OBJECTIVES:To evaluate a single center's experience with intraoperative sonic estimation of elasticity via resonance (SEER)-guided hemostasis management in adult cardiac surgical patients; to explore whether transfusion decisions that were concordant with predefined SEER cutoffs were associated with less bleeding and transfusion in the first 24 hours; and to explore the relationship among SEER cutoffs, intraoperative transfusion, and postoperative chest drain output. DESIGN:A retrospective cohort study. SETTING:A single academic medical center. PARTICIPANTS:Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) over a 1-year period. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Patient characteristics, surgical details, and SEER measurements prior to separation from CPB were recorded. The primary study outcome was transfusion decision concordance with predefined SEER cutoffs for relevant blood products. Secondary outcomes were 24-hour chest drain output, red blood cell transfusion in the first 24 hours after surgery, and reoperation for bleeding. Overall, 260 of 448 patients (52.0%) had transfusion decisions that were fully concordant with predefined SEER cutoffs. In 448 patients, 83.9% of the platelet transfusion decisions were concordant with the platelet contribution to clot stiffness (PCS) cutoff, 76.3% of cryoprecipitate transfusion decisions were concordant with the fibrinogen contribution to clot stiffness (FCS) cutoff, and 86.6% of plasma transfusion decisions were concordant with the clotting time heparinase (CTH) cutoff. Patients who were transfused concordantly with cutoffs had lower median 24-hour chest drain output (310 mL vs 362 mL), a lower rate of RBC transfusion in the 24 hours after surgery (7.3% vs 15.4%), and fewer reoperations for bleeding (2.7% vs 6.4%) (p < 0.05 for all). Lower PCS and FCS values were associated with more intraoperative blood loss and higher 24-hour chest drain output. CONCLUSIONS:In the majority of cases, providers made transfusion decisions that were concordant with predefined SEER cutoffs. Patients with transfusion decisions that were concordant with SEER cutoffs appeared to have less postoperative bleeding.

Objective:Coronary artery bypass grafting is associated with a significant risk of blood transfusion. The clinical efficacy of retrograde autologous priming, a potential blood conservation strategy, lacks consensus. We aim to evaluate the effect of retrograde autologous priming on transfusion requirements and clinical outcomes in patients undergoing coronary artery bypass grafting. Methods:A retrospective review was conducted on all patients undergoing on-pump, isolated coronary artery bypass grafting between October 2018 and March 2023 at a single institution. Those undergoing retrograde autologous priming were identified and compared with non-retrograde autologous priming cases. Wilcoxon rank-sum and chi-square analyses were used to analyze continuous and categorical outcomes, respectively. Risk-adjusted multivariable logistic regression was performed. Results:A total of 1109 patients met inclusion criteria, with 332 (29.9%) receiving retrograde autologous priming. At baseline, patients in the retrograde autologous priming group had higher preoperative hemoglobin (14.0 g/dL vs 13.7 g/dL, P = .03), higher nadir intraoperative hemoglobin (10.2 g/dL vs 9.7 g/dL, P < .0), and less total crystalloid use (900 mL vs 110 0 mL, P < .01) in the operating room. On risk-adjusted analysis, including adjustment for preoperative hemoglobin levels, retrograde autologous priming was found to significantly reduce the risk of postoperative blood transfusion (odds ratio, 0.54, P < .01) and postoperative prolonged ventilation (odds ratio, 0.47, P = .02). Conclusions:Use of retrograde autologous priming may result in fewer transfusions and thus potentially prevent transfusion-associated risks such as prolonged ventilation. Potential mechanisms include avoidance of volume overload and transfusion-related acute lung injury. Retrograde autologous priming should be considered in appropriately selected patients undergoing cardiac surgery.

Objective: We examined trainees in surgery and internal medicine who received National Institutes of Health (NIH) F32 postdoctoral awards to determine their success rates in obtaining future NIH funding. Summary Background Data: Trainees participate in dedicated research years during residency (surgery) and fellowship (internal medicine). They can obtain an NIH F32 grant to fund their research time and have structured mentorship. Methods: We collected NIH F32 grants (1992-2021) for Surgery Departments and Internal Medicine Departments from NIH RePORTER, an online database of NIH grants. Non-surgeons and non-internal medicine physicians were excluded. We collected demographic information on each recipient including gender, current specialty, leadership positions, graduate degrees, and any future NIH grants they received. A Mann-Whitney U test was used for continuous variables and a χ 2 test was utilized to analyze categorical variables. An alpha value of 0.05 was used to determine significance. Results: We identified 269 surgeons and 735 internal medicine trainees who received F32 grants. A total of 48 surgeons (17.8%) and 339 internal medicine trainees (50.2%) received future NIH funding ( P < 0.0001). Similarly, 24 surgeons (8.9%) and 145 internal medicine trainees (19.7%) received an R01 in the future ( P < 0.0001). Surgeons who received F32 grants were more likely to be department chair or division chief ( P =0.0055 and P < 0.0001). Conclusions: Surgery trainees who obtain NIH F32 grants during dedicated research years are less likely to receive any form of NIH funding in the future compared to their internal medicine colleagues who received F32 grants.

Extensive repair of thoracoabdominal aneurysms carries significant risk. Previously, operative outcomes following hybrid thoracic endovascular aortic repair (TEVAR) with open distal thoracoabdominal repair have been promising. However, the long-term durability of this approach remains unclear. The purpose of this study is to further define long-term aortic and graft related-events after hybrid extensive thoracoabdominal aortic repair, both those planned and staged initially, as well as those performed for distal degeneration following surveillance. Between March 2007 and May 2022, 53 patients underwent hybrid thoracoabdominal repairs at a single institution. Baseline characteristics, long-term adverse events, and primary patency were collected. Aortic events were defined as aortic pathologies leading to reintervention or death. Open graft events involved the distal open graft. TEVAR events were related to the endograft only. Open graft events and TEVAR events constitute repair-related events. The mean follow-up was 4.2 ± 3.3 years with the surveillance group followed for longer (5.2 ± 0.7 vs 3.1 ± 0.5, P = .025) (Tables I and II). The mean age was 56.1 ± 15.2 years with 33 males (62%). While most patients were treated for chronic dissection (n = 41; 77%), 42% of the planned, staged repair cohort were repaired for degenerative aneurysms (P < .001). During follow-up, there were eight mortalities (15%), four related to aortic events. Overall, there were nine (17%) aortic, six (11%) open graft, and four (8%) TEVAR events. Aortic size decreased following hybrid repair at 1 month (53.8 ± 1.7 vs 63.3 ± 1.3; P < .001), 6 months (52.6 ± 1.8 vs 63.3 ± 1.7; P < .001), and 12 months (51.1 ± 1.8 vs 63.4 ± 1.7; P < .001). At 12 months, primary patency rates were 97.4% for the celiac, 100% for the SMA, 89.5% for the left renal, and 92.1% for the right renal. Despite being older (P = .009), patients undergoing planned, staged repair trended toward having fewer TEVAR events (0% vs 15%; P = .11), repair-related events (8% vs 30%; P = .076), and events in general (19% vs 44%; P = .077). Multivariate logistic regression controlling for age, duration between TEVAR and open repair, follow-up length, and dissection percentage showed that planned repair was associated with fewer repair-related events (odds ratio, 0.03; 95% confidence interval, 0.002-0.611; P = .02; area under the curve, 0.85) (Tables I and II). Despite limited power, there are trends toward fewer adverse events in the planned, staged repair group. When confounders were controlled, planned hybrid repair shows a correlation with reduced repair-related events. Early full repair should be considered in patients with larger distal diseases. The long-term outcome of hybrid repair appears reasonable given the largely dissection-related patient population. Moreover, extensive hybrid TEVAR/open repair is associated with favorable aortic remodeling and patency at one year.Table IPreoperative characteristics and long-term outcomes between surveilled and planned hybrid repairTotalSurveillancePlannedP valuen = 53n = 27n = 26Demographics Age (pre-TEVAR)56.1 ± 15.250.8 ± 15.261.5 ± 13.4.009 Gender (male)33 (62%)20 (74)13 (50).093 Indication<.001Aneurysmal disease only12 (23)1 (4)11 (42)Dissection with aneurysm dilatation41 (77)26 (96)15 (58) Days between TEVAR and thoracoabdominal aortic aneurysm140.0 (59.0-527.0)489.0 (152.0-877.0)69.0 (47.0-125.0)<.001Long-term results Duration of follow-up4.2 ± 3.35.2 ± 3.73.1 ± 2.6.025 Mortality during follow-up8 (15)5 (19)3 (12).70 Aortic events9 (17)6 (22)3 (12).47 Open graft events6 (11)4 (15)2 (8)1.00 TEVAR events4 (8)4 (15)0 (0).11 Repair-related events10 (19)8 (30)2 (8).076 Any events17 (32)12 (44)5 (19).077TEVAR, thoracic endovascular aortic repair.Values are mean ± standard deviation, median (interquartile range) or number (%). Open table in a new tab Table IIMultivariate logistic regression of predictors for repair-related eventsLR, 16.5; P = .005Odds ratioStandard errorzP > z[95% confidence interval]Age0.9320.037−1.760.0780.8621.008Dissection0.0450.079−1.750.0790.0011.440Follow-up length1.0000.0000.100.9210.9991.001Planned hybrid repair0.0330.049−2.290.0220.0020.611TEVAR and open interval0.9980.001−1.620.1050.9951.000TEVART, Thoracic endovascular aortic repair. Open table in a new tab

The management of patients on direct oral anticoagulants (DOACs) who require emergent cardiac surgery is slowly evolving. The introduction of andexanet alfa, a novel antidote for apixaban and rivaroxaban, added a specific reversal agent to our armamentarium, but its safety and efficacy are still being investigated. We report 2 patients on DOAC treatment who required emergency cardiac surgery. Both received perioperative andexanet alfa together with prothrombin complex concentrate (PCC) at some time during 6 hours before operative management. Heparin resistance was noted in each instance, and pump thrombosis developed in 1 case.

Allogeneic mesenchymal precursor cells (MPCs) have direct cardiac and systemic effects. An important question in stem cell research is whether MPCs have a differential effect based on heart failure etiology. A recent NIH-funded phase II trial of allogeneic mesenchymal precursor cells (MPCs) injected

Introduction: Thoracic aortic repair has risk of brain and spinal cord ischemia. We hypothesized that GSK1278863, an oral prolyl hydroxylase inhibitor (PHI) will reduce cerebrospinal fluid (CSF) markers of injury, clinical strokes, and spinal infarcts via upregulation of hypoxia inducible factor and erythropoietin (EPO). Methods: Double blind randomized trial at 15 sites in North America (funded by GSK) comparing GSK1278863 to placebo in patients undergoing thoracic aortic repair with lumbar drain, stratified by open surgery or stenting. Subjects received 300mg study medication the evening before surgery and then 100mg daily for 4 days. The primary outcome was change in CSF S100β and Glial Fibrillary Acidic Protein (GFAP) from baseline to peak within 48 hours. Results: The study planned to enroll 160 patients but halted early due to more serious adverse events (SAEs) in patients on GSK1278863. Fifty-five patients were enrolled, 39 (71[percnt]) open surgery and 16 (29[percnt]) stenting, mean age 61.5 (±14.5), 19 (35[percnt]) female, 12 (22[percnt]) non-white. Treatment arms were balanced at baseline except for higher risk surgical anatomy in patients receiving GSK1278863. There were trends toward greater changes in CSF S100β (2772 vs 543 ng/L, p=0.08) and GFAP (1070 vs 292 ug/L, p=0.2) on GSK1278863. Change in CSF EPO level from baseline to peak was greater in patients given GSK1278863 (18 vs -16 U/L, p<0.001). Stroke occurred in 7 patients (4 GSK1278863 and 3 placebo, p=0.70) and spinal ischemia in 12 (9 GSK1278863 and 3 placebo, p=0.06). Patients given GSK1278863 had more SAEs, 20 (74[percnt]) vs 14 (50[percnt]), p=0.10, and deaths, 6 (22[percnt]) vs 2 (7[percnt]), p=0.14. Conclusions: Perioperative GSK1278863 was associated with more clinical events and SAEs but this is potentially confounded by imbalanced surgical risk in this small study. Overall, neurologic complications were common in this high risk population and additional studies of neuroprotection are needed.

Left ventricular assist devices (LVADs) are increasingly utilized in the management of advanced heart failure. A transcutaneous driveline is necessary to power the LVAD, and although this technology has improved over the years in terms of smaller size and increased durability, driveline complications continue to develop in up to 20% of all devices implanted. Driveline infections are associated with significant morbidity and mortality. As more patients live longer with ventricular assist devices, minimizing driveline infections is paramount. A systematic, multidisciplinary approach can be used to develop a strategy to prevent, recognize and treat driveline infections. In this paper, we describe our approach to driveline management which has resulted in zero driveline infections between January 2012 and March 2014.