Jay Pal

The Society of Thoracic Surgeons Clinical Practice Guidelines on Arterial Conduits for Coronary Artery Bypass Grafting

Internal thoracic arteries (ITAs) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD is indicated (class of recommendation [COR] I, level of evidence [LOE] B). As an adjunct to left internal thoracic artery (LITA), a second arterial graft (right ITA or radial artery [RA]) should be considered in appropriate patients (COR IIa, LOE B). Use of bilateral ITAs (BITAs) should be considered in patients who do not have an excessive risk of sternal complications (COR IIa, LOE B). To reduce the risk of sternal infection with BITA, skeletonized grafts should be considered (COR IIa, LOE B), smoking cessation is recommended (COR I, LOE C), glycemic control should be considered (COR IIa, LOE B), and enhanced sternal stabilization may be considered (COR IIb, LOE C). As an adjunct to LITA to LAD (or in patients with inadequate LITA grafts), use of a RA graft is reasonable when grafting coronary targets with severe stenoses (COR IIa, LOE: B). When RA grafts are used, it is reasonable to use pharmacologic agents to reduce acute intraoperative and perioperative spasm (COR IIa, LOE C). The right gastroepiploic artery may be considered in patients with poor conduit options or as an adjunct to more complete arterial revascularization (COR IIb, LOE B). Use of arterial grafts (specific targets, number, and type) should be a part of the discussion of the heart team in determining the optimal approach for each patient (COR I, LOE C).

Systematic donor selection review process improves cardiac transplant volumes and outcomes

BACKGROUND Heart transplant remains the definitive therapy for advanced heart failure patients but is limited by organ availability. We identified a large number of donor hearts from our organ procurement organization (OPO) being exported to other regions. METHODS We engaged a multidisciplinary team including transplant surgeons, cardiologists, and our OPO colleagues to identify opportunities to improve our center-specific organ utilization rate. We performed a retrospective analysis of donor offers before and after institution of a novel review process. RESULTS Each donor offer made to our program was reviewed on a monthly basis from July 2013 to June 2014 and compared with the previous year. This review process resulted in a transplant utilization rate of 28% for period 1 versus 49% for period 2 (P = .007). Limiting the analysis to offers from our local OPO changed our utilization rate from 46% to 75% (P = .02). Transplant volume increased from 22 to 35 between the 2 study periods. Thirty-day and 1-year mortality were unchanged over the 2 periods. A total of 58 hearts were refused by our center and transplanted at other centers. During period 1, the 30-day and 1-year survival rates for recipients of those organs were 98% and 90%, respectively, comparable with our historical survival data. CONCLUSIONS The simple process of systematically reviewing donor turndown events as a group tended to reduce variability, increase confidence in expanded criteria for donors, and resulted in improved donor organ utilization and transplant volumes.

Overexpansion of the 29 mm SAPIEN 3 transcatheter heart valve in patients with large aortic annuli (area > 683 mm2): A case series

To evaluate overexpanded 29 mm SAPIEN (S3) transcatheter heart valves in patients with aortic annuli area >683 mm2.

Periportal fibrosis without cirrhosis does not affect outcomes after continuous flow ventricular assist device implantation.

OBJECTIVE This study investigates the relationship of periportal fibrosis on postoperative outcomes after ventricular assist device (VAD) implantation. METHODS Between July 2005 and August 2014, a total of 233 patients were implanted with continuous flow VADs. Liver biopsy was performed on 16 patients with concern for liver disease. Survival was evaluated using the Kaplan-Meier method. The effect of fibrosis on length of stay (LOS) in the intensive care unit was modeled using Poisson regression. Adjustments were made for age, profile from the Interagency Registry for Mechanically Assisted Circulatory Support, biopsy, and model for end-stage liver disease score. RESULTS Fourteen of the 16 patients who underwent biopsy had periportal fibrosis without cirrhosis. One-year survival for the groups with and without biopsy-proven fibrosis was 93% ± 7% and 86% ± 2% (P = .97), respectively. The intensive care unit LOS was not different for those with (median, 7 days; interquartile range: 3-14 days) versus without fibrosis (median, 6 days; interquartile range 4-10 days; P = .65). Fibrosis (P = .42), age (0.95), model for end-stage liver disease excluding internal normalized ratio-XI score (P = .64), performance of a biopsy (P = .28), and Interagency Registry for Mechanically Assisted Circulatory Support class (P = .70) were not associated with intensive care unit LOS. Risk was increased of gastrointestinal bleeding (14% vs 4%; P = .026) in the first year among patients with fibrosis. CONCLUSIONS The presence of periportal fibrosis did not affect survival or outcomes in patients undergoing VAD implantation. These findings suggest that carefully selected patients with advanced heart failure and hepatic fibrosis without cirrhosis may achieve acceptable outcomes with VAD implantation.

Flipping the classroom: Case-based learning, accountability, assessment, and feedback leads to a favorable change in culture

Objective: The 88‐week Thoracic Surgery Curriculum is challenging to implement because of the large content in a traditional lecture format. This study investigates flipping the classroom by using a case‐based format designed to stimulate resident preparation and engagement. Methods: The didactic conference format was altered. Curricular reading assignments, case review, and conference participation prepared residents for novel formative assessment quizzes. Ten residents participated, and faculty served as controls. Scores were compared with the use of linear regression adjusted for clustering of responses for each person. A survey was administered to determine impressions of this educational technique. Results: A majority of residents completed curricular readings (82%) and reviewed case presentations (79%). Resident performance initially lagged behind faculty but exceeded faculty performance by the conclusion (interaction P = .047). Junior resident overall performance was superior to senior residents over the entire analysis (P = .026); however, both groups improved over time similarly (P = .34) Increased reading from the curriculum (5% increase per level, P = .001) and case presentation review (6% increase per level, P < .0001) were associated with improved quiz performance. Residents presenting cases at their session performed no better than other quiz‐takers for the same session (P = .38). The majority of residents viewed this method favorably. Conclusions: This method stimulated increased resident participation and engagement in this pilot study. Assessment scores increased at both resident levels, and resident performance exceeded faculty performance with time. By using experiential learning principles, flipping the classroom in this manner may improve educational culture by enhancing accountability, assessment, and feedback.

Agreement between risk and priority for heart transplant: Effects of the geographic allocation rule and status assignment

BACKGROUND Allocation of donor hearts in the United States is accomplished by an algorithm based on status, time waited, and geographic boundaries. Although not designed to always transplant the highest acuity candidates, the ability of current United Network for Organ Sharing policies to prioritize highest acuity candidates is unknown. METHODS We analyzed 32,866 adult match runs generated from 2007 to 2014. Each candidates sequence number within a match run was compared with the candidates risk of mortality using Kendalls tau-b-a measure of rank correlation. Two primary methods of evaluating risk of mortality were used: status designation-based risk (i.e., status 1A risk > status 1B > status 2) and status justification-based risk (e.g., status 1A justified by presence of a complication). RESULTS Median sequence number for transplanted candidates was 3 (interquartile range [IQR]: 1, 9). Median correlation among match runs for status-based risk was 0.57 (IQR: 0.47, 0.66) and for justification-based risk was 0.51 (IQR: 0.39, 0.60). Sensitivity to status 2 candidates was evident when status 2 candidates were removed from the sample (status-based tau-b = 0.31, justification-based tau-b = 0.1) and with restriction of the data set to only the first 20 candidates (status-based tau-b = 0.35, justification-based tau-b = 0.15). CONCLUSIONS There is only mild correlation between status and priority under the current allocation algorithm and poor concordance when more detailed risks are considered. The geographic allocation rule is responsible for most of the measured discordance.

Temporary and Durable Mechanical Circulatory Support for Single Ventricular Failure in an Adult

Patients palliated with Fontan circulation who require mechanical circulatory support pose anatomic and physiologic challenges. We treated an acutely failed Fontan patient with sequential temporary and durable support devices. Aspects of treatment with each device required modification based on the patient’s anatomy and physiology.

Transcatheter aortic valve repair for management of aortic insufficiency in patients supported with left ventricular assist devices.

The development of new aortic insufficiency after a period of support with a left ventricular assist device can result in progressive heart failure symptoms. Transcatheter aortic valve repair can be an effective treatment in selected patients, but the lack of aortic valve calcification can result in unstable prostheses or paravalvular leak. We describe a technique of deploying a self‐expanding CoreValve (Medtronic, Minneapolis, MN, USA) into the aortic annulus, followed by a balloon‐expandable SAPIEN‐3 (Edwards, Irvine, CA, USA).

Transapical Endovascular Repair of an Ascending Aortic Pseudoaneurysm.

Proximal aortic pathology provides a technical challenge for endovascular repair. We present a case of successful transapical endovascular aortic repair in a patient with a proximal suture line pseudoaneurysm who was not a candidate for open surgical repair. doi: 10.1111/jocs.12766 (J Card Surg 2016;31:456–460)

Outcomes of external repair of HeartMate II™ LVAD percutaneous leads

Background The HeartMate II Left Ventricular Assist Device (LVAD) receives power via a percutaneous lead connected to an external controller and batteries. At times, this lead can be damaged during normal wear, as well as by traumatic fracture, which may jeopardize the functionality of the LVAD. If there is significant internal damage, surgical replacement of the LVAD is required. However it is possible to repair externally damaged leads by replacing the distal portion of the lead to avoid pump replacement. We report the overall experience and outcomes in patients with external lead repairs. Methods A procedure for full external lead replacement has been developed and is approved for implementation by the FDA. Pre-procedural steps include examination of high resolution x-rays of the driveline and analysis of pump log files. Efficacy and outcomes of all attempted external lead repairs were evaluated between initiation of repairs in 2008 through 2014.