Background: Social media may be a useful supplement to physician and trainee interaction... more Background: Social media may be a useful supplement to physician and trainee interactions; however, its role in enhancing mentorship has not been described.
Methods: A 35-item survey investigating trainee and physician social media use was distributed. Responses were analyzed using descriptive statistics.
Results: 282 respondents completed the survey, among whom 136 (48.2%) reported careers in surgical specialties. Women in surgical specialties were more likely to describe the specialty as being dominated by the opposite sex (p < 0.001) and to be mentored by the opposite sex though wish to be mentored by individuals of the same sex (p < 0.001). Respondents in surgical specialties were also more likely to report using social media to build a network of same-sex mentorship (p = 0.031).
Conclusions: Social media serves as a valuable tool to enhance the networking and mentorship of surgeons, particularly for women in surgical specialties who may lack exposure to same-sex mentors at their own institution.
This chapter examines the etiology, diagnostic techniques, and treatment approaches of anastomoti... more This chapter examines the etiology, diagnostic techniques, and treatment approaches of anastomotic complications after esophagectomy. An understanding of these much feared events may help mitigate the impact of the associated negative clinical sequelae. Anastomotic leak has a wide variation in presentation, from an incidental radiologic finding to a catastrophic septic event. Patients should be adequately resucitated, and further management is dependent upon the location of the leak and clinical presentation. Mild cases may be observed or managed with local drainage. The most severe cases are conduit necrosis. In suspected cases, direct visualization of the conduit is necessary, and subsequent resection must be performed if the diagnosis is confirmed. Anastomotic leak is a frequent cause of anastomotic stricture; however, later presentation must raise suspicion for tumor recurrence. In benign cases, endoscopic dilation is often sufficient. Leaks are also a frequent cause of conduit airway fistulas. Such events are rare but are life threatening and must rapidly be identified. In such cases, a trial of conservative treatment may be pursued with subsequent endoscopic therapy and, ultimately, surgical resection if this is not successful.
Purpose: Transplant coronary artery vasculopathy (TCAV) is the major cause of late allograft fail... more Purpose: Transplant coronary artery vasculopathy (TCAV) is the major cause of late allograft failure and death in heart transplant recipients. The aim of this systematic review was to examine the outcomes of percutaneous coronary interventions (PCI) as compared to coronary artery bypass grafting surgery (CABG) in the management of TCAV. Our secondary objective was to compare the use and outcomes of drug eluting stents (DES) as compared to bare metal stents (BMS) in this patient population. Methods: Electronic search was performed to identify all studies in the English literature examining PCI as compared to CABG for TCAV in heart transplant recipients. All identified articles were systematically assessed for inclusion and exclusion criteria. Results: Of the 4989 studies identified, 29 studies were included. Among 1520 patients who developed TCAV, 1470 patients underwent PCI and 50 patients underwent CABG. There were no significant differences in baseline demographics and comorbidities among the PCI and CABG cohorts. Compared to the PCI cohort, patients who underwent CABG had a higher early mortality (CABG 36.4% vs PCI 4.3%, p<0.001) and overall mortality (CABG 42.3% vs PCI 21.4%, p=0.049). When comparing DES versus BMS cohorts, there were no significant differences in the rate of in-stent stenosis (DES14.5% vs BMS 24.4%, p=0.476), overall mortality (DES 17.4% vs BMS 30.8%, p= 0.302) or cardiac related mortality (DES 7.7% vs BMS 21.8%, p=0.415). Conclusion: CABG and PCI are both feasible modalities for revascularization in patients with TCAV where PCI is associated with lower mortality. There were no differences in outcomes among patients who underwent PCI with DES as compared to BMS. Potential bias may exist due to heterogeneity in available data. Further studies are needed to delineate evidence-based guidelines to tailor the appropriate therapy, CABG or PCI, to the appropriate patient.
Background: Long-term efficacy of heart retransplantation (RTx) for end-stage cardiac allograft f... more Background: Long-term efficacy of heart retransplantation (RTx) for end-stage cardiac allograft failure remains unclear given the limited worldwide experience and is an important question to elucidate given the shortage of donor organs. The aim of this systematic review was to examine the outcomes of RTx in patients with cardiac allograft failure. Methods: Electronic search was performed to identify all studies in the English literature assessing RTx for cardiac allograft failure. All identified articles were systematically assessed for inclusion and exclusion criteria. Results: 11 studies were included for analysis, with a total of 7791 patients. 7446 patients underwent primary heart transplant (HTx) whereas 345 patients underwent RTx with average time from primary HTx to RTx interval of 5.03 years (95% CI 3.13-6.94). 35.2 % of patients received RTx within 30 days of primary transplant. Early mortality was significantly higher among RTx patients (RTx 28.2% vs HTx 11.2%, p<0.001) whereas survival was significantly higher among HTx patients when compared to RTx patients at 1 year (HTx 81.8% vs RTx 59.1%, p<0.001), 2 years (HTx 77.9% vs RTx 53.6%, p<0.001), 3 years (HTx 76.1% vs RTx 49.8%, p<0.001), 5 years (HTx 68.8% vs RTx 41.4%, p<0.001) and 10 years (HTx 53.9% vs RTx 31.7%, p<0.001). There were no significant differences between HTx and RTx in terms of freedom from rejection at 1 year (HTx 61% vs RTx 53.7%, p=0.43), 2 years (HTx 63.8% vs RTx 53.7%, p=0.26), 3 years (HTx 62.9% vs RTx 51.9%, p=0.3) and 5 years (HTx 61% vs RTx 51.9%, p=0.36). Conclusions: Patients who underwent heart RTx had a significant lower survival when compared to those who only underwent primary HTx. There were no significant differences in post-transplantation freedom from rejection. Careful patient selection and perioperative care can make heart RTx a viable option for selected recipients.
Driveline infections (DLIs) remain a major source of morbidity for patients requiring long-term v... more Driveline infections (DLIs) remain a major source of morbidity for patients requiring long-term ventricular assist device (VAD) support. We aimed to assess whether VAD driveline exit site (DLES) (abdomen versus chest wall) is associated with DLI. All adult patients who underwent insertion of a HeartWare HVAD or HeartMate II (HMII) between 2009 and 2016 were included. Driveline infection was defined as clinical evidence of DLI accompanied by a positive bacterial swab and need for antibiotics. Competing risks analysis was used to assess the association between patient characteristics and DLI. Ninety-two devices (59 HMII) were implanted in 85 patients (72 men; median age 57.4 years) for bridge to transplant or destination therapy. VAD DLES was chest in 28 (30.4%) devices. Median time on VAD support was 347.5 days (IQR 145.5, 757.5), with 28 transplants and 29 deaths (27 on device). DLI occurred in 24 patients (25 devices) at a median of 140 days (IQR 67, 314) from implant. Staphylococcus aureus accounted for 15 infections (60%). Freedom from infection was 72.8% (95% confidence interval [CI] 53.1–78.0%) at 1 year and 41.9% (95% CI 21.1–61.5%) at 3 years. In competing risks regression, abdominal DLES was not predictive of DLI (hazard ratio, HR 1.65 [95% CI 0.63, 4.29]), but body mass index (BMI) >30 kg/m 2 was (HR 2.72 [95% CI 1.25, 5.92]). In conclusion, risk of DLI is high among patients on long-term VAD support, and a nonabdominal DLES does not reduce this risk. The only predictor of DLI in this series was an elevated BMI. ASAIO Journal 2017; XX:00–00.
Total artificial hearts (TAH) can be used as a bridge to transplant or, occasionally, as destinat... more Total artificial hearts (TAH) can be used as a bridge to transplant or, occasionally, as destination therapy for patients with severe biventricular dysfunction. Not infrequently TAHs are placed in patients with severe low flow states, in which the lungs of these patients are unable to adjust rapidly to the "normal" right ventricular output of a TAH. These patients may develop variable degrees of pulmonary edema secondary to stress failure of the pulmonary capillaries requiring increased respiratory support, which can occasionally be fatal. In this "how to do it" article, we describe the technique for a pulmonary arteriovenous extracorporeal membrane oxygenation with TAH to avoid sudden pulmonary overflow and gradually expose the lungs to increasing flow.
Purpose: The current 1-dimensional fluid structure interaction model (FSI) for understanding cere... more Purpose: The current 1-dimensional fluid structure interaction model (FSI) for understanding cerebrospinal fluid (CSF) circulation requires pulsatility as a precondition and has not been applied to patients with continuous-flow left ventricular assist devices (CF-LVAD) where pulsatility is chronically reduced. Our study aims to characterize the behavior of CSF pressure and flow in patients with CF-LVADs using a computational FSI model.
Methods: Utilizing the computational FSI model, CSF production in choroid plexuses of the 4 ventricles was specified as a boundary condition for the model. The other source of production from capillary ultrafiltrate spaces was accounted for by the mass conservation equation. The primary CSF absorption sites (i.e., arachnoid granulations) were treated as the outlet boundary conditions. We established a low pulse wave to represent patients with a CF-LVAD.
Results: From the model, low pulse conditions resulted in a reduction in CSF pressure amplitude and velocity though the overall flow rate was unchanged.
Conclusions: The existing FSI model is not a suitable representation of CSF flow in CF-LVAD patients. More studies are needed to elucidate the role of pulsatility in CSF flow and the compensatory changes in CSF production and absorption that occur in patients with CF-LVADs in whom pulsatility is diminished.
Background: Available cardiac surgery risk scores have not been validated in octogenarians. Our o... more Background: Available cardiac surgery risk scores have not been validated in octogenarians. Our objective was to compare the predictive ability of the Society of Thoracic Surgeons (STS) score, EuroSCORE I, and EuroSCORE II in elderly patients undergoing isolated coronary artery bypass grafting surgery (CABG). Methods: All patients who underwent isolated CABG (2002 – 2008) were identified from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry. All patients aged 80 and older (n = 304) were then matched 1:2 with a randomly selected control group of patients under age 80 (n = 608 of 4732). Risk scores were calculated. Discriminatory accuracy of the risk models was assessed by plotting the areas under the receiver operator characteristic (AUC) and comparing the observed to predicted operative mortality. Results: Octogenarians had a significantly higher predicted mortality by STS Score (3 ± 2% vs. 1 ± 1%; p < 0.001), additive EuroSCORE (8 ± 3% vs. 4 ± 3%; p < 0.001), logistic EuroSCORE (15 ± 14% vs. 5 ± 6%; p < 0.001), and EuroSCORE II (4 ± 3% vs. 2 ± 2%; p < 0.001) compared to patients under age 80 years. Observed mortality was 2% and 1% for patients age 80 and older and under age 80, respectively (p = 0.323). AUC revealed areas for STS, additive and logistic EuroSCORE I and EuroSCORE II, respectively, for patients age 80 and older (0.671, 0.709, 0.694, 0.794) and under age 80 (0.829, 0.750, 0.785, 0.845). Conclusion: All risk prediction models assessed overestimated surgical risk, particularly in octogenarians. EuroSCORE II demonstrated better discriminatory accuracy in this population. Inclusion of new variables into these risk models, such as frailty, may allow for more accurate prediction of true operative risk.
Background. Donation after circulatory death (DCD) has the potential to significantly alleviate t... more Background. Donation after circulatory death (DCD) has the potential to significantly alleviate the shortage of transplantable lungs. We report our initial experience with the use of portable ex vivo lung perfusion (EVLP) with the Organ Care System Lung device for evaluation of DCD lungs. Methods. We performed a retrospective review of the DCD lung transplantation (LTx) experience at a single institution through the use of a prospective database. Results. From 2011 to 2015, 208 LTx were performed at the University of Alberta, of which 11 were DCD LTx with 7 (64%) that underwent portable EVLP. DCD lungs preserved with portable EVLP had a significantly shorter cold ischemic time (161 � 44 vs 234 � 60 minutes, P = .045), lower grade of primary graft dysfunction at 72 hours after LTx (0.4 � +/- 0.5 vs 2.1 � +/- 0.7, P = .003), similar mechanical ventilation time (55 � +/- 44 vs 103 � +/- 97 hours, P = .281), and hospital length of stay (29 � +/- 11 vs 33 � +/- 10 days, P = .610). All patients were alive at 1-year follow-up after LTx with improved functional outcomes and acceptable quality of life compared with before LTx, although there were no intergroup differences. Conclusions. In our pilot cohort, portable EVLP was a feasible modality to increase confidence in the use of DCD lungs with validated objective evidence of lung function during EVLP that translates to acceptable clinical outcomes and quality of life after LTx. Further studies are needed to validate these initial findings in a larger cohort.
Graft dysfunction is the main cause of early mortality after heart transplantation. In cases of s... more Graft dysfunction is the main cause of early mortality after heart transplantation. In cases of severe graft dysfunction, temporary mechanical circulatory support (TMCS) may be necessary. The aim of this systematic review was to examine the utilization and outcomes of TMCS in patients with graft dysfunction after heart transplantation. Electronic search was performed to identify all studies in the English literature assessing the use of TMCS for graft dysfunction. All identified articles were systematically assessed for inclusion and exclusion criteria. Of the 5,462 studies identified, 41 studies were included. Among the 11,555 patients undergoing heart transplantation, 695 (6.0%) required TMCS with patients most often supported using venoarterial extracorporeal membrane oxygenation (79.4%) followed by right ventricular assist devices (11.1%), biventricular assist devices (BiVADs) (7.5%), and left ven-tricular assist devices (LVADs) (2.0%). Patients supported by LVADs were more likely to be supported longer (p = 0.003), have a higher death by cardiac event (p = 0.013) and retrans-plantation rate (p = 0.015). In contrast, patients supported with BiVAD and LVAD were more likely to be weaned off support (p = 0.020). Overall, no significant difference was found in pooled 30 day survival (p = 0.31), survival to discharge (p = 0.19), and overall survival (p = 0.51) between the subgroups. Temporary mechanical circulatory support is an effective modality to support patients with graft dysfunction after heart transplantation. Further studies are needed to establish the optimal threshold and strategy for TMCS and to augment cardiac recovery and long-term survival. ASAIO Journal 2017; XX:00–00.
Primary cardiac tumors are uncommon clinical entities with an incidence of 0.0017% to 0.03% of al... more Primary cardiac tumors are uncommon clinical entities with an incidence of 0.0017% to 0.03% of all autopsies. Cystic tumor of the atrioventricular (AV) node, also known as mesothelioma of the AV node, is a benign congenital tumor that is located in the triangle of Koch in the AV nodal region of the atrial septum of the heart. It comprises of 2.7% of cardiac tumors and is the most common primary cardiac tumor causing sudden death. We herein review the etiology, presentation, differential diagnosis, diagnosis, management, surgical approaches and outcomes of this rare tumor.
Background: Traditional journal clubs addressing single articles are limited by the lack of a sta... more Background: Traditional journal clubs addressing single articles are limited by the lack of a standardized process for conduct and evaluation. We developed a novel, debate-style journal club for trainees to use best available evidence to address controversial topics in cardiothoracic surgery through discussion of realistic patient scenarios.
Methods: After implementation of our new curriculum, trainee knowledge acquisition and retention were assessed by a summative test of published literature and standardized debate scoring. Feedback was additionally obtained by trainee and faculty surveys.
Results: Cardiothoracic surgery trainees (n = 4) participated in five debates each over 10 monthly sessions. Written examination results after debate revealed a nonsignificant improvement in scores on topics that were debated compared with topics that were not (+9.8% versus −4.2%, p = 0.105). Trainee ability to sway the debate position supported by the attendee strongly correlated with trainee use of supporting literature (r = 0.853), moderately correlated with persuasiveness (r = 0.465), and overall effect of the debate (r = 0.625). Surveys completed by trainees and faculty unanimously favored the debate-style journal club as compared to the traditional journal club in gaining familiarity and applying published literature to questions encountered clinically.
Conclusions: Our novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgery trainees to acquire, retain, and gain practice in applying specialty-specific literature-based evidence to controversial case-based issues. Evaluation by multi-institutional expansion is needed to validate our preliminary findings in this initial trainee cohort.
Study objective: Open educational resources such as blogs are increasingly used for medical educa... more Study objective: Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. Methods: We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. Results: One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r¼0.92) and residents (r¼0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). Conclusion: The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment. [Ann Emerg Med. 2017;-:1-8.]
There is increasing evidence for successful management of end-stage heart failure with continuous... more There is increasing evidence for successful management of end-stage heart failure with continuous-flow left ventricular assist device (CF-LVAD) technology. However, passive flow adjustment at fixed CF-LVAD speed is susceptible to flow balancing issues as well as adverse hemodynamic effects relating to the diminished arterial pulse pressure and flow. With current therapy, flow cannot be adjusted with changes in venous return, which can vary significantly with volume status. This limits the performance and safety of CF-LVAD. Active flow adjustment strategies have been proposed to improve the synchrony between the pump and the native cardiovascular system, mimicking the Frank–Starling mechanism of the heart. These flow adjustment strategies include modulation by CF-LVAD pump speed by synchrony and maintenance of constant flow or constant pressure head, or a combination of these variables. However, none of these adjustment strategies have evolved sufficiently to gain widespread attention. Herein we review the current challenges and future directions of CF-LVAD therapy and sensor technology focusing on the development of a physiologic, long-term active flow adjustment strategy for CF-LVADs. ASAIO Journal 2017; 63:240–250.
Normothermic ex vivo lung perfusion (EVLP) allows for assessment and reconditioning of donor lung... more Normothermic ex vivo lung perfusion (EVLP) allows for assessment and reconditioning of donor lungs. Though a leukocyte filter (LF) is routinely incorporated into the EVLP circuit, its efficacy remains to be determined. Twelve pig lungs were perfused and ventilated ex vivo in a normothermic state for 12 hours. Lungs (n=3) were allocated to 4 groups according to perfusate composition and the presence or absence of a LF in the circuit (acellular +/- LF, cellular +/- LF). Acceptable physiologic lung parameters were achieved during EVLP; however, increased amounts of pro-inflammatory cytokines (TNF-[alpha], IL-6) and leukocytes in the perfusate were observed despite the presence or absence of a LF. Analysis of cells washed off the LF demonstrates that it trapped leukocytes though was ineffective throughout perfusion as it became saturated over 12 hours. We conclude that there is no objective evidence to support the routine incorporation of a LF during EVLP as it does not provide further benefit and its removal does not appear to cause harm. The lack of hypothesized benefit to a LF may be due to the saturation of the LF with donor leukocytes, leading to similar amounts of circulating leukocytes still present in the perfusate with and without a LF.
Aortic valve replacement with sutureless valves has many potential applications including in redo... more Aortic valve replacement with sutureless valves has many potential applications including in redo surgery, minimally invasive scenarios, and heavily calcified aortic roots. Herein we report a case of the development of an aorto-right atrial fistula after replacement of a Medtronic Freestyle stentless subcoronary bioprosthesis (Medtronic Inc, Minneapolis, MN) with a Perceval sutureless valve (LivaNova PLC, London, UK). This eventually necessitated repair with repeat surgery and aortic valve replacement with a stented valve. For patients with failing stentless bioprostheses returning for reintervention, we suggest removal of only Freestyle leaflet tissue without supra-annular debridement to avoid weakening of the native root tissue.
The acquisition of specialty-specific seminal literature and its application to daily, clinical p... more The acquisition of specialty-specific seminal literature and its application to daily, clinical patient-care decisions are critical components of clinical training. This structured, debate-style cardiothoracic surgery journal club module engages trainees in discussion of realistic patient scenarios, incorporating an extensive body of literature identified as the best evidence for the practice of cardiothoracic surgery. We designed the structured, debate-style cardiothoracic surgery journal club and delivered it to University of Texas MD Anderson Cancer Center cardiothoracic surgery trainees. Overall assessment of knowledge acquisition consisted of both direct judging of debates by faculty facilitators and a year-end written test of trainee knowledge. Associated materials include guidelines and resources for faculty facilitators and trainees to prepare them for the journal club debate. Also included are cardiothoracic surgery patient cases, PowerPoint presentation slides, a debate score sheet, and multiple-choice knowledge tests with answer keys. Our structured, debate-style cardio-thoracic surgery journal club is an effective educational intervention for cardiothoracic surgical trainees to gain practice in applying specialty-specific, literature-based evidence to particular patient problems. This resource may be used by course directors for surgery, for independent study by individuals planning to matriculate into surgical residencies, or as a review for those already in surgical training. Moreover, this curriculum can be delivered at other clinical training programs.
With increasing use of left ventricular assist devices (LVAD) for long-term circulatory support c... more With increasing use of left ventricular assist devices (LVAD) for long-term circulatory support comes a growing need for device exchange. The conventional surgical approach for device exchanges has been a reoperative median resternotomy. Less invasive HeartMate II LVAD exchange via a non-muscle-dividing subxiphoid incision as an alternative to a left subcostal incision may reduce pain burden and facilitate recovery. From November 2006 through June 2015, 292 patients underwent HeartMate II LVAD placement, of which 30 (10.3%) required an exchange. Twenty-four (80%) LVAD exchanges were performed through a subxiphoid sternal-sparing approach, and 6 (20%) through reoperative sternotomy. Predominant indication for device exchange was suspected or confirmed pump thrombus (73.3%), followed by electromechanical pump dysfunction (16.7%). The subxiphoid approach resulted in significantly shorter median intensive care unit (7 vs 37 days, p = 0.01) and hospital stay (29 vs 107 days, p = 0.01) compared to reoperative sternotomy. Kaplan-Meier analysis showed comparable survival between the subgroups (p=0.15) as well as between the patients with device exchange and the rest of the HeartMate II LVAD patients at our institution (p = 0.12). Subxiphoid device exchange is a viable option, resulting in low operative morbidity and mortality with no adverse effect on late survival.
There is a large population of patients with end-stage congestive heart failure who cannot be tre... more There is a large population of patients with end-stage congestive heart failure who cannot be treated by means of conventional cardiac surgery, cardiac transplantation, or chronic catecholamine infusions.Implantable cardiac devices, many designated as destination therapy, have revolutionized patient care and outcomes; though infection and complications related to external power sources or routine battery exchange remain a substantial risk. Complications from repeat battery replacement, power failure and infections ultimately endanger the original objectives of implantable biomedical device therapy - eliminating the intended patient autonomy, affecting patient quality of life and survival. We sought to review the limitations of current cardiac biomedical device energy sources and discuss the current state and trends of future potential energy sources in pursuit of a lifelong fully implantable biomedical device. ASAIO Journal 2016; 62:639–645.
Background: Social media may be a useful supplement to physician and trainee interaction... more Background: Social media may be a useful supplement to physician and trainee interactions; however, its role in enhancing mentorship has not been described.
Methods: A 35-item survey investigating trainee and physician social media use was distributed. Responses were analyzed using descriptive statistics.
Results: 282 respondents completed the survey, among whom 136 (48.2%) reported careers in surgical specialties. Women in surgical specialties were more likely to describe the specialty as being dominated by the opposite sex (p < 0.001) and to be mentored by the opposite sex though wish to be mentored by individuals of the same sex (p < 0.001). Respondents in surgical specialties were also more likely to report using social media to build a network of same-sex mentorship (p = 0.031).
Conclusions: Social media serves as a valuable tool to enhance the networking and mentorship of surgeons, particularly for women in surgical specialties who may lack exposure to same-sex mentors at their own institution.
This chapter examines the etiology, diagnostic techniques, and treatment approaches of anastomoti... more This chapter examines the etiology, diagnostic techniques, and treatment approaches of anastomotic complications after esophagectomy. An understanding of these much feared events may help mitigate the impact of the associated negative clinical sequelae. Anastomotic leak has a wide variation in presentation, from an incidental radiologic finding to a catastrophic septic event. Patients should be adequately resucitated, and further management is dependent upon the location of the leak and clinical presentation. Mild cases may be observed or managed with local drainage. The most severe cases are conduit necrosis. In suspected cases, direct visualization of the conduit is necessary, and subsequent resection must be performed if the diagnosis is confirmed. Anastomotic leak is a frequent cause of anastomotic stricture; however, later presentation must raise suspicion for tumor recurrence. In benign cases, endoscopic dilation is often sufficient. Leaks are also a frequent cause of conduit airway fistulas. Such events are rare but are life threatening and must rapidly be identified. In such cases, a trial of conservative treatment may be pursued with subsequent endoscopic therapy and, ultimately, surgical resection if this is not successful.
Purpose: Transplant coronary artery vasculopathy (TCAV) is the major cause of late allograft fail... more Purpose: Transplant coronary artery vasculopathy (TCAV) is the major cause of late allograft failure and death in heart transplant recipients. The aim of this systematic review was to examine the outcomes of percutaneous coronary interventions (PCI) as compared to coronary artery bypass grafting surgery (CABG) in the management of TCAV. Our secondary objective was to compare the use and outcomes of drug eluting stents (DES) as compared to bare metal stents (BMS) in this patient population. Methods: Electronic search was performed to identify all studies in the English literature examining PCI as compared to CABG for TCAV in heart transplant recipients. All identified articles were systematically assessed for inclusion and exclusion criteria. Results: Of the 4989 studies identified, 29 studies were included. Among 1520 patients who developed TCAV, 1470 patients underwent PCI and 50 patients underwent CABG. There were no significant differences in baseline demographics and comorbidities among the PCI and CABG cohorts. Compared to the PCI cohort, patients who underwent CABG had a higher early mortality (CABG 36.4% vs PCI 4.3%, p<0.001) and overall mortality (CABG 42.3% vs PCI 21.4%, p=0.049). When comparing DES versus BMS cohorts, there were no significant differences in the rate of in-stent stenosis (DES14.5% vs BMS 24.4%, p=0.476), overall mortality (DES 17.4% vs BMS 30.8%, p= 0.302) or cardiac related mortality (DES 7.7% vs BMS 21.8%, p=0.415). Conclusion: CABG and PCI are both feasible modalities for revascularization in patients with TCAV where PCI is associated with lower mortality. There were no differences in outcomes among patients who underwent PCI with DES as compared to BMS. Potential bias may exist due to heterogeneity in available data. Further studies are needed to delineate evidence-based guidelines to tailor the appropriate therapy, CABG or PCI, to the appropriate patient.
Background: Long-term efficacy of heart retransplantation (RTx) for end-stage cardiac allograft f... more Background: Long-term efficacy of heart retransplantation (RTx) for end-stage cardiac allograft failure remains unclear given the limited worldwide experience and is an important question to elucidate given the shortage of donor organs. The aim of this systematic review was to examine the outcomes of RTx in patients with cardiac allograft failure. Methods: Electronic search was performed to identify all studies in the English literature assessing RTx for cardiac allograft failure. All identified articles were systematically assessed for inclusion and exclusion criteria. Results: 11 studies were included for analysis, with a total of 7791 patients. 7446 patients underwent primary heart transplant (HTx) whereas 345 patients underwent RTx with average time from primary HTx to RTx interval of 5.03 years (95% CI 3.13-6.94). 35.2 % of patients received RTx within 30 days of primary transplant. Early mortality was significantly higher among RTx patients (RTx 28.2% vs HTx 11.2%, p<0.001) whereas survival was significantly higher among HTx patients when compared to RTx patients at 1 year (HTx 81.8% vs RTx 59.1%, p<0.001), 2 years (HTx 77.9% vs RTx 53.6%, p<0.001), 3 years (HTx 76.1% vs RTx 49.8%, p<0.001), 5 years (HTx 68.8% vs RTx 41.4%, p<0.001) and 10 years (HTx 53.9% vs RTx 31.7%, p<0.001). There were no significant differences between HTx and RTx in terms of freedom from rejection at 1 year (HTx 61% vs RTx 53.7%, p=0.43), 2 years (HTx 63.8% vs RTx 53.7%, p=0.26), 3 years (HTx 62.9% vs RTx 51.9%, p=0.3) and 5 years (HTx 61% vs RTx 51.9%, p=0.36). Conclusions: Patients who underwent heart RTx had a significant lower survival when compared to those who only underwent primary HTx. There were no significant differences in post-transplantation freedom from rejection. Careful patient selection and perioperative care can make heart RTx a viable option for selected recipients.
Driveline infections (DLIs) remain a major source of morbidity for patients requiring long-term v... more Driveline infections (DLIs) remain a major source of morbidity for patients requiring long-term ventricular assist device (VAD) support. We aimed to assess whether VAD driveline exit site (DLES) (abdomen versus chest wall) is associated with DLI. All adult patients who underwent insertion of a HeartWare HVAD or HeartMate II (HMII) between 2009 and 2016 were included. Driveline infection was defined as clinical evidence of DLI accompanied by a positive bacterial swab and need for antibiotics. Competing risks analysis was used to assess the association between patient characteristics and DLI. Ninety-two devices (59 HMII) were implanted in 85 patients (72 men; median age 57.4 years) for bridge to transplant or destination therapy. VAD DLES was chest in 28 (30.4%) devices. Median time on VAD support was 347.5 days (IQR 145.5, 757.5), with 28 transplants and 29 deaths (27 on device). DLI occurred in 24 patients (25 devices) at a median of 140 days (IQR 67, 314) from implant. Staphylococcus aureus accounted for 15 infections (60%). Freedom from infection was 72.8% (95% confidence interval [CI] 53.1–78.0%) at 1 year and 41.9% (95% CI 21.1–61.5%) at 3 years. In competing risks regression, abdominal DLES was not predictive of DLI (hazard ratio, HR 1.65 [95% CI 0.63, 4.29]), but body mass index (BMI) >30 kg/m 2 was (HR 2.72 [95% CI 1.25, 5.92]). In conclusion, risk of DLI is high among patients on long-term VAD support, and a nonabdominal DLES does not reduce this risk. The only predictor of DLI in this series was an elevated BMI. ASAIO Journal 2017; XX:00–00.
Total artificial hearts (TAH) can be used as a bridge to transplant or, occasionally, as destinat... more Total artificial hearts (TAH) can be used as a bridge to transplant or, occasionally, as destination therapy for patients with severe biventricular dysfunction. Not infrequently TAHs are placed in patients with severe low flow states, in which the lungs of these patients are unable to adjust rapidly to the "normal" right ventricular output of a TAH. These patients may develop variable degrees of pulmonary edema secondary to stress failure of the pulmonary capillaries requiring increased respiratory support, which can occasionally be fatal. In this "how to do it" article, we describe the technique for a pulmonary arteriovenous extracorporeal membrane oxygenation with TAH to avoid sudden pulmonary overflow and gradually expose the lungs to increasing flow.
Purpose: The current 1-dimensional fluid structure interaction model (FSI) for understanding cere... more Purpose: The current 1-dimensional fluid structure interaction model (FSI) for understanding cerebrospinal fluid (CSF) circulation requires pulsatility as a precondition and has not been applied to patients with continuous-flow left ventricular assist devices (CF-LVAD) where pulsatility is chronically reduced. Our study aims to characterize the behavior of CSF pressure and flow in patients with CF-LVADs using a computational FSI model.
Methods: Utilizing the computational FSI model, CSF production in choroid plexuses of the 4 ventricles was specified as a boundary condition for the model. The other source of production from capillary ultrafiltrate spaces was accounted for by the mass conservation equation. The primary CSF absorption sites (i.e., arachnoid granulations) were treated as the outlet boundary conditions. We established a low pulse wave to represent patients with a CF-LVAD.
Results: From the model, low pulse conditions resulted in a reduction in CSF pressure amplitude and velocity though the overall flow rate was unchanged.
Conclusions: The existing FSI model is not a suitable representation of CSF flow in CF-LVAD patients. More studies are needed to elucidate the role of pulsatility in CSF flow and the compensatory changes in CSF production and absorption that occur in patients with CF-LVADs in whom pulsatility is diminished.
Background: Available cardiac surgery risk scores have not been validated in octogenarians. Our o... more Background: Available cardiac surgery risk scores have not been validated in octogenarians. Our objective was to compare the predictive ability of the Society of Thoracic Surgeons (STS) score, EuroSCORE I, and EuroSCORE II in elderly patients undergoing isolated coronary artery bypass grafting surgery (CABG). Methods: All patients who underwent isolated CABG (2002 – 2008) were identified from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry. All patients aged 80 and older (n = 304) were then matched 1:2 with a randomly selected control group of patients under age 80 (n = 608 of 4732). Risk scores were calculated. Discriminatory accuracy of the risk models was assessed by plotting the areas under the receiver operator characteristic (AUC) and comparing the observed to predicted operative mortality. Results: Octogenarians had a significantly higher predicted mortality by STS Score (3 ± 2% vs. 1 ± 1%; p < 0.001), additive EuroSCORE (8 ± 3% vs. 4 ± 3%; p < 0.001), logistic EuroSCORE (15 ± 14% vs. 5 ± 6%; p < 0.001), and EuroSCORE II (4 ± 3% vs. 2 ± 2%; p < 0.001) compared to patients under age 80 years. Observed mortality was 2% and 1% for patients age 80 and older and under age 80, respectively (p = 0.323). AUC revealed areas for STS, additive and logistic EuroSCORE I and EuroSCORE II, respectively, for patients age 80 and older (0.671, 0.709, 0.694, 0.794) and under age 80 (0.829, 0.750, 0.785, 0.845). Conclusion: All risk prediction models assessed overestimated surgical risk, particularly in octogenarians. EuroSCORE II demonstrated better discriminatory accuracy in this population. Inclusion of new variables into these risk models, such as frailty, may allow for more accurate prediction of true operative risk.
Background. Donation after circulatory death (DCD) has the potential to significantly alleviate t... more Background. Donation after circulatory death (DCD) has the potential to significantly alleviate the shortage of transplantable lungs. We report our initial experience with the use of portable ex vivo lung perfusion (EVLP) with the Organ Care System Lung device for evaluation of DCD lungs. Methods. We performed a retrospective review of the DCD lung transplantation (LTx) experience at a single institution through the use of a prospective database. Results. From 2011 to 2015, 208 LTx were performed at the University of Alberta, of which 11 were DCD LTx with 7 (64%) that underwent portable EVLP. DCD lungs preserved with portable EVLP had a significantly shorter cold ischemic time (161 � 44 vs 234 � 60 minutes, P = .045), lower grade of primary graft dysfunction at 72 hours after LTx (0.4 � +/- 0.5 vs 2.1 � +/- 0.7, P = .003), similar mechanical ventilation time (55 � +/- 44 vs 103 � +/- 97 hours, P = .281), and hospital length of stay (29 � +/- 11 vs 33 � +/- 10 days, P = .610). All patients were alive at 1-year follow-up after LTx with improved functional outcomes and acceptable quality of life compared with before LTx, although there were no intergroup differences. Conclusions. In our pilot cohort, portable EVLP was a feasible modality to increase confidence in the use of DCD lungs with validated objective evidence of lung function during EVLP that translates to acceptable clinical outcomes and quality of life after LTx. Further studies are needed to validate these initial findings in a larger cohort.
Graft dysfunction is the main cause of early mortality after heart transplantation. In cases of s... more Graft dysfunction is the main cause of early mortality after heart transplantation. In cases of severe graft dysfunction, temporary mechanical circulatory support (TMCS) may be necessary. The aim of this systematic review was to examine the utilization and outcomes of TMCS in patients with graft dysfunction after heart transplantation. Electronic search was performed to identify all studies in the English literature assessing the use of TMCS for graft dysfunction. All identified articles were systematically assessed for inclusion and exclusion criteria. Of the 5,462 studies identified, 41 studies were included. Among the 11,555 patients undergoing heart transplantation, 695 (6.0%) required TMCS with patients most often supported using venoarterial extracorporeal membrane oxygenation (79.4%) followed by right ventricular assist devices (11.1%), biventricular assist devices (BiVADs) (7.5%), and left ven-tricular assist devices (LVADs) (2.0%). Patients supported by LVADs were more likely to be supported longer (p = 0.003), have a higher death by cardiac event (p = 0.013) and retrans-plantation rate (p = 0.015). In contrast, patients supported with BiVAD and LVAD were more likely to be weaned off support (p = 0.020). Overall, no significant difference was found in pooled 30 day survival (p = 0.31), survival to discharge (p = 0.19), and overall survival (p = 0.51) between the subgroups. Temporary mechanical circulatory support is an effective modality to support patients with graft dysfunction after heart transplantation. Further studies are needed to establish the optimal threshold and strategy for TMCS and to augment cardiac recovery and long-term survival. ASAIO Journal 2017; XX:00–00.
Primary cardiac tumors are uncommon clinical entities with an incidence of 0.0017% to 0.03% of al... more Primary cardiac tumors are uncommon clinical entities with an incidence of 0.0017% to 0.03% of all autopsies. Cystic tumor of the atrioventricular (AV) node, also known as mesothelioma of the AV node, is a benign congenital tumor that is located in the triangle of Koch in the AV nodal region of the atrial septum of the heart. It comprises of 2.7% of cardiac tumors and is the most common primary cardiac tumor causing sudden death. We herein review the etiology, presentation, differential diagnosis, diagnosis, management, surgical approaches and outcomes of this rare tumor.
Background: Traditional journal clubs addressing single articles are limited by the lack of a sta... more Background: Traditional journal clubs addressing single articles are limited by the lack of a standardized process for conduct and evaluation. We developed a novel, debate-style journal club for trainees to use best available evidence to address controversial topics in cardiothoracic surgery through discussion of realistic patient scenarios.
Methods: After implementation of our new curriculum, trainee knowledge acquisition and retention were assessed by a summative test of published literature and standardized debate scoring. Feedback was additionally obtained by trainee and faculty surveys.
Results: Cardiothoracic surgery trainees (n = 4) participated in five debates each over 10 monthly sessions. Written examination results after debate revealed a nonsignificant improvement in scores on topics that were debated compared with topics that were not (+9.8% versus −4.2%, p = 0.105). Trainee ability to sway the debate position supported by the attendee strongly correlated with trainee use of supporting literature (r = 0.853), moderately correlated with persuasiveness (r = 0.465), and overall effect of the debate (r = 0.625). Surveys completed by trainees and faculty unanimously favored the debate-style journal club as compared to the traditional journal club in gaining familiarity and applying published literature to questions encountered clinically.
Conclusions: Our novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgery trainees to acquire, retain, and gain practice in applying specialty-specific literature-based evidence to controversial case-based issues. Evaluation by multi-institutional expansion is needed to validate our preliminary findings in this initial trainee cohort.
Study objective: Open educational resources such as blogs are increasingly used for medical educa... more Study objective: Open educational resources such as blogs are increasingly used for medical education. Gestalt is generally the evaluation method used for these resources; however, little information has been published on it. We aim to evaluate the reliability of gestalt in the assessment of emergency medicine blogs. Methods: We identified 60 English-language emergency medicine Web sites that posted clinically oriented blogs between January 1, 2016, and February 24, 2016. Ten Web sites were selected with a random-number generator. Medical students, emergency medicine residents, and emergency medicine attending physicians evaluated the 2 most recent clinical blog posts from each site for quality, using a 7-point Likert scale. The mean gestalt scores of each blog post were compared between groups with Pearson's correlations. Single and average measure intraclass correlation coefficients were calculated within groups. A generalizability study evaluated variance within gestalt and a decision study calculated the number of raters required to reliably (>0.8) estimate quality. Results: One hundred twenty-one medical students, 88 residents, and 100 attending physicians (93.6% of enrolled participants) evaluated all 20 blog posts. Single-measure intraclass correlation coefficients within groups were fair to poor (0.36 to 0.40). Average-measure intraclass correlation coefficients were more reliable (0.811 to 0.840). Mean gestalt ratings by attending physicians correlated strongly with those by medical students (r¼0.92) and residents (r¼0.99). The generalizability coefficient was 0.91 for the complete data set. The decision study found that 42 gestalt ratings were required to reliably evaluate quality (>0.8). Conclusion: The mean gestalt quality ratings of blog posts between medical students, residents, and attending physicians correlate strongly, but individual ratings are unreliable. With sufficient raters, mean gestalt ratings provide a community standard for assessment. [Ann Emerg Med. 2017;-:1-8.]
There is increasing evidence for successful management of end-stage heart failure with continuous... more There is increasing evidence for successful management of end-stage heart failure with continuous-flow left ventricular assist device (CF-LVAD) technology. However, passive flow adjustment at fixed CF-LVAD speed is susceptible to flow balancing issues as well as adverse hemodynamic effects relating to the diminished arterial pulse pressure and flow. With current therapy, flow cannot be adjusted with changes in venous return, which can vary significantly with volume status. This limits the performance and safety of CF-LVAD. Active flow adjustment strategies have been proposed to improve the synchrony between the pump and the native cardiovascular system, mimicking the Frank–Starling mechanism of the heart. These flow adjustment strategies include modulation by CF-LVAD pump speed by synchrony and maintenance of constant flow or constant pressure head, or a combination of these variables. However, none of these adjustment strategies have evolved sufficiently to gain widespread attention. Herein we review the current challenges and future directions of CF-LVAD therapy and sensor technology focusing on the development of a physiologic, long-term active flow adjustment strategy for CF-LVADs. ASAIO Journal 2017; 63:240–250.
Normothermic ex vivo lung perfusion (EVLP) allows for assessment and reconditioning of donor lung... more Normothermic ex vivo lung perfusion (EVLP) allows for assessment and reconditioning of donor lungs. Though a leukocyte filter (LF) is routinely incorporated into the EVLP circuit, its efficacy remains to be determined. Twelve pig lungs were perfused and ventilated ex vivo in a normothermic state for 12 hours. Lungs (n=3) were allocated to 4 groups according to perfusate composition and the presence or absence of a LF in the circuit (acellular +/- LF, cellular +/- LF). Acceptable physiologic lung parameters were achieved during EVLP; however, increased amounts of pro-inflammatory cytokines (TNF-[alpha], IL-6) and leukocytes in the perfusate were observed despite the presence or absence of a LF. Analysis of cells washed off the LF demonstrates that it trapped leukocytes though was ineffective throughout perfusion as it became saturated over 12 hours. We conclude that there is no objective evidence to support the routine incorporation of a LF during EVLP as it does not provide further benefit and its removal does not appear to cause harm. The lack of hypothesized benefit to a LF may be due to the saturation of the LF with donor leukocytes, leading to similar amounts of circulating leukocytes still present in the perfusate with and without a LF.
Aortic valve replacement with sutureless valves has many potential applications including in redo... more Aortic valve replacement with sutureless valves has many potential applications including in redo surgery, minimally invasive scenarios, and heavily calcified aortic roots. Herein we report a case of the development of an aorto-right atrial fistula after replacement of a Medtronic Freestyle stentless subcoronary bioprosthesis (Medtronic Inc, Minneapolis, MN) with a Perceval sutureless valve (LivaNova PLC, London, UK). This eventually necessitated repair with repeat surgery and aortic valve replacement with a stented valve. For patients with failing stentless bioprostheses returning for reintervention, we suggest removal of only Freestyle leaflet tissue without supra-annular debridement to avoid weakening of the native root tissue.
The acquisition of specialty-specific seminal literature and its application to daily, clinical p... more The acquisition of specialty-specific seminal literature and its application to daily, clinical patient-care decisions are critical components of clinical training. This structured, debate-style cardiothoracic surgery journal club module engages trainees in discussion of realistic patient scenarios, incorporating an extensive body of literature identified as the best evidence for the practice of cardiothoracic surgery. We designed the structured, debate-style cardiothoracic surgery journal club and delivered it to University of Texas MD Anderson Cancer Center cardiothoracic surgery trainees. Overall assessment of knowledge acquisition consisted of both direct judging of debates by faculty facilitators and a year-end written test of trainee knowledge. Associated materials include guidelines and resources for faculty facilitators and trainees to prepare them for the journal club debate. Also included are cardiothoracic surgery patient cases, PowerPoint presentation slides, a debate score sheet, and multiple-choice knowledge tests with answer keys. Our structured, debate-style cardio-thoracic surgery journal club is an effective educational intervention for cardiothoracic surgical trainees to gain practice in applying specialty-specific, literature-based evidence to particular patient problems. This resource may be used by course directors for surgery, for independent study by individuals planning to matriculate into surgical residencies, or as a review for those already in surgical training. Moreover, this curriculum can be delivered at other clinical training programs.
With increasing use of left ventricular assist devices (LVAD) for long-term circulatory support c... more With increasing use of left ventricular assist devices (LVAD) for long-term circulatory support comes a growing need for device exchange. The conventional surgical approach for device exchanges has been a reoperative median resternotomy. Less invasive HeartMate II LVAD exchange via a non-muscle-dividing subxiphoid incision as an alternative to a left subcostal incision may reduce pain burden and facilitate recovery. From November 2006 through June 2015, 292 patients underwent HeartMate II LVAD placement, of which 30 (10.3%) required an exchange. Twenty-four (80%) LVAD exchanges were performed through a subxiphoid sternal-sparing approach, and 6 (20%) through reoperative sternotomy. Predominant indication for device exchange was suspected or confirmed pump thrombus (73.3%), followed by electromechanical pump dysfunction (16.7%). The subxiphoid approach resulted in significantly shorter median intensive care unit (7 vs 37 days, p = 0.01) and hospital stay (29 vs 107 days, p = 0.01) compared to reoperative sternotomy. Kaplan-Meier analysis showed comparable survival between the subgroups (p=0.15) as well as between the patients with device exchange and the rest of the HeartMate II LVAD patients at our institution (p = 0.12). Subxiphoid device exchange is a viable option, resulting in low operative morbidity and mortality with no adverse effect on late survival.
There is a large population of patients with end-stage congestive heart failure who cannot be tre... more There is a large population of patients with end-stage congestive heart failure who cannot be treated by means of conventional cardiac surgery, cardiac transplantation, or chronic catecholamine infusions.Implantable cardiac devices, many designated as destination therapy, have revolutionized patient care and outcomes; though infection and complications related to external power sources or routine battery exchange remain a substantial risk. Complications from repeat battery replacement, power failure and infections ultimately endanger the original objectives of implantable biomedical device therapy - eliminating the intended patient autonomy, affecting patient quality of life and survival. We sought to review the limitations of current cardiac biomedical device energy sources and discuss the current state and trends of future potential energy sources in pursuit of a lifelong fully implantable biomedical device. ASAIO Journal 2016; 62:639–645.
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Papers by Jessica Luc
Methods: A 35-item survey investigating trainee and physician social media use was distributed. Responses were analyzed using descriptive statistics.
Results: 282 respondents completed the survey, among whom 136 (48.2%) reported careers in surgical specialties. Women in surgical specialties were more likely to describe the specialty as being dominated by the opposite sex (p < 0.001) and to be mentored by the opposite sex though wish to be mentored by individuals of the same sex (p < 0.001). Respondents in surgical specialties were also more likely to report using social media to build a network of same-sex mentorship (p = 0.031).
Conclusions: Social media serves as a valuable tool to enhance the networking and mentorship of surgeons, particularly for women in surgical specialties who may lack exposure to same-sex mentors at their own institution.
Methods: Utilizing the computational FSI model, CSF production in choroid plexuses of the 4 ventricles was specified as a boundary condition for the model. The other source of production from capillary ultrafiltrate spaces was accounted for by the mass conservation equation. The primary CSF absorption sites (i.e., arachnoid granulations) were treated as the outlet boundary conditions. We established a low pulse wave to represent patients with a CF-LVAD.
Results: From the model, low pulse conditions resulted in a reduction in CSF pressure amplitude and velocity though the overall flow rate was unchanged.
Conclusions: The existing FSI model is not a suitable representation of CSF flow in CF-LVAD patients. More studies are needed to elucidate the role of pulsatility in CSF flow and the compensatory changes in CSF production and absorption that occur in patients with CF-LVADs in whom pulsatility is diminished.
Methods: After implementation of our new curriculum, trainee knowledge acquisition and retention were assessed by a summative test of published literature and standardized debate scoring. Feedback was additionally obtained by trainee and faculty surveys.
Results: Cardiothoracic surgery trainees (n = 4) participated in five debates each over 10 monthly sessions. Written examination results after debate revealed a nonsignificant improvement in scores on topics that were debated compared with topics that were not (+9.8% versus −4.2%, p = 0.105). Trainee ability to sway the debate position supported by the attendee strongly correlated with trainee use of supporting literature (r = 0.853), moderately correlated with persuasiveness (r = 0.465), and overall effect of the debate (r = 0.625). Surveys completed by trainees and faculty unanimously favored the debate-style journal club as compared to the traditional journal club in gaining familiarity and applying published literature to questions encountered clinically.
Conclusions: Our novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgery trainees to acquire, retain, and gain practice in applying specialty-specific literature-based evidence to controversial case-based issues. Evaluation by multi-institutional expansion is needed to validate our preliminary findings in this initial trainee cohort.
Methods: A 35-item survey investigating trainee and physician social media use was distributed. Responses were analyzed using descriptive statistics.
Results: 282 respondents completed the survey, among whom 136 (48.2%) reported careers in surgical specialties. Women in surgical specialties were more likely to describe the specialty as being dominated by the opposite sex (p < 0.001) and to be mentored by the opposite sex though wish to be mentored by individuals of the same sex (p < 0.001). Respondents in surgical specialties were also more likely to report using social media to build a network of same-sex mentorship (p = 0.031).
Conclusions: Social media serves as a valuable tool to enhance the networking and mentorship of surgeons, particularly for women in surgical specialties who may lack exposure to same-sex mentors at their own institution.
Methods: Utilizing the computational FSI model, CSF production in choroid plexuses of the 4 ventricles was specified as a boundary condition for the model. The other source of production from capillary ultrafiltrate spaces was accounted for by the mass conservation equation. The primary CSF absorption sites (i.e., arachnoid granulations) were treated as the outlet boundary conditions. We established a low pulse wave to represent patients with a CF-LVAD.
Results: From the model, low pulse conditions resulted in a reduction in CSF pressure amplitude and velocity though the overall flow rate was unchanged.
Conclusions: The existing FSI model is not a suitable representation of CSF flow in CF-LVAD patients. More studies are needed to elucidate the role of pulsatility in CSF flow and the compensatory changes in CSF production and absorption that occur in patients with CF-LVADs in whom pulsatility is diminished.
Methods: After implementation of our new curriculum, trainee knowledge acquisition and retention were assessed by a summative test of published literature and standardized debate scoring. Feedback was additionally obtained by trainee and faculty surveys.
Results: Cardiothoracic surgery trainees (n = 4) participated in five debates each over 10 monthly sessions. Written examination results after debate revealed a nonsignificant improvement in scores on topics that were debated compared with topics that were not (+9.8% versus −4.2%, p = 0.105). Trainee ability to sway the debate position supported by the attendee strongly correlated with trainee use of supporting literature (r = 0.853), moderately correlated with persuasiveness (r = 0.465), and overall effect of the debate (r = 0.625). Surveys completed by trainees and faculty unanimously favored the debate-style journal club as compared to the traditional journal club in gaining familiarity and applying published literature to questions encountered clinically.
Conclusions: Our novel debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgery trainees to acquire, retain, and gain practice in applying specialty-specific literature-based evidence to controversial case-based issues. Evaluation by multi-institutional expansion is needed to validate our preliminary findings in this initial trainee cohort.