Background: Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). Although most have normalization of pulmonary artery (PA) pressures, development of residual pulmonary hypertension (RPH) is challenging to predict. Research Question: Among patients with CTEPH undergoing PEA, is there a relationship between specimen histopathology and postoperative hemodynamics? Study Design and Methods In this single-center retrospective cohort study, patients with CTEPH who underwent PEA were classified by thrombus chronicity: organized (chronic), organizing (subacute), or mixed (combined organizing and organized). Change in mean PA pressure, pulmonary vascular resistance (PVR), and transpulmonary gradient (TPG) were examined by thrombus organization. Associations with RPH were assessed with multivariable logistic regression. Results: A total of 163 patients were identified: 34% had organized thrombi, 17% had organizing thrombi, and 49% had mixed thrombi. Pre-PEA mean TPG and PVR were highest in the mixed group (TPG: 37 mm Hg [29-42 mm Hg]; PVR: 8.7 Wood units [WU] [interquartile range (IQR), 5.6-11.2 WU]) compared with the organized (TPG: 30 mm Hg [24-38 mm Hg]; PVR: 6.2 WU [IQR, 4.2-8.8 WU]) and organizing (TPG: 24 mm Hg [19-37 mm Hg]; PVR: 4.2 WU [IQR, 3.5-9.2 WU]) groups (TPG: P = .05; PVR: P = .01). The adjusted change in mean PA pressure among the mixed group was -19.8 mm Hg (-21.7 to -17.8 mm Hg), significantly greater than -16.2 mm Hg (-18.4 to -14.1 mm Hg) in the organized group and -14.1 mm Hg (-17.3 to -10.9 mm Hg) in the organizing group (P = .004). Fifty-two patients (32%) had RPH. Mixed thrombus organization was associated with lower odds of RPH (OR, 0.35; 95% CI, 0.14-0.85; P = .02), whereas preoperative mean PA pressure (OR, 1.10; 95% CI, 1.06-1.16; P < .001) and age (OR, 1.04; 95% CI, 1.01-1.07; P = .02) were associated with higher odds of RPH. Interpretation: Patients with mixed thrombi were less likely to have RPH, suggesting there may be an optimum time to perform PEA after the clot has mostly organized, but prior to development of irreversible small vessel disease.

Purpose Life-long anticoagulation is required for patients following pulmonary thromboendarterectomy (PTE). Warfarin is the default anticoagulant; however, many patients request direct oral anticoagulants (DOACs) as they do not require monitoring or dietary changes. There is limited data on the safety and efficacy of DOACs following PTE, and the aim of this study is to better understand the bleeding and clotting risks in patients taking the two classes of medications after PTE in a non-trial setting. Methods To better understand real-world anticoagulation prescribing patterns and their potential implications following PTE, we retrospectively identified all patients who underwent PTE at our institution since July 2011 and determined their post-discharge anticoagulation regimen and the occurrence of complications using a standardized telephone questionnaire. Comparisons were made using Fisher's exact text. Results 246 patients underwent a PTE at our institution after July 2011; our hospital electronic medical record indicated 33 (13%) died since their index operation. Of the 213 remaining, 72 (34%) patients were successfully contacted and 51 (23%) agreed to participate in the questionnaire for a response rate of 24%. The mean time from the index PTE for these 51 patients was 5.2 years +/- 3.2 years. Table 1 displays the results of the questionnaire. Nine patients (18%) who were discharged on warfarin switched to a DOAC. Notably, all 3 patients with a recurrent pulmonary embolism (PE) after PTE had been switched from warfarin to a DOAC prior to the PE (P = 0.04). Each required hospitalization (P = 0.04). There was no difference in bleeding complications between the groups. Conclusion Patients transitioned from warfarin to DOACs were more likely to experience recurrent PE and require in-hospital PE treatment. Larger studies assessing the use of DOACs in this population are needed to determine effectiveness and safety.

To the Editor: Chronic thromboembolic pulmonary hypertension (CTEPH), an infrequent although serious complication of acute pulmonary embolism (PE), results from the fibrotic transformation of pulmonary artery (PA) thrombi leading to chronic obstruction of PAs and associated remodeling of the microvasculature.1 CTEPH is the only cause of severe pulmonary hypertension that is potentially curable via surgery. Pulmonary endarterectomy is the treatment of choice for CTEPH in patients with the surgically accessible disease and often results in significant improvements in right ventricular function.2 Bronchoscopy with convex probe endobronchial ultrasound (EBUS) is an established tool for examining mediastinal and hilar lymph nodes. EBUS provides unique access to the central pulmonary and proximal lobar arteries. Several case reports have described the identification of acute PE during the EBUS examination.3–6 To our knowledge, EBUS has not been used to characterize the appearance of chronic thromboemboli in the PA vasculature. We report the first use of vascular endobronchial ultrasound (VEBUS) to detect many of the characteristic angiographic signs of CTEPH. We report a 64-year-old male, a former smoker with a past medical history of the chronic obstructive pulmonary disease who initially presented with several months of worsening shortness of breath on exertion. Computed tomography angiogram (CTA) showed a large thrombus in the right main PA as well as eccentric thrombus with recanalization and webs in the bilateral lobar and segmental arteries consistent with chronic PE. Echocardiogram showed a severely dilated right ventricle with moderate right ventricular hypertrophy, moderate to severe tricuspid regurgitation, and a right ventricular systolic pressure of 100 mm Hg consistent with severe pulmonary hypertension. A ventilation-perfusion scan revealed bilateral mismatched perfusion defects compatible with CTEPH. He was treated with oral anticoagulation with no improvement of his symptoms. The decision was made to undergo pulmonary endarterectomy. After the patient was intubated and before the start of the surgery, EBUS was performed to examine the central and proximal lobar PAs as previously described.7 The examination was initiated by advancing the EBUS bronchoscope into the right lower lobe to visualize the right lower lobe PA (basal trunk) located between 12 and 3 o'clock position. Once the right lower lobe PA is visualized between the 12 and 3 o'clock position, the scope is slowly fanned clockwise and counterclockwise to visualize the entire vessel at this level. The scope was retracted and turned counterclockwise to following the course of the interlobar PA on the medial wall of the right bronchial tree until the level of the carina, where the right main PA and the PA trunk were seen. During this process, the scope was fanned clockwise and counterclockwise every 1 cm to see the entire vessel. The scope was then advanced distally to the left lower lobe bronchus between 9 and 12 o'clock position to examine the basal trunk. The scope was then slowly retracted into the left main bronchus while scanning between the 9 and 12 o'clock positions to examine the interlobar artery and rotated towards 9 o'clock to examine the left upper lobar artery branches. Finally, the main PA was visualized by placing the scope at the 12 o'clock position in the proximal left mainstem bronchus. Again, the scope was fanned clockwise and counterclockwise every 1 cm during scope withdrawal to see the entire vessel. The EBUS balloon was utilized as needed during the procedure to obtain good visualization of the vasculature. Doppler mode was used to assess blood flow when areas of narrowing or obstruction were noted. A frequency of 12 MHz was used for the procedure. Using convex probe EBUS, we were able to identify several findings consistent with the diagnosis of chronic thromboembolic pulmonary disease including thickening of the right interlobar PA wall (Fig. 1), an intraluminal thrombus (Fig. 2), and an intraluminal fibrous PA web (with corresponding CTA image) (Fig. 3). The patient underwent pulmonary endarterectomy with good outcomes after surgery and the resolution of his pulmonary hypertension.FIGURE 1: Arrow pointing at hyperechoic horizontal line parallel to the right interlobar pulmonary artery vessel wall consistent with thrombus lining the wall (A) and a comparison image with arrow pointing at a normal right interlobar pulmonary artery vessel wall (B).FIGURE 2: Wavy hyperechoic density adjacent to the right interlobar pulmonary artery wall consistent with organized thrombus (arrow).FIGURE 3: A, Endobronchial ultrasound image with Doppler mode revealing an intraluminal fibrotic web (larger arrow) and intravascular thrombus (smaller arrow) in the right intralobar pulmonary artery, both observed as a heterogenous hypoechoic filling defect within the vessel. B, Computed tomography angiography of the chest, coronal view, and the arrow pointing at the right intralobar pulmonary artery intravascular fibrotic web.Ventilation-perfusion scan, CTA, and pulmonary angiography are the primary imaging techniques currently used to diagnose chronic thromboembolic disease and identify patients who may benefit from pulmonary endarterectomy.2 The angiographic patterns associated with the presence of organized thromboembolic material are mainly intimal irregularity, pouch defects, bands, and webs traversing the vascular lumen, and abrupt vascular cutoff denoting complete occlusion of vessels.8 One retrospective study looked at patients with a known diagnosis of acute PE on CTA. In 32 patients with central PE, EBUS was found to have a 97% accuracy in detecting PE compared with CTA.7 EBUS, a well-established modality for the assessment of hilar and mediastinal lymph nodes, could potentially be an important minimally invasive tool to visualize the location and characteristics of chronic thromboembolic disease within the PAs. Determining the proximal extent of disease in the PA is a critical part of patient selection, as the distal disease may not be amenable to surgery.8 Using VEBUS we were able to identify several angiographic signs characteristic of CTEPH, including: (a) thrombus lining the vessel wall, (b) organized intravascular thrombus, and (c) intravascular fibrotic web. VEBUS is a minimally invasive tool that carries minimal procedural risk and no risk of radiation exposure, or risks associated with the administration of intravenous contrast. Further experience will determine if VEBUS can add to the currently available imaging techniques in the diagnosis and management of CTEPH. We believe EBUS may have a role in the evaluation of some patients with CTEPH, to help determine the proximal extent of disease. We have had cases in whom CTA and even pulmonary angiography has been misleading and, at time of surgery, the more proximal organized disease is found, allowing a dissection plane to be developed and extended distally. In addition, VEBUS could add real-time intraprocedural visualization for endovascular interventions. VEBUS has its limitations, as the size of the EBUS probe (6.9 mm) prevents the evaluation of the PA vasculature much beyond the branch point of the lobar PAs. Thus, with the current technology, chronic thromboemboli in the lobar and more distal PA branches cannot be adequately assessed. Also, EBUS assessment of the central PA vasculature could miss some of the endovascular diseases. Further studies comparing findings on EBUS imaging and CTA are needed. We conclude that VEBUS is a minimally invasive tool that can visualize the location and characteristics of chronic thromboembolic disease within the central PAs. VEBUS can detect angiographic signs characteristic of CTEPH, including vascular wall thickening due to lining thrombus, organized intravascular thrombus, and fibrotic intravascular bands. VEBUS could potentially be used as a preoperative assessment tool in patients undergoing pulmonary endarterectomy. Christian Ghattas, MD* Richard N. Channick, MD† Cameron D. Wright, MD‡ Gus J. Vlahakes, MD§ Colleen Channick, MD†*Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH†Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy David Geffen School of Medicine at UCLA Los Angeles, CA‡Divisions of ‡Thoracic Surgery§Cardiac Surgery, Massachusetts General Hospital, Boston, MA

BACKGROUND: Surgeons are prone to feelings of sadness, guilt, and anxiety when involved in major adverse events. We aimed to create and evaluate a second victim peer support program for surgeons and surgical trainees. STUDY DESIGN: The second victim peer support program was an intervention performed in the Department of Surgery at a tertiary care academic medical center. Surgical attendings and trainees participated as peer supporters or affected peers. In this article, we describe the design of the program and its 1-year impact, which was evaluated through the number of interventions attempted and realized and feedback received from all participants using an anonymous qualitative and quantitative survey. RESULTS: The program was established using the following 5 steps: creation of a conceptual framework, choice of peer supporters, training of peer supporters, multifaceted identification of major adverse events, and design of a systematic intervention plan. In 1 year, the program had 47 interventions distributed evenly between attendings and trainees; 19% of affected peers opted out of receiving support. Most participants expressed satisfaction with the program's confidentiality, the safe/trusting environment it provided, and the timeliness of the intervention (89%, 73%, and 83%, respectively); 81% suggested that the program had a positive impact on the department's “safety and support” culture and would recommend the program to a colleague. Several areas for improvement were identified, including the need to improve identification of events requiring outreach, and the desire for increased awareness of the program throughout the department. CONCLUSIONS: We successfully designed, implemented, and assessed the impact of the first surgery-specific peer support program in the US. Our 1-year experience suggests that the program is highly used and well received, albeit with opportunities for improvement.

BACKGROUND:Surgical excellence demands teamwork. Poor team behaviors negatively affect team performance and are associated with adverse events and worse outcomes. Interventions to improve surgical teamwork focusing on frontline team members' nontechnical skills have proliferated but shown mixed results. Literature on teamwork in organizations suggests that team behaviors are also contingent on psychosocial, cultural, and organizational factors. This study examined factors influencing surgical team behaviors to inform more contextually sensitive and effective approaches to optimizing surgical teamwork. METHODS:This qualitative study of cardiac surgical teams in a large United States teaching hospital included 34 semistructured interviews. Thematic network analysis was used to examine perceptions of ideal teamwork and factors influencing team behaviors in the operating room. RESULTS:Perceptions of ideal teamwork were largely shared, but team members held discrepant views of which team and leadership behaviors enhanced or undermined teamwork. Other factors affecting team behaviors were related to the local organizational culture, including management of staff behavior, variable case demands, and team members' technical competence, and fitness of organizational structures and processes to support teamwork. These factors affected perceptions of what constituted optimal interpersonal and team behaviors in the operating room. CONCLUSIONS:Team behaviors are contextually contingent and organizationally determined, and beliefs about optimal behaviors are not necessarily shared. Interventions to optimize surgical teamwork require establishing consensus regarding best practice, ability to adapt as circumstances require, and organizational commitment to addressing contextual factors that affect teams.

SESSION TITLE: Pediatrics SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Introduction: Heated high flow nasal cannula (HFNC) therapy is a method of providing oxygen using flow rates higher than that used with traditional oxygen therapy. There is a dearth of evidence regarding the efficacy, effectiveness and safety of HFNC in the paediatric population. Objectives: to describe HFNC therapy at SickKids, including predictors of treatment failure. METHODS: Retrospective chart review of patients treated with HFNC in the Critical Care Unit (CCU), wards and Emergency Department between September 1st 2013 and January 31st 2016. Patients were categorized as non-responders (NR) (intolerance/agitation, transition to non-invasive (NIV) or invasive mechanical ventilation (IV), transfer to the CCU, cardiac arrest or death) or responders (R) (all other scenarios). Analysis: descriptive statistics; R vs. NR using chi-square (categorical), two-sample t-test (continuous) and Wilcoxon rank sums tests (skewed variables). Significant predictors in past literature and deemed important by the clinical respiratory therapists (RTs) were included in a multiple logistic regression model for predicting NR. RESULTS: 357 patients used HFNC: n=158(44%) females; n=208(58%) after extubation; n=139 (39%) for respiratory distress or work of breathing; mean(SD) age=2.1(2.9) years; duration of therapy=57.6(84.3) days. N=117(33%) were NRs, the majority requiring NIV or IV (98(84%)). Significant associations of NR: change in flowrate/kg in the first 4 hours (NR vs. R: 0.05(0.1) vs. -0.08(0.05) lpm/kg), p=0.05; change in respiratory rate (RR) in the first 4 hours (-5.8(3.3) vs. 0.2(2.4) bpm), p=0.04; hospital LOS (111.4(17.9) vs. 65.6(9.9) days), p=0.02. CONCLUSIONS: The majority of children at SickKids were placed on HFNC after extubation or due to respiratory distress. An increased flowrate and decreased RR in the first 4 hours, and longer hospital LOS was associated with failure of HFNC. CLINICAL IMPLICATIONS: Monitoring these parameters may help RTs anticipate HFNC failure and avoid higher forms of respiratory support. This may help inform HFNC protocols for initiation, weaning and discontinuation. DISCLOSURE: The following authors have nothing to disclose: Mika Nonoyama, Katherine Reise, Jason Macartney, Cameron Wright No Product/Research Disclosure Information

Background. The importance of effective team leadership for achieving surgical excellence is widely accepted, but we understand less about the behaviors that achieve this goal. We studied cardiac surgical teams to identify leadership behaviors that best support surgical teamwork.Methods. We observed, surveyed, and interviewed cardiac surgical teams, including 7 surgeons and 116 team members, from September 2013 to April 2015. We documented 1,926 surgeon/team member interactions during 22 cases, coded them by behavior type and valence (ie, positive/negative/neutral), and characterized them by leadership function (conductor, elucidator, delegator, engagement facilitator, tone setter, being human, and safe space maker) to create a novel framework of surgical leadership derived from direct observation. We surveyed nonsurgeon team members about their perceptions of individual surgeon's leadership effectiveness on a 7-point Likert scale and correlated survey measures with individual surgeon profiles created by calculating percentage of behavior types, leader functions, and valence.Results. Surgeon leadership was rated by nonsurgeons from 4.2 to 6.2 (mean, 5.4). Among the 33 types of behaviors observed, most interactions constituted elucidating (24%) and tone setting (20%). Overall, 66% of interactions (range, 43%-84%) were positive and 11% (range, 1%-45%) were negative. The percentage of positive and negative behaviors correlated strongly (r = 0.85 for positive and r = 0.75 for negative, p < 0.05) with nonsurgeon evaluations of leadership. Facilitating engagement related most positively (r = 0.80; p = 0.03), and negative forms of elucidating, ie, criticism, related most negatively (r = -0.81; p = 0.03).Conclusions. We identified 7 surgeon leadership functions and related behaviors that impact perceptions of leadership. These observations suggest actionable opportunities to improve team leadership behavior. (C) 2017 The Authors. Published by Elsevier Inc. on behalf of The Society of Thoracic Surgeons.

Error rates in surgery are high relative to other areas of healthcare, with preventable errors more likely to be related to nontechnical issues such as failures in teamwork. Drawing on 34 semi-structured interviews with cardiac surgery professionals and observations of 22 cardiac surgery cases, this article explores factors that affect teamwork in cardiac surgery operating rooms in order to inform the design of evidence-based interventions to improve teamwork. Participants held a largely shared mental model of ideal teamwork wherein clinical work was well coordinated and flowed effortlessly. Relational competence and surgeons’ leadership were considered important, but there were discrepancies in participants’ preferences for how these interactions should look in practice, leading to tension and divergent expectations. Team functioning also depended on contextual factors, including case-related factors, team composition, local organisational culture, and organisational processes. The findings reveal the contingent nature of surgical teamwork: wider institutional, professional and cultural contexts impact team functioning through influencing surgical team members’ expectations and by constraining or enabling team members’ enactment of ideal team behaviours. Thus interventions to improve teamwork need to address the multifaceted ways in which healthcare institutions promote or curtail opportunities to acquire and enact the nontechnical skills that support effective teamwork.

In the United States, the Centers for Disease Control and Prevention estimates more than 50 million procedures are performed every year [1]. In the era of physician report cards, transparency, medical innovation, increased litigation, and hybridization or cross-disciplinary nature of surgery, privileging for new technology continues to lack a standardized process for implementation. With the absence of established national standards to direct granting of privileges for new technology, The Society of Thoracic Surgeons (STS) convened a task force to address this problem and create a pathway, checklist, and list of recommendations to guide the process.

Objective: Failure of anastomotic healing is a rare but serious complication of laryngotracheal resection. Treatment options include reoperation, tracheostomy, or T-tube placement. Hyperbaric oxygen therapy (HBOT) is the delivery of 100% O-2 at pressures greater than 1 atm, and has been shown to enhance wound healing after tracheal resection in animal models. To date, there have been no reports describing its usefulness in humans after tracheal resection.Methods: Five consecutive patients with varying degrees of failed anastomotic healing, from necrotic cartilage to partial separation identified by bronchoscopy were treated with HBOT. HBOT was administered for 90 minutes via a hyperbaric chamber pressurized to 2 atm with 100% oxygen. Patients were treated with daily or twice daily HBOT. Four of 5 patients had buttressing of the anastomosis by strap muscle at the initial surgery.Results: All patients had evidence of anastomotic healing on bronchoscopy. None of the patients in this series required tracheostomy, T-tube, or reoperation after initiation of HBOT. On average it took 9.6 days for healing to occur (5-14 days). The size of the anastomotic defect ranged between 3 and 13 mm. One patient required bilateral tympanostomy tubes for inner ear discomfort and experienced blurry vision as complications of HBOT. One patient developed tracheal stenosis from granulation tissue that required bronchoscopic debridement.Conclusions: In select patients with anastomotic complications after tracheal resection, HBOT may aid in healing and avoid tracheostomy. Future investigations are necessary to further define the benefits of HBOT in the management of airway anastomotic complications.