Jorge D. Salazar

Effect of Sex and Race on Outcome in Patients Undergoing Congenital Heart Surgery: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database

BACKGROUNDnPrevious studies on the impact of race and sex on outcome in children undergoing cardiac operations were based on analyses of administrative claims data. This study uses clinical registry data to examine potential associations of sex and race with outcomes in congenital cardiac operations, including in-hospital mortality, postoperative length of stay (LOS), and complications.nnnMETHODSnThe Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) was queried for patients younger than 18 years undergoing cardiac operations from 2007 to 2009. Preoperative, operative, and outcome data were collected on 20,399 patients from 49 centers. In multivariable analysis, the association of race and sex with outcome was examined, adjusting for patient characteristics, operative risk (Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery [STAT] mortality category), and operating center.nnnRESULTSnMedian age at operation was 0.4 years (interquartile range 0.1-3.4 years), and 54.4% of patients were boys. Race/ethnicity included 54.9% white, 17.1% black, 16.4% Hispanic, and 11.7% other. In adjusted analysis, black patients had significantly higher in-hospital mortality (odds ratio [OR], 1.67; 95% confidence interval [CI], 1.37-2.04; p<0.001) and complication rate (OR, 1.15; 95% CI, 1.04-1.26; p<0.01) in comparison with white patients. There was no significant difference in mortality or complications by sex. Girls had a shorter LOS than boys (-0.8 days; p<0.001), whereas black (+2.4 days; p<0.001) and Hispanic patients (0.9 days; p<0.01) had longer a LOS compared with white patients.nnnCONCLUSIONSnThese data suggest that black children have higher mortality, a longer LOS, and an increased complication rate. Girls had outcomes similar to those of boys but with a shorter LOS of almost a day. Further study of potential causes underlying these race and sex differences is warranted.

“How to Do It” Hybrid Stent Placement for Pulmonary Vein Stenosis

Pulmonary vein stenosis (PVS) is often progressive and severe. Surgical and percutaneous angioplasty are acutely successful; however, restenosis is common and many patients require multiple reinterventions. We perform intraoperative “hybrid” stent placement to deliver larger, stronger stents. Hybrid stent placement is well described for pulmonary arterial stenosis (PAS). The PAS data demonstrate that smaller stents are associated with rapid in-stent restenosis. Data from PVS in adults demonstrate superior outcomes with larger stents. Hybrid stent placement requires a strong collaborative effort between congenital heart surgeons and interventional cardiologists.

A Decade of Change: Training and Career Paths of Cardiothoracic Surgery Residents 2003 to 2014

BACKGROUNDnDuring the past decade, cardiothoracic surgery (CTS) education has undergone tremendous change with the advent of new technologies and the implementation of integrated programs, to name a few. The goal of this study was to assess how residents career paths, training, and perceptions changed during this period.nnnMETHODSnThe 2006 to 2014 surveys accompanying the Thoracic Surgery Residents Association/Thoracic Surgery Directors Association in-training examination taken by CTS residents were analyzed, along with a 2003 survey of graduating CTS residents. Of 2,563 residents surveyed, 2,434 (95%) responded.nnnRESULTSnDuring the decade, fewer residents were interested in mixed adult cardiac/thoracic practice (20% in 2014 vs 52% in 2003, pxa0= 0.004), more planned on additional training (10% in 2003 vs 41% to 47% from 2011 to 2014), and the frequent use of simulation increased from 1% in 2009 to 24% in 2012 (p < 0.001). More residents recommended CTS to potential trainees (79% in 2014 vs 65% in 2010, pxa0= 0.007). Job offers increased from a low of 12% in 2008 with three or more offers to 34% in 2014. Debt increased from 0% with more than

Ascending Aortic Slide for Interrupted Aortic Arch Repair

200,000 in 2003 to 40% in 2013 (p < 0.001). Compared with residents in traditional programs, more integrated residents in 2014 were interested in adult cardiac surgery (53% vs 31%) and congenital surgery (22% vs 7%), fewer were interested in general thoracic surgery (5% vs 31%, p < 0.001), and more planned on additional training (66% vs 36%, p < 0.001).nnnCONCLUSIONSnWith the evolution in CTS over the last decade, residents training and career paths have changed substantially, with increased specialization and simulation accompanied by increased resident satisfaction and an improved job market.

Percutaneous Closure of Perimembranous Ventricular Septal Defects Using the Second-Generation Amplatzer Vascular Occluders.

For repair of interrupted aortic arch, unfavorable anatomy challenges a tension-free anastomosis. We describe a useful alternative surgical technique used in five neonates/infants, involving splitting the ascending aorta from the sinotubular junction to the arch origin, leftward and posterior “sliding” of the flap with anastomosis to the distal arch creating a native tissue bridge, and reconstruction with a patch. With wide interruption gaps between proximal and distal aortic portions, the ascending aortic slide is a safe and reproducible technique, providing a tension-free native tissue bridge with potential for growth, and a scaffold for patch augmentation in biventricular hearts, or for Norwood stage I in univentricular palliation.

Left ventricular diverticulum: how we do it.

Earlier attempts at percutaneous closure of perimembranous ventricular septal defects (Pm VSDs) were abandoned because of incidence of heart block likely as a result of device rigidity and/or oversizing. This is retrospective review and data reporting of patients who underwent percutaneous closure using the softer second-generation Amplatzer vascular occluders; namely the Amplatzer vascular plug, second generation, (AVP II) and the Amplatzer duct occluder, second generation (ADO II) in our institution. A total of 20 patients were identified; AVP II was used in 9 patients and ADO II in 11 patients. Median weight was 13.45 kg (range 6.5 to 76); age 28.5 months (range 11 to 352). After procedure, 4 were noted to have aortic insufficiency; trivial in 3 and mild in 1 (unrelated to the device). Mild tricuspid regurgitation possibly device or procedure related was seen in 4. Residual flow through the device was common after procedure and disappeared in all but 3, graded as trivial in 1, small in 2. Average follow-up period was 7.54 months ± 7.5 (1 day to 25 months). There was no incidence of heart block, bacterial endocarditis, hemolysis, device embolization, or fracture. The aortic insufficiency resolved in 1 patient and was estimated to be trivial in the remaining 3 patients. In conclusion, percutaneous closure of Pm VSDs using the softer new generation devices as the AVP II and the ADO II is feasible and safe. Longer follow-up and larger series are needed.

Fontan completion in reverse order out of necessity: secondary Glenn after primary extracardiac inferior cavopulmonary artery connection.

Left ventricular diverticulum is an extremely rare anomaly, especially in the absence of other findings, and as such it has been rarely imaged, rarely seen intraoperatively, and has no standardized management algorithm. We report our suggested imaging and management in the context of previous management philosophies.

Resource and cost considerations in treating hypoplastic left heart syndrome

The primary extracardiac inferior cavopulmonary connection is an unusual novel palliation for single-ventricle physiology, which we first performed in the setting of unfavourable upper-body systemic venous anatomy for a standard bi-directional Glenn, and in lieu of leaving our patient with shunt-dependent physiology. After an initial 16-month satisfactory follow-up, increasing cyanosis led to the discovery of a veno-venous collateral that was coiled, but, more importantly, to impressive growth of a previously diminutive superior caval vein, which allowed us to perform completion Fontan with a good outcome. Performing the single-ventricle staging in a reverse manner, first from below with a primary inferior cavopulmonary connection, followed by Fontan completion from above with a standard superior caval vein bi-directional Glenn, is also possible when deemed necessary.

When the bi-directional Glenn is an unfavourable option: primary extracardiac inferior cavopulmonary connection as an alternative palliation

Hypoplastic left heart syndrome (HLHS) was a uniformly fatal diagnosis before 1983, when surgical treatment was first undertaken with the Norwood I operation as the first of 3-staged operations. Since then, operative survival rate of stage I has risen from 53% to over 90% in the current era, not only thanks to technical advances in surgery but also through prenatal diagnosis and imaging, enhanced cardiopulmonary bypass technology, better perioperative intensive care, and closer interstage monitoring. The improvements in patient outcomes achieved through rigorous multidisciplinary teamwork have come at a tremendous cost in manpower and resources, making HLHS still a challenge to all congenital heart programs, established or emerging. We review the various surgical steps to treat HLHS and their current expected outcomes, and put into perspective cost considerations compared to other more “simple” congenital heart defects.

Alternative strategies in newborns and infants with major co-morbidities to improve congenital heart surgery outcomes at an emerging programme.

The superior cavopulmonary anastomosis - bi-directional Glenn - is the standard palliation for single ventricle physiology. When upper body systemic venous anatomic concerns such as superior caval vein stenosis, hypoplasia, or inadequate collateral tributaries are present, a Glenn may be precluded or have a high risk of poor outcome. A primary inferior cavopulmonary connection with an extracardiac conduit is an alternative palliation that provides a generous pathway for pulmonary blood flow, with the additional benefit of including hepatic venous return. We report a case of primary extracardiac inferior cavopulmonary connection in a patient unsuitable for Glenn, with successful post-operative outcome and early follow-up.