Rapid Prototyping Techniques for the Development of a Take-Home Surgical Anastomosis Simulation Model.

OBJECTIVE: The objective of this paper is to describe the techniques and process of developing and testing a take-home surgical anastomosis simulation model. DESIGN: Through an iterative process, a simulation model was customized and designed to target specific skill development and performance objectives that focused on anastomotic techniques in thoracic surgery and consist of 3D printed and silicone molded components. Various manufacturing techniques such as silicone dip spin coating and injection molding have been described in this paper and explored as part of the research and development process. The final prototype is a low-cost, take-home model with reusable and replaceable components. SETTING: The study took place at a single-center quaternary care university-affiliated hospital. PARTICIPANTS: The participants included in the model testing were 10 senior thoracic surgery trainees who completed an in-person training session held during an annual hands- on thoracic surgery simulation course. Feedback was then collected in the form of an evaluation of the model from participants. RESULTS: All 10 participants had an opportunity to test the model and complete at least 1 pulmonary artery and bronchial anastomosis. The overall experience was rated highly, with minor feedback provided regarding the set- up and fidelity of the materials used for the anastomoses. Overall, the trainees agreed that the model was suitable for teaching advanced anastomotic techniques and expressed an interest in being able to use this model to practice skill development. CONCLUSIONS: Developed simulation model can be easily reduced, with customized components that accurately simulate real-life vascular and bronchial components suitable for training of anastomoses technique amongst senior thoracic surgery trainees.

Gender trends in cardiothoracic surgery authorship.

OBJECTIVE: In recent years, the historically low proportion of women cardiothoracic surgeons and trainees has been a subject of intense focus. Publications remain a key metric of academic success and career advancement. We sought to identify trends in the gender of first and last author publications in cardiothoracic surgery. METHODS: We searched for publications between 2011 and 2020 in 2 US cardiothoracic surgery journals, identifying those with Medical Subject Heading publication types of clinical trials, observational studies, meta-analyses, commentary, reviews, and case reports. A commercially available, validated software (Gender-API) was used to associate gender with author names. Association of American Medical Colleges Physician Specialty Data Reports were used to identify concurrent changes in the proportion of active women in cardiothoracic surgery. RESULTS: We identified 6934 (57.1%) pieces of commentary; 3694 (30.4%) case reports; 1030 (8.5%) reviews, systematic analyses, meta-analyses, or observational studies; and 484 (4%) clinical trials. In total, 15,189 total names were included in analysis. Over the 10-year study period, first authorship by women rose from 8.5% to 16% (0.42% per year, on average), whereas the percentage of active US women cardiothoracic physicians rose from 4.6% to 8% (0.42% per year). Last authorship was generally flat over the decade, going from 8.9% in 2011% to 7.8% in 2020 and on average, increased at just 0.06% per year (P = .79). CONCLUSIONS: Over the past decade, authorship by women has steadily increased, more so at the first author position. Author-volunteered gender identification at the time of manuscript acceptance may be useful to more accurately follow trends in publication.

Gender differences in Medicare payments to cardiothoracic surgeons in 2019.

OBJECTIVES: The STS Thoracic Surgery Practice and Access Task Force - 2019 Workforce Report noted gender-based differences in the income of cardiothoracic surgeons in the United States. We analysed the 2019 Medicare payment data for thoracic and cardiac surgeons to investigate the gender-based payment gap among cardiothoracic surgeons. METHODS: The 2019 Medicare Physician and Other Practitioners by Provider and Services data set merged with the Doctors and Clinicians National Downloadable File was utilized to conduct a cross-sectional analysis of gender differences in Medicare payments, numbers of services, unique billing codes, years in practice, Medicare beneficiary age, regional population density (rural-urban commuting area code) and patient panel complexity (hierarchical condition category) for providers. The providers' self-reported gender (women or men) and provider type (thoracic surgery or cardiac surgery) were binarily set according to the Center for Medicare and Medicaid Services standards. Independent analyses were performed with thoracic and cardiac surgeons. We also used the 2013 and 2016 Medicare Physician and Other Practitioners by Provider and Services data sets to analyse the trends in adjusted gender-based payment differences across 2013, 2016 and 2019. RESULTS: After controlling for the covariates, women thoracic surgeons received $25,183.50 [95% confidence interval (CI) $16,307.60, $34,059.40] less than the mean Medicare payment than men thoracic surgeons. Likewise, women cardiac surgeons received $20,960 [95% confidence interval (CI) $1,014.80, $40,902.80] less than the mean adjusted Medicare payment than their men counterparts. CONCLUSIONS: In 2019, women cardiothoracic surgeons received a significantly lower mean Medicare payment than men cardiothoracic surgeons after controlling for the number of services, unique billing codes, the complexity of the patient panel, years in practice and regional population density. The payment gap between women and men exhibited no statistically significant change over 2013, 2016 and 2019. Future studies are warranted to understand the association between gender representation and the pay gap.

Development of the Minimalist Approach for Transcatheter Aortic Valve Replacement at a Veterans Affairs Medical Center.

OBJECTIVES: While a minimalist transcatheter aortic valve replacement (TAVR) approach has shown safety and efficacy at civilian hospitals, limited data exist regarding developing this approach at Veterans Affairs (VA) medical centers (VAMCs). We implemented TAVR with minimalist approach (MA) using conscious sedation (CS) with transthoracic echocardiography (TTE) and compared safety and outcomes with general anesthesia (GA) with transesophageal echocardiography (TEE) at a university-affiliated VAMC. METHODS: A total of 258 patients underwent transfemoral TAVR at a VAMC between November 2013 and October 2019. Ninety-three patients underwent GA/TEE and 165 patients underwent CS/TTE with dexmedetomidine and remifentanil. Propensity-score matching with nearest-neighbor matching was used to account for baseline differences, yielding 227 participants (81 GA, 146 CS). RESULTS: MA-TAVR had no effect on 30-day mortality or paravalvular leakage. No differences were found in permanent pacemaker implantation, major vascular complications, or postoperative hemodynamics. In this population, MA-TAVR did not reduce procedural time, hospital length of stay, or intensive care unit length of stay. CONCLUSIONS: Unlike civilian hospitals, MA with CS/TTE did not reduce overall length of stay in the veteran population; however, it was safe and effective for transfemoral TAVR without impacting clinical outcomes of mortality, major vascular complications, and paravalvular leakage.

Veterans Affairs Heart Team Experience With Transcatheter Aortic Valve Replacement and Minimally Invasive Surgical Aortic Valve Replacement.

OBJECTIVES: Aortic valve disease is prevalent in the veteran population. Transcatheter aortic valve replacement (TAVR) and minimally invasive surgical aortic valve replacement (MIAVR) are minimally invasive approaches predominantly performed at higher-volume cardiac centers. The study aim was to evaluate our experience with minimally invasive techniques at a Veterans Affairs Medical Center (VAMC), since outcomes from lower-volume federal facilities are relatively unknown. METHODS: This study examined retrospective data from 228 consecutive patients who underwent treatment for isolated aortic valve disease with MIAVR or TAVR via intent-to-treat at a VAMC between January 2011 and July 2017. Perioperative outcomes were analyzed using Stata version 15. RESULTS: Operative mortality was 1.1% for MIAVR and 0.7% for TAVR (Χ² P=.79). Median length of hospital stay was 10 days (interquartile range [IQR], 7-14 days) for MIAVR and 4 days for TAVR (IQR, 3-6 days; Mann-Whitney P<.001). Postoperative new-onset atrial fibrillation occurred in 52% of MIAVR patients and 5.2% of TAVR patients (Χ² P<.001). Stroke occurred in 2.2% of MIAVR patients and 3.0% of TAVR patients (Χ² P=.71). In patients who underwent MIAVR, 5.4% required placement of a permanent pacemaker postoperatively, compared with 14% of TAVR patients (Χ² P=.04). Mild paravalvular leak (PVL) affected 2.2% of MIAVR and 28% of TAVR patients, with moderate PVL reported in 2.2% of MIAVR and 3% of TAVR patients (Χ² P<.001). CONCLUSIONS: The VAMC heart team offers MIAVR and TAVR to veterans with isolated aortic valve disease, and has achieved excellent outcomes despite relatively lower case volumes. Both offer excellent hemodynamic results, with low mortality in a complex population.

Evolution of Bilateral Mammary Arterial Grafting Program in Veterans Affairs Medical Center.

BACKGROUND: Coronary revascularization with bilateral internal mammary arteries is associated with increased long-term survival, but underutilized due to sternal wound infection concerns. Dedicated bilateral mammary grafting programs are typically high-volume academic or private practices, rather than lower-volume federal institutions whose results are not captured in the Society of Thoracic Surgeons database. Our institution used only single internal mammary arterial grafting in the year prior to implementing a dedicated bilateral grafting program using skeletonized technique. We describe our experience transitioning to bilateral mammary grafting and its impact on sternal wound infection. METHODS: Retrospective cohort study at San Francisco Veterans Affairs Medical Center in 200 patients undergoing first-time isolated, multi-vessel coronary artery bypass from August 2014 to October 2017. Sternal wound infection was defined broadly to include any patient receiving antibiotics for suspicion of sternal infection. Patients were followed for wound complications until 3 post-operative months. RESULTS: Of 200 total patients, 45.5% (n=91) were diabetic, 44% (n=88) had BMI >30, and 61.5% (n=123) underwent bilateral mammary grafting. Bilateral mammary grafting population had 2.4% (n=3/123) deep sternal wound infection with 1.6% (n=2/123) requiring sternal reconstruction while single mammary population had 1.3% (n=1/77, p=1.0). Bilateral mammary grafting population had 6.5% (n=8/123) superficial sternal wound infection compared to 5.2% (n=4/77, p=0.77) in single mammary grafting population. CONCLUSIONS: Transitioning to high rates of bilateral mammary utilization was possible in a year with low rates of complications. Based on our experience, surgeons should consider adopting a skeletonized bilateral mammary grafting approach given potential long-term survival benefit.

A mass that has no (EBUS) echo.

We report findings for a patient that underwent endobronchial ultrasound (EBUS) guided transbronchial needle aspiration (TBNA) for diagnostic purposes after an abnormal chest CT. The patient initially presented with cough and shortness of breath. Chest CT revealed a 6 cm soft tissue mass with mildly enlarged right hilar lymph nodes (LNs) and a small right sided pleural effusion. Based on these radiologic findings, the patient underwent an EBUS guided FNA of the mass. To our surprise, the mass was hypoechoic by EBUS and on aspiration, the syringe filled with yellow fluid. This finding in combination with a re-review of the CT scans with a special focus on the Hounsfield Units of the lesion confirmed the diagnosis of a mediastinal bronchogenic cyst. This case demonstrates the role of Hounsfield units in analyzing mediastinal masses and highlights the effectiveness of EBUS guided TBNA in diagnosis and treatment of bronchogenic cysts.

Adjuvant Chemotherapy Guided by Molecular Profiling and Improved Outcomes in Early Stage, Non-Small-Cell Lung Cancer.

INTRODUCTION: Many early stage non-small-cell lung cancer (NSCLC) patients who are not considered candidates for adjuvant treatment according to current guidelines do harbor occult metastasis, and have disease recurrence despite complete resection. Although National Comprehensive Cancer Network (NCCN) guidelines suggest clinicopathologic characteristics to identify high-risk patients for adjuvant intervention, molecular profiling more accurately predicts 5-year survival. Early evidence of clinical benefit from application of this molecular-based management strategy, however, has not been reported. PATIENTS AND METHODS: An internationally validated, prognostic, 14-gene quantitative polymerase chain reaction expression assay was used to stratify risk prospectively in 100 consecutive patients with stage IA, IB, and IIA nonsquamous NSCLC. Kaplan-Meyer estimates, log rank analysis, and Cox regression were used to compare disease-free survival (DFS) between high-risk patients who did or did not elect adjuvant chemotherapy. RESULTS: Forty-eight patients (48%) were deemed high-risk according to molecular testing and 36 (36%) met NCCN high-risk criteria; risk designations were discordant in 34 (34%) of all patients. Estimated 5-year DFS was 48.9% among molecular high-risk patients who did not undertake adjuvant chemotherapy, 93.8% among untreated molecular low-risk patients, and 91.7% in molecular high-risk patients who did undergo chemotherapy (P = .004). In contrast, DFS was only 75.2% in untreated NCCN low-risk patients, and 61.9% in untreated NCCN high-risk patients (P = .183). CONCLUSION: This prospective, nonrandomized study provides initial evidence that high-risk designation according to the 14-gene prognostic assay also predicts benefit from adjuvant chemotherapy for very early stage NSCLC, and further supports the superiority of molecular stratification over current NCCN criteria at identifying high-risk patients.