung re-inflation after pathologic collapse or intentional deflation. The presentation of REPE may be highly variable, ranging from a clinically asymptomatic, incidental radiologic finding to acute respiratory failure accompanied by severe, life-threatening hypoxemia. With the current report, we present a patient with severe aortic insufficiency, severe mitral regurgitation, coronary artery disease, pulmonary hypertension, who underwent aortic valve replacement, mitral valvuloplasty, coronary artery bypass grafting, and developed at the immediate post- operative period severe respiratory failure due to REPE, requiring venous-venous Extracorporeal Membrane Oxygenation (VV-ECMO).

Risks and Rewards of Advanced Practice Providers in Cardiothoracic Surgery Training: National Survey.

BACKGROUND: Changes in healthcare have led to increasing use of advanced practice providers (APPs), but their role in cardiothoracic surgery (CTS) education remains undefined. This study aimed to analyze the extent of APP use on the CTS team, their role within the hierarchy of clinical care, and the impact of physician extenders on CTS training from the resident perspective. METHODS: CTS residents' responses to the 2017 Thoracic Surgery Residents Association/Thoracic Surgery Directors Association In-Service Training Examination survey regarding the role of APPs in specific clinical scenarios and perception of APP contribution to residents' educational environment were analyzed. Statistical analysis of categorical variables was performed in SPSS (version 22.0; IBM, Chicago, IL) using a Fisher's exact test and Pearson χ2 test with statistical significance set at p < 0.05. RESULTS: Response rate was 82.1% (280/341). The median number of employed APPs was 16 to 20, and 50.4% (n = 141) reported 11 to 25 physician extenders at their institution. The median numbers of APPs in the operating room, floor, and intensive care unit were three, three, and two, respectively. Overall impression of APPs was positive in 87.5% (n = 245) of respondents, with 47.7% (n = 133) "very positive" and 40.1% "positive" (n = 112). In general, residents reported greater resident involvement in postoperative issues and operative consults and greater APP involvement in floor issues; 72.5% of residents had not missed a surgical opportunity due to APPs, whereas 9.6% missed an opportunity due to APPs despite being at an appropriate level of training. Of those that reported missed opportunities 44% were integrated thoracic surgery residents. There were no significant differences in APPs' operative role based on resident seniority. CONCLUSIONS: The overall impression of APPs among CTS residents was favorable, and they are more commonly involved in assisting on the floor or the operating room. Occasionally residents reported missing a surgical opportunity due to APPs. There is further opportunity to optimize and standardize their role within programs to improve clinical outcomes and enhance the CTS educational experience for residents.

Appraisal of mentorship in cardiothoracic surgery training.

OBJECTIVES: Although the importance of mentorship in training the next generation of cardiothoracic surgeons is widely recognized, the current state of mentorship remains undefined. METHODS: Trainee responses to questions in the 2017 In-Training Examination regarding aspects of mentorship were analyzed. Response rate was 78% (288/370). Mentor-related and trainee-related characteristics were assessed. RESULTS: The majority (84%) of residents had mentors, with a high impact on specialty choice (80%), and 91% of respondents viewed mentorship as critical to success. Nearly half (42%) had program-assigned mentors; 53% found them as productive, and 13% reported more consistent/frequent meetings than personally selected mentors, with 22% reporting less ideal personality match compared with personally selected mentors. Among residents with mentors, 36% lacked mentorship in work-life balance, 23% lacked mentorship in job assistance, and 22% lacked mentorship in career advice. Junior residents more often valued mentors as role models, whereas mentors chosen by senior residents were more impactful in technical training, job counseling, and societal involvement. Compared with men, women more often valued mentors as role models and assisting in networking. Men reported their mentors were more impactful in teaching technical skills and clinical ability than women. CONCLUSIONS: The majority of current cardiothoracic surgery trainees had mentorship; however, gaps remain: Many residents lacked career path guidance, assistance obtaining a job, and advice regarding life-work balance. The role of mentorship varied with program type, seniority, and gender, emphasizing the need to tailor mentorship to the individual and changing needs of the resident.

Outcomes of a novel intrathoracic esophagogastric anastomotic technique.

OBJECTIVES: Anastomotic complications represent a significant source of morbidity and occasionally mortality after esophagectomy. Since 2009, we have used a novel "side-to-side: staple line-on-staple line" (STS) technique for intrathoracic esophagogastric anastomoses, designed to create a wide-diameter esophagogastric anastomosis while preserving stomach conduit blood supply. In this study, we describe the technique and review outcomes of our institution's initial 6-year experience. METHODS: An institutional database query identified 278 consecutive patients who underwent Ivor Lewis esophagogastrectomy using an STS esophagogastric anastomotic technique from 2009 through 2015. A retrospective review was conducted to assess outcomes with a focus on anastomotic complications. RESULTS: There were a total of 8 (2.9%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis, 3 of which were grade I/II leaks and required no intervention. There was a leak rate of 6.3% (2 of 32) after esophagectomy for benign conditions (both leaks occurring in 8 total patients (25%) who received surgery for end-stage achalasia) compared with a 2.4% leak rate (6 of 246) in whom esophagectomy was performed for malignancy (P = .22). Fourteen patients (5.0%) required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of these patients after hospital discharge. CONCLUSIONS: We believe this novel STS technique provides excellent results with respect to the incidence of intrathoracic esophagogastric anastomotic leak and stricture after esophagectomy. Additionally this technique has significantly reduced the need for enteral feeding after hospital discharge.

Congenital aortic paravalvular tunnel masquerading as a recurrent ventricular septal defect.

A 4-year-old female underwent surgical repair of an unusual variation of an aorto-left ventricular tunnel (ALVT). Serial echocardiograms had demonstrated previous spontaneous closure of a perimembranous ventricular septal defect (VSD). The patient presented with concern for residual VSD which was later demonstrated to be an eccentric jet through an ALVT. This case emphasizes early and accurate diagnosis for ALVTs and how they can be misdiagnosed as VSDs.

Academic versus Clinical Productivity of Cardiac Surgeons in the State of New York: Who Publishes More and Who Operates More.

We investigated whether/how cardiac surgeons can be productive both academically and clinically. Using online resources (New York State Adult Cardiac Surgery database, SCOPUS), we collected individual clinical volumes (operations performed/year), academic metrics (ongoing publications, role as author), practice setting, and seniority for all cardiac surgeons in the State of New York from 1994 to 2011. Over time, individual clinical volumes decreased (median operations/year: 193 in 1995 vs 126 in 2010; P < 0.001), whereas academic productivity remained unchanged (median publications/year: 0.7 vs 0.3; P = 0.55). There was no correlation (Spearman's correlation coefficient: -0.061; P = 0.08) between the number of new publications and operations/year for the whole population. More operations/year (median: 155 vs 144; P = 0.03) were performed by surgeons without versus with publications during that same year. Who published more worked at hospitals with higher clinical volumes (Spearman's correlation coefficient: 0.16; P < 0.001) and was more likely affiliated with thoracic surgery fellowship programs (median publications/year: 1.7 for affiliated vs 0 for nonaffiliated surgeons; P < 0.001). Cardiac surgeons could be classified into four categories: ∼40 per cent clinically busy, but not publishing at all; ∼45 per cent operating less, but publishing a little; ∼15 per cent clinically very productive (operating as much as the nonpublishers) and publishing a lot; and ∼1 per cent operating the least, but publishing the most.

Current Status of Endovascular Training for Cardiothoracic Surgery Residents in the United States.

BACKGROUND: Endovascular interventions for cardiovascular pathology are becoming increasingly relevant to cardiothoracic surgery. This study assessed the perceived prevalence and efficacy of endovascular skills training and identified differences among training paradigms. METHODS: Trainee responses to questions in the 2016 In-Service Training Examination survey regarding endovascular training were analyzed based on the four different cardiothoracic surgery training pathways: traditional 2- and 3-year thoracic, integrated 6-year, and combined 4+3 general and thoracic residency programs. RESULTS: The duration of endovascular training was substantially different among programs, at a median of 17 weeks for integrated 6-year, 8.5 weeks for 3-year, 6 weeks for 4+3, and 4 weeks for 2-year residency (p < 0.0001). After adjusting for year of training and program type, the duration of endovascular rotations was significantly associated with self-assessed comfort with catheter-based skills (p < 0.0001). Eighty-two percent of residents rotated with trainees from other specialties, and 58% experienced competition for cases. Residents reported greater exposure to transcatheter aortic valve replacement than to thoracic endovascular aortic repair, cardiac catheterization, percutaneous closure of atrial septal defect, and transcatheter mitral valve surgery (p < 0.0001). A significant proportion of responders reported feeling uncomfortable performing key steps of transcatheter aortic valve replacement (52%) or thoracic endovascular aortic repair (49%). CONCLUSIONS: Considerable heterogeneity exists in endovascular training among cardiothoracic surgery training pathways, with a significant number of residents having minimal to no exposure to these emerging techniques. These findings highlight the need for a standardized curriculum to improve endovascular exposure and training.