Outcomes of minimally invasive isolated tricuspid valve repair and replacement through right mini-thoracotomy

Objective

Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR).

Methods

We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery.

Results

Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease.

Conclusions

A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.

Authorship Trends and Disparities in Cardiothoracic Surgery

BACKGROUND

Previous investigations have revealed significant gender disparities in the academic arenas of cardiothoracic surgery. However, the status of gender representation in cardiothoracic publications has not been well described. This study aimed to evaluate authorship trends by gender in two high-impact cardiothoracic surgical journals.

METHODS

In this bibliometric analysis, PubMed was searched for articles published in The Annals of Thoracic Surgery and the Journal of Thoracic and Cardiovascular Surgery from 2010 to 2021. The web-based application Genderize.io was used to classify names of first and last authors as men vs women. The Cochran-Armitage trend test and multivariable logistic regression were used to evaluate authorship per year and the association of first and last author gender, respectively.

RESULTS

Among 14,443 articles, 16.7% had women first authors and 8.1% had women last authors. The proportion of articles written by women authors increased, rising from 12.6% to 21.1% (P < .0001) for first and 5.4% to 11.5% (P < .0001) for last authors. Papers written with women as first author were associated with 2.0 higher odds of having a woman as last author (95% CI, 1.7-2.3; P < .0001). The mean number of last author publications was higher for men than for women (2.4 vs 1.7, P < .0001).

CONCLUSIONS

Over the past decade, despite a welcomed increase in women authorship in high-impact journals in cardiothoracic surgery, women represent a small proportion of published authors. Women first authors are more likely to publish with women last authors, demonstrating the impact of same-gender collaborations while emphasizing a need for cross-gender mentorship.

Demographics of Current and Aspiring Integrated Six-year Cardiothoracic Surgery Trainees

BACKGROUND

The integrated 6-year thoracic surgery (I-6) residency model was developed in part to promote early interest in cardiothoracic surgery in diverse trainees. To determine gaps in and opportunities for recruitment of women and minority groups in the pipeline for I-6 residency, we quantified rates of progression at each training level and trends over time.

METHODS

We obtained 2015 to 2019 medical student, I-6 applicant, and I-6 resident gender and race/ethnicity demographic data from the American Association of Medical Colleges and Electronic Residency Application Service public databases and Accreditation Council for Graduate Medical Education Data Resource Books. We performed χ², Fisher exact, and Cochran-Armitage tests for trend to compare 2015 and 2019.

RESULTS

Our cross-sectional analysis found increased representation of women and all non-White races/ethnicities, except Native American, at each training level from 2015 to 2019 (P < .001 for all). The greatest trends in increases were seen in the proportions of women (28% vs 22%, P = .46) and Asian/Pacific Islander (25% vs 15%, P = .08) applicants. There was also an increase in the proportions of women (28% vs 24%, P = .024) and White (61% vs 58%, P = .007) I-6 residents, with a trend for Asian/Pacific Islanders (20% vs 17%, P = .08). The proportions of Hispanic (5%) and Black/African American (2%) I-6 residents in 2019 remained low.

CONCLUSIONS

I-6 residency matriculation is not representative of medical student demographics and spotlights a need to foster early interest in cardiothoracic surgery among all groups underrepresented in medicine while ensuring that we mitigate bias in residency recruitment.

Endovascular therapy for patients with heritable thoracic aortic disease

BACKGROUND

Patients with genetic or heritable aortic conditions and thoracic aortic aneurysm syndrome often develop cardiovascular abnormalities originating at the aortic root and affecting the entire thoracoabdominal aorta. Although thoracic endovascular aortic repair (TEVAR) is usually avoided in these patients, TEVAR may be worthwhile for those at high risk for surgical complications and in certain emergency circumstances. We explored indications for TEVAR in patients with suspected or confirmed genetic or heritable aortic conditions and investigated early and mid-term outcomes.

METHODS

Our institutional aortic surgery database was queried for patients with suspected or confirmed Marfan syndrome, Loeys-Dietz syndrome, Ehlers-Danlos syndrome, Turner syndrome, neurofibromatosis, or familial aortic aneurysm and dissection who underwent TEVAR between February 1, 2002 and October 31, 2020. We extracted operative details and in-hospital, follow-up, and survival data.

RESULTS

Thirty-seven patients who underwent 40 endovascular interventions met the inclusion criteria; 25 previously underwent ascending aorta or aortic root surgery, and 21 previously underwent open thoracoabdominal surgery. Postoperative complications included respiratory failure (24.3%), cardiac complications (16.2%), renal failure (13.5%), tracheostomy (8.1%), and spinal cord ischemia (paraplegia/paraparesis) (8.1%). Follow-up ranged from 1.3 to 8.5 years (median: 3.6 years), with 15 deaths overall (three early/in-hospital). Thirteen patients (35.1%) had 22 repeat interventions (open and endovascular) post-TEVAR; five had the endograft removed.

CONCLUSIONS

Despite consensus that thoracic aneurysms in patients with genetic or heritable aortic conditions should be treated with conventional open surgery, the outcomes from our study suggest that TEVAR might be suitable in emergency settings or for patients in this population who are not candidates for open surgery, who are at high risk for reintervention, or who have a previously implanted Dacron graft. Nonetheless, lifelong surveillance is important for these patients after TEVAR to monitor for new dissection at distal or proximal landing zones, as repeat interventions are frequent.

Outcomes of cardiac surgical procedures performed by trainees versus consultants: A systematic review with meta-analysis

OBJECTIVES

Cardiac surgery is highly demanding and the ideal teaching method to reach competency is widely debated. Some studies have shown that surgical trainees can safely perform full operations with equivocal outcomes compared with their consultant colleagues while under supervision. We aimed to compare outcomes after cardiac surgery with supervised trainee involvement versus consultant-led procedures.

METHODS

We systematically reviewed databases (PubMed/MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Google Scholar) and reference lists of relevant articles for studies that compared outcomes of cardiac surgery performed by trainees versus consultants. Primary end points included: operative mortality, coronary events, neurological/renal complications, reoperation, permanent pacemaker implantation, and sternal complications. Secondary outcomes included cardiopulmonary bypass and aortic cross-clamp times and intensive care/in-hospital length of stay. Random effects meta-analysis was performed.

RESULTS

Thirty-three observational studies that reported on a total of 81,616 patients (trainee: 20,154; consultant: 61,462) were included. There was a difference favoring trainees in terms of operative mortality in the main analysis and in an analysis restricted to propensity score-matched samples, whereas other outcomes were not consistently different in both analyses. Overall cardiopulmonary bypass and aortic cross-clamp times were longer in the trainee group but did not translate in longer intensive care unit or hospital stay.

CONCLUSIONS

In the right conditions, good outcomes are possible in cardiac surgery with trainee involvement. Carefully designed training programs ensuring graduated hands-on operative exposure as primary operator with appropriate supervision is fundamental to maintain high-quality training in the development of excellent cardiac surgeons.

Demographic Landscape of Cardiothoracic Surgeons and Residents at United States Training Programs

BACKGROUND

Recruiting and promoting women and racial/ethnic minorities could help enhance diversity and inclusion in the academic cardiothoracic (CT) surgery workforce. However, the demographics of trainees and faculty at US training programs have not yet been studied.

METHODS

Traditional, integrated (I-6), and fast-track (4+3) programs listed in the Accreditation Council for Graduate Medical Education (ACGME) public database were analyzed. Demographics of trainees and surgeons, including gender, race/ethnicity, subspecialty, and academic appointment (if applicable), were obtained from ACGME Data Resource Books, institutional websites, and public profiles. Chi-square and Cochran-Armitage trend tests were performed.

RESULTS

In July 2020, 78 institutions had at least one CT surgery training program; 40 (51%) had only a traditional program, 20 (26%) traditional and I-6, 6 (8%) all three types of program, and 4 (5%) only I-6. The proportion of female trainees increased significantly from 2011 to 2019 (19% vs 24%, p<0.001), with female I-6 trainees outnumbering female traditional trainees since 2018. Significant increases by race/ethnicity were observed overall and by program type, notably for Asians and Hispanics in I-6 programs and Blacks in traditional programs. Finally, of the 1,175 CT surgeons identified, 633 (54%) were adult cardiac surgeons, 360 (37%) assistant professors, 116 (10%) women, and 33 (3%) Black.

CONCLUSIONS

The demographic landscape of CT surgery trainees and faculty across multiple training pathways reflects increasing representation by gender and race/ethnicity. However, we must continue to work toward equitable representation in the workforce to benefit the diverse patients we treat.

Impact of Psychiatric Comorbidities on Surgical Outcomes for Non-Small Cell Lung Cancer

BACKGROUND

Psychiatric comorbidities (PC) have been associated with poor surgical outcomes in several malignancies. However, the impact of PC on surgical outcomes for non-small cell lung cancer (NSCLC) remains largely unknown.

METHODS

NSCLC patients who underwent pulmonary resection at a single institution between 2006-2017 were included. Presence of preoperative PC was identified by documented diagnostic codes. Demographic, histopathologic, perioperative, and survival data were analyzed. Categorical variables were compared using chi-squared or Fisher's exact test. Overall and disease-free survival were analyzed using Kaplan-Meier method. Univariable and multivariable logistic regression analyses were performed for 30-day readmission.

RESULTS

Among 2907 patients, PC were present preoperatively in 180 (6%), including 130 (72%) anxiety, 52 (29%) depression, 28 (16%) adjustment disorder, 16 (9%) alcohol abuse, 8 (4%) sleep disorder, and 3 (2%) schizophrenia. Patients with PC were younger, with fewer cardiovascular complications. There were no differences in length of stay. However, PC led to increased 30-day readmission (12% vs 6%, p=0.004). Reasons for readmission did not differ between groups (p=0.679). Upon multivariable analysis, PC independently predicted 30-day readmission (OR: 2.00, p=0.005). Importantly, there were no differences in 30- or 90-day mortality (p=0.495 and 0.748, respectively), overall survival (p=0.439), or disease-free survival (p=0.924).

CONCLUSIONS

NSCLC patients with and without PC experienced similar perioperative and long-term outcomes, suggesting that individuals should not be denied surgical care on the basis of such comorbidities. However, further research should seek to identify reasons for increased risk of readmission for patients with PC and validate these findings in other settings.

Routine intraoperative jejunostomy placement and minimally invasive oesophagectomy: an unnecessary step?†

OBJECTIVES

Adequate nutrition is challenging after oesophagectomy. A jejunostomy is commonly placed during oesophagectomy for nutritional support. However, some patients develop jejunostomy-related complications and the benefit over oral nutrition alone is unclear. This study aims to assess jejunostomy-related complications and the impact of intraoperative jejunostomy placement on weight loss and perioperative outcomes in patients with oesophageal cancer treated with minimally invasive Ivor Lewis oesophagectomy (MIE).

METHODS

From a prospectively maintained database, patients were identified who underwent MIE with gastric reconstruction. Between 2007 and 2016, a jejunostomy was routinely placed during MIE. After 2016, a jejunostomy was not utilized. Postoperative feeding was performed according to a standardized protocol and similar for both groups. The primary outcomes were jejunostomy-related complications, relative weight loss at 3 and 6 months postoperative and perioperative outcomes, including anastomotic leak, pneumonia and length of stay, respectively.

RESULTS

A total of 188 patients were included, of whom 135 patients (72%) received a jejunostomy. Ten patients (7.4%) developed jejunostomy-related complications, of whom 30% developed more than 1 complication. There was no significant difference in weight loss between groups at 3 months (P = 0.73) and 6 months postoperatively (P = 0.68) and in perioperative outcomes (P-value >0.999, P = 0.591 and P = 0.513, respectively).

CONCLUSIONS

The use of a routine intraoperative jejunostomy appears to be an unnecessary step in patients undergoing MIE. Intraoperative jejunostomy placement is associated with complications without improving weight loss or perioperative outcomes. Its use should be tailored to individual patient characteristics. Early oral nutrition allows patients to maintain an adequate nutritional status.

Aortic valve replacement using stented or sutureless/rapid deployment prosthesis via either full-sternotomy or a minimally invasive approach: a network meta-analysis

Background

New technologies such as sutureless or rapid deployment prosthetic valves and access via minimally invasive incisions offer alternatives to traditional full-sternotomy aortic valve replacement (SAVR). However, a comprehensive comparison of these surgical techniques along with alternative valve prosthesis has not been completed.

Methods

Electronic databases were searched for studies comparing outcomes for SAVR, minimally invasive AVR (MiAVR), sutureless/rapid-deployment AVR (SuAVR) via full-sternotomy, or minimally invasive SuAVR (MiSuAVR) from their inception until September 2018. Early postoperative outcomes and follow-up data were included in a Bayesian network meta-analysis.

Results

Twenty-three studies with 8,718 patients were identified. Compared with standard SAVR, SuAVR had significantly lower incidence of postoperative AF [odds ratio (OR) 0.33, 95% confidence interval (CI): 0.14-0.79, P=0.013] and MiSuAVR greater requirement for postoperative permanent pacemaker (OR 2.27, 95% CI: 1.25-4.14, P=0.008). All sutureless/rapid-deployment procedures had reduced cardiopulmonary bypass and cross-clamp times, by a mean of 25.9 and 25.0 min, respectively. Hospital length of stay (LOS), but not intensive care LOS, was reduced for all groups (MiAVR -1.53 days, MiSuAVR -2.79 days, and SuAVR 3.37 days). A signal towards reduced early mortality, wound infections, and acute kidney injury was noted in both sutureless/rapid-deployment and minimally invasive techniques but did not achieve significance. Sutureless/rapid-deployment procedures had favourable survival and freedom from valve related reoperation, however follow-up times were short and demonstrated significant heterogeneity between intervention groups.

Conclusions

Minimally invasive and sutureless techniques demonstrate equivalent early postoperative outcomes to SAVR and may reduce ventilation time, hospital LOS and postoperative atrial fibrillation (POAF) burden.

Brachiocephalic vein aneurysm: a systematic review of the literature

Brachiocephalic vein aneurysms are rare lesions with only 36 cases reported in the literature. They usually present incidentally as mediastinal widening on chest X-ray, with thromboembolism or mass effect on adjacent structures, or rupture. Imaging is usually sufficient to identify and characterize the aneurysm, however, certain diagnostic pitfalls can lead to misinterpretation and misdiagnosis. Exploratory surgery is sometimes needed to confirm diagnosis. Brachiocephalic vein aneurysms have been treated both conservatively with watchful waiting, antithrombotic therapy or anticoagulation as well as surgically depending on patient presentation and aneurysm characteristics. Endovascular treatment is also becoming a therapeutic option. Prognosis following surgical treatment is excellent with no reported cases of recurrence. The present systematic review aims to describe the etiology, clinical presentation, diagnosis, management and outcomes of brachiocephalic vein aneurysms.

Representation of Women in the Southern Thoracic Surgical Association: Evidence for Positive Change

BACKGROUND

Despite increases in female representation within the cardiothoracic surgical workforce and societal memberships, our previous work has demonstrated that at the national level, women's roles have remained stagnant among conference presentations and leadership opportunities. In this study, we sought to identify whether similar findings exist at the regional level, specifically within the Southern Thoracic Surgical Association (STSA).

METHODS

STSA Annual Meeting Program Books from 2003, 2008, 2013, and 2018 were reviewed for women's representation among oral abstract authors, invited speakers, moderators, STSA leadership, and award recipients. Differences between the sexes and time points were assessed with χ² analyses and t tests, respectively.

RESULTS

In 2003, women accounted for 4 of 102 authors (3.9%), including 2 of 51 (3.9%) presenting and 2 of 51 (3.9%) senior roles. From 2003 to 2018, increases in female authorship were observed, with 18 of 85 (21.2%) presenting and 13 of 85 (15.3%) senior author positions filled by women (P = .017 and P = .072, respectively). Compared with men, women consistently accounted for fewer invited speakers (P < .050 for all years). Although women represented fewer session moderators (P < .050 for all years), a significant increase was observed over time, from 0 of 2 (0.0%) in 2003 to 18 of 105 (17.1%) in 2018 (P = .009). Compared with 2003, women also increased significantly among STSA committee members in 2018 (0 of 7 [0.0%] vs 6 of 40 [15.0%], P < .001).

CONCLUSIONS

Over the last 15 years, women have been increasingly represented among STSA Annual Meeting presenting authors, session moderators, and committee members. However, opportunity for greater emphasis on diversity and inclusion exists, particularly among invited speakers and STSA leadership.

Correction: The state of the antivaccine movement in the United States: A focused examination of nonmedical exemptions in states and counties

[This corrects the article DOI: 10.1371/journal.pmed.1002578.].

Abstract 34: Acetylation of GATA 4 Enhanced Direct Cardiac Reprogramming of Induced Cardiomyocytes

Objective: Direct reprogramming of fibroblasts into induced cardiomyocytes (iCMs) by forced expression of cardiomyogenic factors, GMT (GATA4, Mef2c and Tbx5), has recently been demonstrated, suggesting a promising statregy for cardiac regeneration. However, the efficiency of direct reprogramming is usually relatively low and requires extensive epigenetic redesigning, although the underlying mechanism are largely unknown.

Methods: In a recent study, we created a novel mutation in rat GATA 4 by replacing lysine residue with glutamine at position 299 i.e. (K299Q), to mimic constitutive acetylation and examined whether constitutive acetylation of GATA4, when compared with wild type GATA4, further enhance GMT-mediated direct reprogramming efficiency of induced cardiomyocytes in vitro and accordingly ventricular function after myocardial infarction in rat, in vivo .

Results: We found that acetylated GATA 4 (K299Q), in the presence of Mef2c and Tbx5 upregulated cardiac-specific markers, suppressed fibroblast genes, in rat cardiac fibroblasts (RCFs) more efficiently when compared with Mef2c, Tbx5 plus wild type GATA4. FACS analyses revealed that G(K299Q) MT induced significantly more cardiomyocyte marker cardiac troponin T (cTnT) expression compared with GMT alone. Mechanistic studies demonstrated that the K299Q substitution, resulting in enriched p300 occupancy at the GATA 4 promoter, induced acetylation of Histine 3, decreased HDAC expression. In addition, substitution augmented the increase in an acetylated form of GATA-4 and its DNA binding and transcriptional activity, compared with wildtype GATA 4. In agreement with upregulated cTNT gene expression in vitro , echocardiographic analysis demonstrate that the acetylated G(K299Q) MT vectors have improved effect in enhancing ventricular function than GMT vectors from postinfarct baselines as compared to negative control [G(K299Q) MT, 15.6% ± 2.7%; G(WT)MT, 12.8% ± 1.7%; GFP, -2.3% ± 1.1%].

Conclusions: Collectivily, these data indicate that acetylated GATA4 (K299Q) significantly increases reprogramming efficiency of induced cardiomyocytes (iCMs), in vitro and in vivo, and provide new insight into the molecular mechanism underlying cardiac regeneration.

Abstract 192: Persistence of First Generation Adenovirus in the Myocardium: Refuting Old Dogma

Introduction: Adenovirus (Ad) vectors do not integrate into host genomes and thus offer clinical benefits as non-mutagenic, acute-term gene delivery vehicles. One limitation to Ad vector use is the transient duration of transgene expression, supposedly resulting from immune-mediated cytolysis of Ad-infected cells. Our recent observation of Ad-induced transdifferentiation of infected cardiac fibroblasts into induced cardiomyocytes over 28 days in vivo called this premise into question. Therefore, we hypothesized that Ad remains in the myocardium for over 28 days and, to our knowledge, are the first to suggest alternate mechanisms for this persistence.

Methods and Results: Ad encoding green fluorescent protein (AdGFP) or mock was administered via intramyocardial injection into Sprague-Dawley rats, and Ad genome and GFP expression were analyzed 3 or 28 days later (n=6 per group, 3 euthanized at each time point). Polymerase chain reaction typing and amplicon sequencing confirmed the presence of Ad DNA in all 6 treated animals. Quantitative real time polymerase chain reaction assays further demonstrated more than a three-fold increase in Ad DNA levels at both days 3 and 28 compared to untreated control animals (3.41±1.40 and 3.37±1.23, respectively). Thus, at 28 days Ad DNA persisted at a high level comparable to that which was present at 3 days. Next, AdGFP expression and host immune response were characterized by fluorescence microscopy and histology. We found that GFP-expressing cells decreased five-fold by 28 days (49±9 v. 3±0 cells). In addition, hematoxylin and eosin staining showed minimal infiltrating mononuclear inflammatory cells in AdGFP and mock-treated animals at both time points.

Conclusions: Ad DNA and infected host cell persistence suggests that host-mediated cytolysis may not be responsible for the downregulation of transgene expression, indicating that Ad vectors may consequently be useful for therapies like cellular reprogramming wherein host cell persistence is required.