Conor F. Hynes

“Just-In-Time” Simulation Training Using 3-D Printed Cardiac Models After Congenital Cardiac Surgery

Background: High-fidelity simulation using patient-specific three-dimensional (3D) models may be effective in facilitating pediatric cardiac intensive care unit (PCICU) provider training for clinical management of congenital cardiac surgery patients. Methods: The 3D-printed heart models were rendered from preoperative cross-sectional cardiac imaging for 10 patients undergoing congenital cardiac surgery. Immediately following surgical repair, a congenital cardiac surgeon and an intensive care physician conducted a simulation training session regarding postoperative care utilizing the patient-specific 3D model for the PCICU team. After the simulation, Likert-type 0 to 10 scale questionnaire assessed participant perception of impact of the training session. Results: Seventy clinicians participated in training sessions, including 22 physicians, 38 nurses, and 10 ancillary care providers. Average response to whether 3D models were more helpful than standard hand off was 8.4 of 10. Questions regarding enhancement of understanding and clinical ability received average responses of 9.0 or greater, and 90% of participants scored 8 of 10 or higher. Nurses scored significantly higher than other clinicians on self-reported familiarity with the surgery (7.1 vs 5.8; P = .04), clinical management ability (8.6 vs 7.7; P = .02), and ability enhancement (9.5 vs 8.7; P = .02). Compared to physicians, nurses and ancillary providers were more likely to consider 3D models more helpful than standard hand off (8.7 vs 7.7; P = .05). Higher case complexity predicted greater enhancement of understanding of surgery (P = .04). Conclusion: The 3D heart models can be used to enhance congenital cardiac critical care via simulation training of multidisciplinary intensive care teams. Benefit may be dependent on provider type and case complexity.

Timing of Gastrostomy Tube Feeding in Three‐stage Palliation of Single‐ventricle Physiology

OBJECTIVE Gastrostomy tube (G-tube) placement during three-stage surgical palliation of single-ventricle cardiac physiology has been shown to improve weight gain in this population of infants who often suffer from inadequate feeding. The optimal timing of this intervention is unclear and requires further investigation. DESIGN A retrospective review of all patients who underwent G-tube placement at any stage of surgical palliation of single-ventricle physiology from January 2005 to December 2012 was performed at a single congenital cardiac surgery center. Analysis of weight gain and survival was undertaken by comparing patients who received the G-tube either less than or greater than 90 days after the first surgical stage. RESULTS Fifty-four patients were identified that met the criteria, 26 (48%) of which received the G-tube within 90 days of stage 1, while 28 (52%) patients received the tube at greater than 90 days. Percentage of weight gain at time of discharge from stage 1 was significantly higher for group B (A: median 9.9%, interquartile range [IQR] 4.9-29.8; B: median 29.0%, IQR 16.0-44.3; P = .05). However, total hospital length of stay was decreased for the patients who received G-tubes earlier (A: median 60 days, IQR 35-100; B: median 83, IQR 48-184) as was intensive care unit length of stay (A: median 27 days, IQR 13-69; B: median 48, IQR 16-119) by nearly half, although not statistically significant (P = .47). Survival to time of discharge from stage 1 surgery was not significantly different between earlier tube placements vs. later (92% vs. 100%, respectively; P = .14). Multivariable analysis found inclusion of fundoplication to predict weight gain (P = .006) at time of first discharge. CONCLUSION Earlier placement of G-tube may increase the rate of recovery from stage 1 of multistage palliative cardiac surgery for single-ventricle physiology. Fundoplication may improve perioperative weight gain when indicated.

Reoperation rates after open and endovascular abdominal aortic aneurysm repairs

Objective: This study compared reoperation rates associated with open abdominal aortic aneurysm (AAA) repair (OR) outcomes vs endovascular AAA repair (EVAR). Methods: A retrospective review of the Veterans Affairs Surgical Quality Improvement Project data was performed with inclusion criteria defined as all patients who underwent AAA repair from October 1, 2007, to October 1, 2013. The primary outcome was the incidence of reoperations. Reoperations included subsequent OR or EVAR procedures performed on the abdominal aorta or iliac arteries, surgical treatment of temporally related bowel obstruction, as well as treatment of abdominal or groin wound complications ≤6 months and treatment of bowel or lower limb ischemia ≤10 days. Results: Of 6677 patients who underwent AAA repair, 476 (7.1%) required reoperations. OR was associated with a higher rate of reoperations overall (10.0% vs 6.3%; P < .01), with most being intra‐abdominal and wound complications. OR also had higher rates of bowel ischemia requiring operation (0.7% vs 0.3%; P = .01) and lower extremity ischemia (0.5% and 0.06%; P < .01). Significantly more endovascular stents were placed during EVAR (2.8% vs 0.5%; P < .01). Logistic regression showed EVAR is a negative predictor for reoperation after controlling for comorbidities (P < .001). Conclusions: The long‐term burden of reoperations after OR may actually be more significant than current understanding when including all possible abdominal complications in an extended analysis. Future prospective trials should include all potential reoperations extended >30 days with associated cost analysis. As surgical innovation in EVAR technology advances, complication comparisons with OR should undergo frequent re‐evaluation given that endovascular indications and outcomes continue to expand and improve.

Transcatheter Treatment of Thrombosis in the Single Ventricle Pathway: An Institutional Experience.

BACKGROUND Shunt or conduit thrombosis in a single ventricle circuit is a life-threatening complication that requires prompt treatment to rapidly restore shunt/conduit patency. Transcatheter interventions represent an attractive alternative to systemic thrombolysis or open surgical procedures. We report our centers experience with catheter-based approaches in patients with palliated single ventricle who present with shunt/conduit thrombosis. METHODS A retrospective review was performed of all patients with palliated single ventricle physiology who were diagnosed over a 5-year period with shunt/conduit thrombosis and received catheter-based interventions. Patients were followed up to hospital discharge. RESULTS Thirteen patients were identified that were diagnosed with thrombosis of a modified Blalock-Taussig shunt (five patients), bidirectional cavopulmonary shunt (one patient), and total cavopulmonary pathway (seven patients). Shunt/conduit thrombosis occurred both early and late after palliation surgery. Catheter-based interventions included balloon angioplasty (one patient), stent implantation (12 patients), and mechanical thrombectomy (one patient). Thrombophilia was identified in seven patients. Technical and clinical success with restoration of normal shunt flow and improvement in clinical status was achieved in 12 patients. Reversible procedure-related complications occurred in three patients with no significant sequelae. CONCLUSIONS Our experience suggests that percutaneous catheter-based interventions are safe and effective in managing shunt/conduit thrombosis in infants and children with palliated single ventricle circulation.

Risk of tumor transmission after thoracic allograft transplantation from adult donors with central nervous system neoplasm‐a UNOS database study

We analyzed the UNOS database to better define the risk of transmission of central nervous system (CNS) tumors from donors to adult recipients of thoracic organs.

Reversibility of Sympathectomy for Primary Hyperhidrosis

Endoscopic thoracic sympathectomy (ETS) is an effective treatment of primary hyperhidrosis of the face, upper extremities, and axillae. The major limitation is the side effect of compensatory sweating severe enough that patients request reversal in up to 10% of cases. When ETS is performed by cutting the sympathetic chain, reversal requires nerve grafting. However, for ETS done with clips, reversal is a simple thoracoscopic outpatient procedure of removing the clips. Subsequent reversal of the sympathectomy, ie, nerve regeneration, is successful in many cases. However, follow-up is short. Factors contributing to success rates require further study.

Intracardiac Fungal Mass in a Term Neonate

Systemic fungal infections pose insidious challenges in neonatal intensive care settings. We present the case of a 9-day-old male term neonate admitted for polymicrobial sepsis and hepatic dysfunction who later developed candidemia superinfection. Despite broad antifungal therapy, the fungemia was complicated by progressive growth of a fungus ball in the right ventricular outflow tract that threatened cardiac function. Surgical excision of the mass was undertaken by right atriotomy and histologic examination confirmed Candida albicans.

Outpatient video-assisted thoracoscopic thymectomy in an octogenarian

Video-assisted thoracoscopic thymectomy has gained acceptance for the treatment of small thymomas. Appropriately selected elderly patients may benefit as much as younger patients from this procedure. Specific benefits of minimally invasive surgery include shorter hospital stays, decreased complications and improved oncologic outcomes. Outpatient thoracic surgery is an established model for some procedures. In this report, we present an 80-year-old patient with an enlarging 2.5 cm thymoma who successfully underwent an outpatient right video-assisted thoracoscopic thymectomy at our institution. The patients postoperative course was uncomplicated. He continues to do well 3 years after his surgery. To our knowledge, this is the first reported outpatient video-assisted thoracoscopic thymectomy in an octogenarian.