Walter F. DeNino

Resident Perceptions of 2-Year Versus 3-Year Cardiothoracic Training Programs

BACKGROUND Resident perceptions of 2-year (2Y) vs 3-year (3Y) programs have never been characterized. The objective was to use the mandatory Thoracic Surgery Residents Association and Thoracic Surgery Directors Association In-Training Examination survey to compare perceptions of residents graduating from 2Y vs 3Y cardiothoracic programs. METHODS Each year Accreditation Council for Graduate Medical Education cardiothoracic residents are required to take a 30-question survey designed by the Thoracic Surgery Residents Association and the Thoracic Surgery Directors Association accompanying the In-Training Examination with a 100% response rate. The 2013 and 2014 survey responses of residents graduating from 2Y vs 3Y training programs were compared. The Wilcoxon signed rank test was used to analyze ordinal and interval data. RESULTS Graduating residents completed 167 surveys, including 96 from 2Y (56%) and 71 from 3Y (43%) programs. There was no difference in the perception of being prepared for the American Board of Thoracic Surgery examinations or amount of debt between 2Y and 3Y respondents. There was no difference in intended academic vs private practice. Graduating 3Y residents felt more prepared to meet case requirements and better trained, were more likely to pass their written American Board of Thoracic Surgery examinations, and were less likely to pursue additional training beyond their cardiothoracic residency. CONCLUSIONS There was no difference in field of interest, practice type, and amount of debt between graduating 2Y vs 3Y residents. Respondents from 2Y programs expressed more difficulty in meeting case requirements, whereas residents from 3Y programs felt more prepared for independent practice and had higher American Board of Thoracic Surgery written pass rates.

Comparison of David V valve-sparing root replacement and bioprosthetic valve conduit for aortic root aneurysm

OBJECTIVE Valve sparing root replacement (VSRR) is an attractive option for the management of aortic root aneurysms with a normal native aortic valve. Therefore, we reviewed our experience with a modification of the David V VSRR and compared it with stented pericardial bioprosthetic valve conduit (BVC) root replacement in an age-matched cohort of older patients. METHODS A total of 48 VSRRs were performed at our institution, excluding those on bicuspid aortic valves. We compared these cases with 15 aortic root replacements performed using a BVC during the same period. Subgroup analysis was performed comparing 16 VSRR cases and 15 age-matched BVC cases. RESULTS The greatest disparity between the VSRR and BVC groups was age (53 vs 69 years, respectively; P < .0005). The matched patients were similar in terms of baseline demographics and differed only in concomitant coronary artery bypass grafting (2 VSRR vs 7 BVC patients; P = .036). None of the VSRR and 3 of the BVC procedures were performed for associated dissection (P = .101). Postoperative aortic insufficiency grade was significantly different between the 2 groups (P = .004). The cardiopulmonary bypass, crossclamp, and circulatory arrest times were not different between the VSRR and BVC groups (174 vs 187 minutes, P = .205; 128 vs 133 minutes, P = .376; and 10 vs 13 minutes, respectively; P = .175). No differences were found between the 2 groups with respect to postoperative complications. One postoperative death occurred in the BVC group and none in the VSRR group. The postoperative length of stay and aortic valve gradients were less in the VSRR group (6 vs 8 days, P = .038; 6 vs 11.4 mm Hg, P = .001). The intensive care unit length of stay was significantly less in the VSRR group (54 vs 110 hours, P = .001). CONCLUSIONS VSRR is an effective alternative to the BVC for aortic root aneurysm.

Orthotopic heart transplantation after left ventricular assist device implantation and laparoscopic Roux-en-Y gastric bypass.

growth factor. The mTOR pathway is highly active in HHV-8–infected KS cells, and mTOR inhibitors have been shown to inhibit the production as well as the effect of vascular endothelial growth factor. More recently, mTOR inhibitor was found to inhibit HHV-8 replication. Accordingly, mTOR inhibitors have been recommended for the treatment of KS lesions in transplant recipients, and a switch to mTOR inhibitor is recommended, as was done in the present patient. Successful treatment of malignancies in transplant recipients will invariably require a reduction in immunosuppression and hence the risk of allograft rejection. In our patient, the change in therapy may have triggered bronchiolitis obliterans syndrome, although the two events may be unrelated. Renal function is likely to have benefited from a reduced trough level of ciclosporin. Although the combination of mTOR inhibitor and reduced ancillary immunosuppression resulted in tumor regression, the long-term effects of this approach on the outcome of the lung allograft may be compromised and require close vigilance and follow-up.

The effect of ultrafiltration with cardiopulmonary bypass on the removal of dabigatran from the circulation of adult pigs

Objective: Dabigatran etexilate is a direct thrombin inhibitor approved for use in patients with non-valvular atrial fibrillation. There is no currently available pharmacological therapy to reverse this renally cleared anticoagulant. Dabigatran has a low level of plasma protein binding and has been considered dialyzable. We used a pig model with renal artery ligation to exclude intrinsic drug excretion to examine the efficacy of ultrafiltration (UF) during cardiopulmonary bypass (CPB) for dabigatran removal. Method: Dabigatran was intravenously infused (20 mg) in Yorkshire pigs (male, n=7, 70±1 kg) following renal artery ligation. CPB with UF was initiated after heparinization and continued until a total volume of 6 liters of UF effluent was removed. Serial labs, including dabigatran concentration, activated coagulation times (ACT), hematocrit and creatinine were drawn at intervals before the start of CPB and then incrementally during UF (0, 2, 4 and 6 L removed). Hemodialysis (HD) was performed on one animal following UF. Results: Dabigatran concentration (ng/mL) rose from undetectable levels at baseline to 296±70 (p<0.05) at the conclusion of infusion, but dropped significantly upon administration of heparin (178±40, p<0.05). A further decrement in dabigatran concentration was observed from the administration of heparin to the start of CPB (to 135±28, p<0.05). Once on CPB, dabigatran remained stable, with the end UF (eUF) dabigatran concentration being 133±34. Dabigatran concentration in the UF effluent was measured in one animal and was 98.8, with 6 L of effluent having been removed. The total recovery of dabigatran was calculated to be less than 5%. Dabigatran concentrations also did not decrease appreciably with HD on CPB following UF. Conclusions: UF in conjunction with CPB was ineffective at removing dabigatran. Heparin demonstrated a dabigatran-lowering effect, suggesting a possible drug interaction or assay impairment. Based on these findings, emergent cardiac surgery with UF on cardiopulmonary bypass to remove dabigatran is not advisable. Alternative forms of drug removal or reversal must be identified.

Aspirin resistance: A role in left ventricular assist device thrombosis?

From the Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC; and the Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication June 26, 2015; revisions received Aug 13, 2015; accepted for publication Aug 18, 2015. Address for reprints: John S. Ikonomidis, MD, PhD, FRCS(C), FACS, FAHA, FACC, Horace G. Smithy Professor, Chief, Division of Cardiothoracic Surgery, Director, South Carolina Heart Valve Center, Director, Heart and Vascular Service Line, Medical University of South Carolina, Suite BM 282, 114 Doughty St, Charleston, SC 29425-2950 (E-mail: ikonomij@musc.edu). J Thorac Cardiovasc Surg 2015;-:e1-2 0022-5223/

Predictors of Career Choice Among Cardiothoracic Surgery Trainees

36.00 Copyright 2015 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.08.060 HeartMate II rotor with gross thrombus at the time of pump exchange.

Assessment of Bleeding and Thrombosis Based on Aspirin Responsiveness after Continuous-Flow Left Ventricular Assist Device Placement

BACKGROUND The impact of factors influencing career choice by cardiothoracic surgery (CTS) trainees remains poorly defined in the modern era. We sought to examine the associations between CTS trainee characteristics and future career aspirations. METHODS The 2012 Thoracic Surgery In-Training Examination survey results were used to categorize responders according to career interest: congenital, adult cardiac, mixed cardiac/thoracic, and general thoracic surgery. Univariate and multivariable analyses were used to identify and analyze characteristics associated with career interest categories. RESULTS With a 100% response rate, 300 responses from trainees in programs accredited by the Accreditation Council for Graduate Medical Education were included in the analysis. Multinomial logistic regression identified three factors associated with career choice in CTS: level of training (p < 0.001), type of training pathway (p < 0.001), and primary motivating factor to pursue CTS (p = 0.002). Trainees interested in general thoracic surgery were more likely to commit to CTS during their senior years of general surgery training and were more likely to enroll in 2-year or 3-year traditional fellowships, whereas individuals pursuing adult or congenital cardiac surgery were more likely to commit earlier during training and were more commonly interested in 6-year integrated or joint training pathways. Moreover, trainees interested in general thoracic surgery were predominantly influenced by early mentorship (p = 0.025 vs adult cardiac), and trainees interested in adult cardiac surgery were more likely to be influenced by types of operations (p = 0.047 vs general thoracic). CONCLUSIONS Career choice in CTS appears strongly associated with level of training, exposure to mentors, and training paradigm. These results demonstrate the importance of maintaining all four currently approved training pathways to retain balance and diversity in future CTS practices.

Recurrent esophagopericardial fistula in a patient with human immunodeficiency virus

Pump thrombosis (PT) is a severe complication of left ventricular assist device (LVAD) support. This study evaluated PT and bleeding after LVAD placement in patients responsive to a standard aspirin dose of 81 mg using platelet inhibition monitoring compared with initial nonresponders who were then titrated upward to achieve therapeutic response. Patients ≥ 18 years of age with initial placement of HeartMate II LVAD at our institution and at least one VerifyNow Aspirin test performed during initial hospitalization were included. The primary endpoints were bleeding and PT compared between initial aspirin responders and nonresponders. Of 85 patients, 19 (22%) were nonresponsive to initial aspirin therapy. Responders and nonresponders showed similar survival (p = 0.082), freedom from suspected/confirmed PT (p = 0.941), confirmed PT (p = 0.273), bleeding (p = 0.401), and incidence rates in PT and bleeding. Among the initial responders (<500 vs. 500–549 aspirin reaction units), there were no significant differences in survival (p = 0.177), freedom from suspected/confirmed PT (p = 0.542), confirmed PT (p = 0.159), bleeding (p = 0.879), and incidence of PT and bleeding. Platelet function testing may detect resistance to standard aspirin regimens used in LVAD patients. Dose escalation in initially nonresponsive patients to achieve responsiveness may confer a similar PT risk to patients initially responsive to standard aspirin dosing without increased bleeding risk.

Transition from ECMO to left ventricular support via trans-septal cannula using a single CentriMag device

FIGURE 1. The diagnostic esophagogram showed contrast extravasation fro From the Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Oct 23, 2013; revisions received Dec 8, 2013; accepted for publication Dec 13, 2013; available ahead of print Feb 7, 2014. Address for reprints: Chadrick E. Denlinger, MD, 25 Courtenay Dr ART Suite 7018, Charleston, SC 29425 (E-mail: denlinge@musc.edu). J Thorac Cardiovasc Surg 2014;147:e48-9 0022-5223/

Mechanical Aortic Valve Without Anticoagulation or Mechanical Failure for 24 Years

36.00 Copyright 2014 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2013.12.057