Congenital heart defects (CHDs) are complex conditions affecting the heart and/or great vessels that are present at birth. These defects occur in approximately 9 in every 1000 live births. From diagnosis to intervention, care has dramatically improved over the last several decades. Patients with CHDs are now living well into adulthood. However, there are factors that have been associated with poor outcomes across the lifespan of these patients. These factors include sociodemographic and socioeconomic positions. This commentary examined the disparities and solutions within the evolution of CHD care in the United States.

OBJECTIVE:Patients are increasingly using the internet to obtain health care information. US News and World Report Best Hospital rankings received more than 103 million views in 2021. Considering 21% of thoracic surgery patients are minorities, 27.9% are in the bottom quartile of household income, and 70% have Medicare/Medicaid or no insurance, online patient educational materials (PEMs) should be accessible and written at a level easily understood by majority of patients. We performed a comprehensive analysis of readability of websites containing patient-centered resources across all adult thoracic surgery areas.METHODS:Online PEMs on thoracic surgical procedures were collected from top 50 hospitals for pulmonology and lung surgery ranked by US News and World Report Best Hospital as of December 1, 2021. Text pertaining to thoracic surgical procedures was collected and divided into 4 procedural genres: esophageal, lung, transplant procedures, and other. Texts were analyzed using OleanderSoftware's Readability Suite through the Raygor readability test.RESULTS:Three hundred seventy-two articles met criteria for analysis. Websites were difficult to read; mean (standard deviation) readability score for all content required a 13.9 (3.6) grade level for comprehension. The mean (standard deviation) readability for esophageal, lung, lung transplant, and other surgeries were 14.5 (3.6), 13.1 (3.6), 11.5 (3.9), and 13.4 (3.7), respectively.CONCLUSIONS:Online PEMs required at least a college reading level to comprehend, well exceeding the sixth-grade level recommended by the American Medical Association. As digital health becomes increasingly relevant, improving the readability of online PEMs in adult cardiac surgery will facilitate equitable access to high-quality care.

Objective: Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. Methods: From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). Results: Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). Conclusions: The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

OBJECTIVES:To identify preoperative predictors of postcardiotomy cardiogenic shock in patients with ischemic and nonischemic cardiomyopathy and evaluate trajectory of postoperative ventricular function. METHODS:From January 2017 to January 2020, 238 patients with ejection fraction <30% (206/238) or 30% to 34% with at least moderately severe mitral regurgitation (32/238) underwent conventional cardiac surgery at Cleveland Clinic, 125 with ischemic and 113 with nonischemic cardiomyopathy. Preoperative ejection fraction was 25 ± 4.5%. The primary outcome was postcardiotomy cardiogenic shock, defined as need for microaxial temporary left ventricular assist device, extracorporeal membrane oxygenation, or vasoactive-inotropic score >25. RandomForestSRC was used to identify its predictors. RESULTS:Postcardiotomy cardiogenic shock occurred in 27% (65/238). Pulmonary artery pulsatility index <3.5 and pulmonary capillary wedge pressure >19 mm Hg were the most important factors predictive of postcardiotomy cardiogenic shock in ischemic cardiomyopathy. Cardiac index <2.2 L·min-1 m-2 and pulmonary capillary wedge pressure >21 mm Hg were the most important predictive factors in nonischemic cardiomyopathy. Operative mortality was 1.7%. Ejection fraction at 12 months after surgery increased to 39% (confidence interval, 35-40%) in the ischemic group and 37% (confidence interval, 35-38%) in the nonischemic cardiomyopathy group. CONCLUSIONS:Predictors of postcardiotomy cardiogenic shock were different in ischemic and nonischemic cardiomyopathy. Right heart dysfunction, indicated by low pulmonary artery pulsatility index, was the most important predictor in ischemic cardiomyopathy, whereas greater degree of cardiac decompensation was the most important in nonischemic cardiomyopathy. Therefore, preoperative right heart catheterization will help identify patients with low ejection fraction who are at greater risk of postcardiotomy cardiogenic shock.

In this issue of Seminars in Thoracic and Cardiovascular Surgery, Aranda-Michel and colleagues evaluated the change in cardiothoracic surgery residency application towards a more holistic approach. This is a shift away from traditional numerical metrics such as USMLE scores to research, sub-internships and away rotations, interviews, and letters of recommendation (LOR). 1 Aranda-Michel E. Trager L.E. Han J.J. et al. Considerations for a holistic model in evaluating medical students for cardiothoracic surgical residency. Semin Thorac Cardiovasc Surg. 2022; (in press) Abstract Full Text Full Text PDF Scopus (1) Google Scholar Reply: A Paradigm Shift is Starting PointSeminars in Thoracic and Cardiovascular SurgeryPreviewWe thank Marrero et al for their thoughtful response to our recent manuscript exploring the changing evaluatory paradigms in cardiothoracic surgery.1,2 Discourse is essential to any paradigm shift, as we all grapple with what these new ideas signify in the context of our own lives and programs, and their letter raises thoughtful questions about equitability. Full-Text PDF Considerations for a Holistic Model in Evaluating Medical Students for Cardiothoracic Surgical ResidencySeminars in Thoracic and Cardiovascular SurgeryPreviewProgram directors are tasked with selecting whom they think will be the best fit for residency and the next leaders of the field. While numerical metrics have played a vital role in this process, recent changes to student evaluation are reducing the availability of these metrics. This poses unique challenges for both applicants and program directors. Here we discuss how this will likely shift the focus on other parts of the application and the consequences (good and bad) of doing so. Full-Text PDF

Objective: To maximize successful repair of bicuspid aortic valves by adding figure- of-8 hitch -up stitches at commissures. Methods: From 2000 to 2022, bicuspid aortic valve repair was performed on 1112 patients at Cleveland Clinic, with 367 patients receiving figure -of -8 hitch -up stitches along with classical techniques, including Cabrol suture, cusp plication, raphe resection, and valve -sparing root replacement. Operative outcomes, repair durability, and survival were assessed in the figure -of -8 hitch -up stitches cohort, and outcomes were compared among 195 balancing -score -matched patient pairs who underwent bicuspid aortic valve repair with and without figure -of -8 hitch -up stitches. Results: Patients who underwent bicuspid aortic valve repair with figure -of -8 stitches had an operative mortality of 0.3 % (1 of 367) and in -hospital reoperation for aortic valve dysfunction of 1.1 % (4 of 367). At 10 years, prevalence of severe aortic regurgitation was 8.6 % , mean gradient 24 mm Hg, freedom from aortic valve reoperation 75 % , and survival 98 % . In matched cohorts, operative mortality was similar (0.51 % vs 0 % ; P > .9) as were morbidities, including in -hospital reoperation due to aortic valve dysfunction (1.0 % vs 1.5 % ; P > .9). Comparable long-term outcomes were observed at 10 years (prevalence of severe aortic regurgitation of 8.7 % vs 5.0 % [ P = .11], mean gradient 18 vs 17 mm Hg [ P = .40]; freedom from aortic valve reoperation 80 % vs 81 % [ P = .73]; and survival 99.5 % vs 94.6 % [ P = .18]). Conclusions: Figure -of -8 hitch -up stitch is a safe bicuspid aortic valve repair technique. It increases the likelihood of a successful repair without increasing risk of cusp tear and achieves satisfactory long-term survival and durability when added to classical repair techniques. (JTCVS Techniques 2024;24:27-40)

BACKGROUND In 2007, congenital cardiac surgery became a recognized fellowship by the American Council of Graduate Medical Education (ACGME). Beginning in 2023, the fellowship transitioned from a 1-year to a 2-year program. Our objective is to provide current benchmarks by surveying current training programs and assessing characteristics contributing to career success. METHODS This was a survey-based study in which tailored questionnaires were distributed to program directors (PDs) and graduates of the ACGME accredited training programs. Data collection included responses to multiple-choice and open-ended questions relevant to didactics, operative training, training center characteristics, mentorship, and employment characteristics. Results were analyzed using summary statistics and subgroup and multivariable analyses. RESULTS The survey yielded responses from 13 of 15 PDs (86%) and 41 of 101 graduates (41%) from ACGME accredited programs. Perceptions among PDs and graduates were somewhat discordant, with PDs more optimistic than graduates. Of PDs, 77% (n = 10) believed current training adequately prepares fellows and is successful in securing employment for graduates. The responses from graduates demonstrated 30% (n = 12) were dissatisfied with operative experience and 24% (n = 10) with overall training. Being supported during the first 5 years of practice was significantly associated with retention in congenital cardiac surgery and greater practicing case volumes. CONCLUSIONS Dichotomous views exist between graduates and PDs regarding success in training. Mentorship during the early career was associated with increased case volumes, career satisfaction, and retention in the congenital cardiac surgery field. Educational bodies should incorporate these elements during training and after graduation.

A workforce reflective of the patient population promotes a successful and clinically effective specialty.1 Diverse health care teams have been shown to improve quality of care and patient satisfaction, address health disparities, and foster medical innovation. In the October 2022 issue of The Annals of Thoracic Surgery, Zhu and colleagues2 evaluated racial and gender diversity in cardiothoracic surgery training.

In the June 2022 issue of the Canadian Journal of Cardiology, Rahmouni and colleagues reviewed management strategies for aortic stenosis in the low-risk patient. 1 Rahmouni K. Buchko M. Boodhwani M. et al. Aortic stenosis in the low-risk patient: overview of the management options and possible permutations. Can J Cardiol. 2022; 38: 836-839 Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar We commend the authors for their well-written overview. Although the treatment for aortic valve pathologies in older patients is more straightforward, the ideal treatment in younger low-risk patients remains a subject of debate. 2 Chen L. Salim Hammoud M. Jiang M. Bakir N. Karamlou T. Age- and sex-matched controls should not be the standard for the Ross procedure. JTCVS Open. 2022; https://doi.org/10.1016/j.xjon.2022.05.015 Abstract Full Text Full Text PDF Scopus (1) Google Scholar This subset of patients constitutes a clinical challenge owing to longer life expectancy and higher cumulative lifetime risk of prosthesis-related complications. Aortic Stenosis in the Low-Risk Patient: Overview of the Management Options and Possible PermutationsCanadian Journal of CardiologyVol. 38Issue 6PreviewAortic valve intervention can take several forms: surgical valve replacement with a stented or stentless bioprosthesis or with a mechanical prosthesis, transcatheter aortic valve implantation (TAVI), and the Ross procedure.1 Although the choice of strategy is often straightforward in the elderly and high-risk population, young and low-risk patients with aortic stenosis are challenging to the heart team, namely because of their longer life expectancy, and higher cumulative lifetime risk of valve-related complications. Full-Text PDF

In this issue of The Annals of Thoracic Surgery, Sengupta and colleagues 1 Sengupta A. Gauvreau K. Kohlsaat K. et al. Intraoperative technical performance score predicts outcomes after congenital cardiac surgery. Ann Thorac Surg. 2023; 115: 471-478 Abstract Full Text Full Text PDF Scopus (8) Google Scholar from Boston Children’s Hospital evaluate the utility of the intraoperative technical performance score (IO-TPS) to prospectively identify patients who may benefit from early reintervention during the index admission. This metric could represent a critical improvement, given that the IO-TPS presents an opportunity for repair revision during the index operation. Among 6792 patients who underwent surgery between 2011 and 2019, 2042 patients had residual lesions, most of which were valvular lesions involving the atrioventricular valve in 53.7% and the semilunar valve in 23.6%. In addition, the primary outcome (a composite of in-hospital mortality, transplant, early reintervention, and new permanent pacemaker), observed in 784 patients (11.5%), was associated with the IO-TPS. Intraoperative Technical Performance Score Predicts Outcomes After Congenital Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 115Issue 2PreviewThe utility of the intraoperative technical performance score (IO-TPS) in predicting outcomes after congenital cardiac surgery remains unknown. Full-Text PDF

Objective: Intravascular ultrasound (IVUS) use in lower extremity interventions is growing in popularity owing to its imaging in the axial plane, superior detail in imaging lesion characteristics, and its enhanced ability to delineate lesion severity and extent compared with catheter angiograms. However, there are conflicting data regarding whether IVUS affects outcomes. The purpose of this study was to assess the effect associated with IVUS implementation in femoropopliteal interventions. Methods: This retrospective cohort study used Vascular Quality Initiative data. Patients undergoing an index endovascular femoropopliteal revascularization from 2016 to 2021 were included. Patients were differentiated by whether or not IVUS was used to assess the femoropopliteal segment during intervention (no IVUS, IVUS). Propensity score matching, based on preoperative demographics and measures of disease severity was used. Primary outcomes were major amputation-free survival (AFS), femoropopliteal reintervention-free survival (RFS), and primarily patent survival (PPS) at 12 months. Results: IVUS use grew steadily throughout the study period, comprising 0.6% of interventions in 2016 and increasing to 8.2% of interventions by 2021; growth was most dramatic in ambulatory surgical center or office-based laboratory settings where IVUS use grew from 4.4% to 43% to 47% of interventions. In unmatched cohorts, patients receiving interventions using IVUS tended to have lower prevalence of multiple cardiovascular comorbidities (eg, congestive heart failure, hypertension, diabetes, and dialysis dependence) and presented more often with claudication and less often with chronic limb-threatening ischemia (CLTI). Intraoperatively, IVUS was used more often in complex femoropopliteal lesions (Transatlantic Intersociety grade D vs A), and more often in conjunction with stenting and/or atherectomy. IVUS use was associated with improved AFS, but similar RFS and PPS at 12 months. However, in multivariable analysis IVUS was not associated with any of the primary outcomes independently; rather, all outcomes were influenced primarily by CLTI, dialysis dependence, and prior major amputation status; technical outcomes (ie, RFS and PPS loss) were further driven by complexity of lesion (worse in Transatlantic Intersociety grade D vs A lesions) and treatment setting (ie, ambulatory surgical center or office-based laboratory setting associated with increased hazard for RFS and PPS loss). Conclusions: IVUS implementation in femoropopliteal interventions is growing, with rapid adoption among interventions in ambulatory surgical centers and office-based laboratories. IVUS was not associated with an effect on technical outcomes at 12 months; improvement in major AFS was observed; however, multivariable analysis suggests this finding may be an effect of confounding by multiple factors highly associated with IVUS use, namely, in patients with lower prevalence of CLTI, dialysis dependence, and prior major amputations, thus conveying baseline lower risk for major amputation and death.

Program Directors, faculty involved in resident education, and professional societies such as the Thoracic Surgery Medical Student Association are uniquely positioned to promote and increase the utilization of Underrepresented in Medicine Visiting Medical Student Clerkship Programs. Reply to a Letter to the Editor – Cardiothoracic Surgery Training Program Directors Have a Fiduciary Responsibility for Diverse RecruitmentSeminars in Thoracic and Cardiovascular SurgeryVol. 35Issue 1PreviewThe cardiothoracic surgery specialty needs to intentionally invest in a next generation of surgeons who reflect the increasingly diverse patient population of the United States. Finding, recruiting, and retaining talented future cardiothoracic surgeons, many of whom are future healthcare leaders, requires awareness of the systemic barriers diverse trainees face, and support of initiatives that eliminate attrition. In response to our analysis of program director awareness of readily available Underrepresented in Medicine Visiting Student Clerkship Programs,1 Chen et al. Full-Text PDF

Endovascular interventions are a mainstay of treating aortoiliac occlusive disease. Intravascular ultrasound (IVUS) imaging offers unique information capable of identifying lesions missed by catheter angiography. The specific benefit of IVUS for aortoiliac interventions remains unclear as prior studies detail mixed outcomes. The purpose of this study is to evaluate the impact of IVUS on outcomes in endovascular interventions for aortoiliac occlusive disease.

Latifi, Mani1; Chen, Lin2; Hua, Vivian2; Lane, Charles1; Mireles-Cabodevila, Eduardo3; Tolle, Leslie1; Duggal, Abhijit4; Krishnan, Sudhir1 Author Information

Introduction: Patients are increasingly using the Internet to obtain healthcare information. Considering 21% of cardiac surgery patients are minorities, 27.9% are in the bottom quartile of household income, and 70% have Medicare/Medicaid or no insurance, online patient educational materials (PEMs) should be accessible and written at a level easily understood by majority of patients. We performed a comprehensive analysis of readability of websites containing patient-centered resources across all adult cardiac surgery areas. Hypothesis: Methods: Online PEMs on cardiac surgical procedures (CSP) were collected from top 50 hospitals for cardiology and heart surgery ranked by US News and World Report as of December 1st, 2021. Text pertaining to CSPs was collected and divided into five procedural genres: mitral valve, coronary artery bypass, heart transplant, aortic valve, and aortic surgeries. Texts were analyzed using OleanderSoftware’s Readability Suite through the Raygor readability test. Results: N=282 articles met criteria for analysis. Online content for all 5 surgical genres were difficult to read, with mean (SD) grade level readability score for all content at 13.8 (3.1, panel a). The mean (SD) readability for mitral valve, coronary artery bypass, heart transplant, aortic valve, and aortic surgeries were 14.4 (3.0, panel b), 13.9 (3.3, panel c), 12.2 (2.7, panel d), 13.5 (3.1, panel e), and 14.3 (2.8, panel f) respectively. Online resources for content within the 5 genres required at least college reading level for comprehension. Conclusions: Online PEMs exceeded the sixth-grade level recommended by the American Medical Association and the second-grade level previous established at our institution in all included genres of adult cardiac surgery. Improving the readability of online PEMs in adult cardiac surgery will facilitate equitable access to high-quality care.

Central MessageA novel technique of “inverted” rat lung transplant with left donor lung rotated 180° and implanted to recipient contralateral/right chest provides a promising model for future experiments.See Article page 429.Animal models have been a cornerstone in the development of lung transplantation. The first long-term clinical successes with heart–lung transplant at Stanford in 1981 and isolated lung transplantation by the Toronto group in 1983 were built on preceding decades of animal model research.1Venuta F. Van Raemdonck D. History of lung transplantation.J Thorac Dis. 2017; 9: 5458-5471Crossref PubMed Scopus (31) Google Scholar,2Bribriesco A.C. Li W. Nava R.G. Spahn J.H. Kreisel D. Experimental models of lung transplantation.Front Biosci (Elite Ed). 2013; 5: 266-272Crossref PubMed Google ScholarEarly animal experiments were aimed at developing surgical techniques, such as en bloc double-lung transplantation in canine models.3Dark J.H. Patterson G.A. Al-Jilaihawi A.N. Hsu H. Egan T. Cooper J.D. Experimental en bloc double-lung transplantation.Ann Thorac Surg. 1986; 42: 394-398Abstract Full Text PDF PubMed Scopus (36) Google Scholar Presently, more cost-effective and reproducible rodent models are the predominant platform for mechanistic experiments in exploring critical items such as primary graft dysfunction, acute rejection, and chronic lung allograft dysfunction. Compared with other lung transplant models such as hilar occlusion or tracheal transplant, orthotopic left lung transplantation (OLLT) is a robust and versatile experimental technique that most closely simulates the human situation.4Lama V.N. Belperio J.A. Christie J.D. El-Chemaly S. Fishbein M.C. Gelman A.E. et al.Models of lung transplant research: a consensus statement from the National Heart, Lung, and Blood Institute workshop.JCI Insight. 2017; 2: e93121Crossref PubMed Scopus (37) Google Scholar, 5Okazaki M. Krupnick A.S. Kornfeld C.G. Lai J.M. Ritter J.H. Richardson S.B. et al.A mouse model of orthotopic vascularized aerated lung transplantation.Am J Transplant. 2007; 7: 1672-1679Crossref PubMed Scopus (126) Google Scholar, 6Lin X. Li W. Lai J. Okazaki M. Sugimoto S. Yamamoto S. et al.Five-year update on the mouse model of orthotopic lung transplantation: scientific uses, tricks of the trade, and tips for success.J Thorac Dis. 2012; 4: 247-258PubMed Google Scholar However, there are notable limitations to the OLLT model. Anatomically, the rodent left lung consists of only 1 lobe compared with the 5 lobes of the right such that the contribution from the transplanted left lung can be completely masked by the native right lung. This negates the important experimental end point of animal survival as a marker of allograft status. Orthotopic right lung transplant has been described but is technically more challenging, thereby hindering widespread adoption.7Li W. Sugimoto S. Lai J. Patterson G.A. Gelman A.E. Krupnick A.S. et al.Orthotopic vascularized right lung transplantation in the mouse.J Thorac Cardiovasc Surg. 2010; 139: 1637-1643Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar To date, orthotopic bilateral lung transplant (either en bloc or sequential) in the rodent has not been achieved.In this issue of JTCVS Open, Huang and colleagues8Huang H. Yan H.-J. Zheng X.-Y. Wang J.J. Tang H.T. Li C.H. et al.Right lung transplantation with a left-to-right inverted anastomosis in a rat model.J Thorac Cardiovasc Surg Open. 2022; 10: 429-439Scopus (1) Google Scholar turn the tables of the animal model-to-human paradigm with a technical report of a novel “inverted” rat single-lung transplant procedure inspired by the Kyoto group's successful human lobar lung transplantation of a right lower lobe implanted into the left chest.9Chen F. Miyamoto E. Takemoto M. Minakata K. Yamada T. Sato M. et al.Right and left inverted lobar lung transplantation.Am J Transplant. 2015; 15: 1716-1721Crossref PubMed Scopus (22) Google Scholar Elegantly described and depicted in the accompanying video, a rat donor left lung is rotated 180° and transplanted to the recipient's right chest using a standard 3-cuff anastomotic technique (inverted left-right transplant, IL-RT). This innovative model leverages the anatomic size discrepancy between the smaller left lung versus larger right chest cavity, allowing for a technically simpler and reproducible procedure compared with other techniques of right lung transplant.In 10 IL-RT procedures, the authors report 100% intraoperative technical success with 90% survival to the planned end point of 7 days. Total procedure time was comparable between IL-RT and 10 standard/control OLLT animals (58.2 vs 56.6 minutes, P = not significant). Important experimental details to note were the differences in cold and warm ischemic times between the IL-RT and OLLT groups. When compared with the OLLT, the IL-RT group had shorter cold ischemia time (14 minutes vs 25.5 minutes, P < .001) but longer warm ischemia time (19.8 vs 13.7 minutes, P < .001). It is unclear whether these small absolute differences in ischemic times will have meaningful biologic effect, but these and other facets of the IL-RT model will likely be explored and potentially gainfully used in forthcoming experiments.The authors are to be commended for their impressive technical achievement. As with all animal models, there are limitations to be addressed but, overall, this innovative procedure represents an exciting new tool for future research in lung transplantation. A novel technique of “inverted” rat lung transplant with left donor lung rotated 180° and implanted to recipient contralateral/right chest provides a promising model for future experiments. A novel technique of “inverted” rat lung transplant with left donor lung rotated 180° and implanted to recipient contralateral/right chest provides a promising model for future experiments. See Article page 429. See Article page 429. Animal models have been a cornerstone in the development of lung transplantation. The first long-term clinical successes with heart–lung transplant at Stanford in 1981 and isolated lung transplantation by the Toronto group in 1983 were built on preceding decades of animal model research.1Venuta F. Van Raemdonck D. History of lung transplantation.J Thorac Dis. 2017; 9: 5458-5471Crossref PubMed Scopus (31) Google Scholar,2Bribriesco A.C. Li W. Nava R.G. Spahn J.H. Kreisel D. Experimental models of lung transplantation.Front Biosci (Elite Ed). 2013; 5: 266-272Crossref PubMed Google Scholar Early animal experiments were aimed at developing surgical techniques, such as en bloc double-lung transplantation in canine models.3Dark J.H. Patterson G.A. Al-Jilaihawi A.N. Hsu H. Egan T. Cooper J.D. Experimental en bloc double-lung transplantation.Ann Thorac Surg. 1986; 42: 394-398Abstract Full Text PDF PubMed Scopus (36) Google Scholar Presently, more cost-effective and reproducible rodent models are the predominant platform for mechanistic experiments in exploring critical items such as primary graft dysfunction, acute rejection, and chronic lung allograft dysfunction. Compared with other lung transplant models such as hilar occlusion or tracheal transplant, orthotopic left lung transplantation (OLLT) is a robust and versatile experimental technique that most closely simulates the human situation.4Lama V.N. Belperio J.A. Christie J.D. El-Chemaly S. Fishbein M.C. Gelman A.E. et al.Models of lung transplant research: a consensus statement from the National Heart, Lung, and Blood Institute workshop.JCI Insight. 2017; 2: e93121Crossref PubMed Scopus (37) Google Scholar, 5Okazaki M. Krupnick A.S. Kornfeld C.G. Lai J.M. Ritter J.H. Richardson S.B. et al.A mouse model of orthotopic vascularized aerated lung transplantation.Am J Transplant. 2007; 7: 1672-1679Crossref PubMed Scopus (126) Google Scholar, 6Lin X. Li W. Lai J. Okazaki M. Sugimoto S. Yamamoto S. et al.Five-year update on the mouse model of orthotopic lung transplantation: scientific uses, tricks of the trade, and tips for success.J Thorac Dis. 2012; 4: 247-258PubMed Google Scholar However, there are notable limitations to the OLLT model. Anatomically, the rodent left lung consists of only 1 lobe compared with the 5 lobes of the right such that the contribution from the transplanted left lung can be completely masked by the native right lung. This negates the important experimental end point of animal survival as a marker of allograft status. Orthotopic right lung transplant has been described but is technically more challenging, thereby hindering widespread adoption.7Li W. Sugimoto S. Lai J. Patterson G.A. Gelman A.E. Krupnick A.S. et al.Orthotopic vascularized right lung transplantation in the mouse.J Thorac Cardiovasc Surg. 2010; 139: 1637-1643Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar To date, orthotopic bilateral lung transplant (either en bloc or sequential) in the rodent has not been achieved. In this issue of JTCVS Open, Huang and colleagues8Huang H. Yan H.-J. Zheng X.-Y. Wang J.J. Tang H.T. Li C.H. et al.Right lung transplantation with a left-to-right inverted anastomosis in a rat model.J Thorac Cardiovasc Surg Open. 2022; 10: 429-439Scopus (1) Google Scholar turn the tables of the animal model-to-human paradigm with a technical report of a novel “inverted” rat single-lung transplant procedure inspired by the Kyoto group's successful human lobar lung transplantation of a right lower lobe implanted into the left chest.9Chen F. Miyamoto E. Takemoto M. Minakata K. Yamada T. Sato M. et al.Right and left inverted lobar lung transplantation.Am J Transplant. 2015; 15: 1716-1721Crossref PubMed Scopus (22) Google Scholar Elegantly described and depicted in the accompanying video, a rat donor left lung is rotated 180° and transplanted to the recipient's right chest using a standard 3-cuff anastomotic technique (inverted left-right transplant, IL-RT). This innovative model leverages the anatomic size discrepancy between the smaller left lung versus larger right chest cavity, allowing for a technically simpler and reproducible procedure compared with other techniques of right lung transplant. In 10 IL-RT procedures, the authors report 100% intraoperative technical success with 90% survival to the planned end point of 7 days. Total procedure time was comparable between IL-RT and 10 standard/control OLLT animals (58.2 vs 56.6 minutes, P = not significant). Important experimental details to note were the differences in cold and warm ischemic times between the IL-RT and OLLT groups. When compared with the OLLT, the IL-RT group had shorter cold ischemia time (14 minutes vs 25.5 minutes, P < .001) but longer warm ischemia time (19.8 vs 13.7 minutes, P < .001). It is unclear whether these small absolute differences in ischemic times will have meaningful biologic effect, but these and other facets of the IL-RT model will likely be explored and potentially gainfully used in forthcoming experiments. The authors are to be commended for their impressive technical achievement. As with all animal models, there are limitations to be addressed but, overall, this innovative procedure represents an exciting new tool for future research in lung transplantation. Right lung transplantation with a left-to-right inverted anastomosis in a rat modelJTCVS OpenVol. 10PreviewRight lung transplantation in rats has been attempted occasionally, but the technical complexity makes it challenging to apply routinely. Additionally, basic research on inverted lobar lung transplantation is scarce because of the lack of a cost-effective experimental model. We first reported right lung transplantation in a rat model using left-to-right inverted anastomosis to imitate the principle of clinically inverted lung transplantation. Full-Text PDF Open Access

Intravascular ultrasound (IVUS) examination use in lower extremity endovascular interventions is growing in popularity owing to its ability to identify lesions missed by catheter angiography. However, there is conflicting data regarding whether IVUS examination aff5cts technical or limb outcomes. The purpose of this study was to assess the independent effect of IVUS examination implementation on technical and limb outcomes in femoropopliteal interventions.

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.The optimal treatment for aortic valve pathology in young patients is a subject of debate in the current literature. This subset of patients constitutes a clinical challenge due to their longer life expectancy and increased lifetime risk of prosthesis-related complications.1Chen L. Salim Hammoud M. Karamlou T. The tale of two valves: role of the Ross procedure for aortic stenosis in young adults.Can J Cardiol. Published online 2022; https://doi.org/10.1016/j.cjca.2022.04.012Abstract Full Text Full Text PDF Scopus (1) Google Scholar With numerous options for aortic valve replacement, the Ross procedure has been championed as the only intervention capable of restoring late survival to that of the age- and sex-matched general population.2David T.E. David C. Woo A. Manlhiot C. The Ross procedure: outcomes at 20 years.J Thorac Cardiovasc Surg. 2014; 147: 85-93Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar, 3El-Hamamsy I. Toyoda N. Itagaki S. Stelzer P. Varghese R. Williams E.E. et al.propensity-matched comparison of the Ross procedure and prosthetic aortic valve replacement in adults.J Am Coll Cardiol. 2022; 79: 805-815Crossref PubMed Scopus (17) Google ScholarDedicated Ross programs have been established at several high-volume tertiary-care centers, with expert surgeons and ancillary staff experienced in the complex postoperative care required by these patients. Notable disparities in access, quality, and cost of tertiary-care centers have been well-established.4Riley W.J. Health disparities: gaps in access, quality and affordability of medical care.Trans Am Clin Climatol Assoc. 2012; 123 (discussion 172-4): 167-172PubMed Google Scholar The patient population at these centers is generally highly educated, wealthier, and has longer life expectancies than the general population.5Evans L.A. Go R. Warsame R. Nandakumar B. Buadi F.K. Dispenzieri A. et al.The impact of socioeconomic risk factors on the survival outcomes of patients with newly diagnosed multiple myeloma: a cross-analysis of a population-based registry and a tertiary care center.Clin Lymphoma Myeloma Leuk. 2021; 21: 451-460.e2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar A recent Society of Thoracic Surgeons Adult Cardiac Surgery Database study of 3054 patients who underwent the Ross procedure across registered centers in North America between 1994 and 2010 reported that 87% of patients were White, compared with 75.1% and 72.4% of the US population from the 2000 and 2010 census, respectively.6Reece T.B. Welke K.F. O'Brien S. Grau-Sepulveda M.V. Grover F.L. Gammie J.S. Rethinking the Ross procedure in adults.Ann Thorac Surg. 2014; 97: 175-181Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar,7US Census BureauRace and ethnicity in the United States: 2000 census and 2010 census.https://www.census.gov/library/visualizations/interactive/race-and-ethnicity-in-the-united-state-2010-and-2020-census.htmlDate accessed: May 20, 2022Google Scholar Our own registry of Ross patients between 1990 and 2021 showed similar disparities, with 94% of patients self-reporting as non-Hispanic White compared with 86.1% and 84.5% of the Ohio population from the 2000 and 2010 census, respectively.7US Census BureauRace and ethnicity in the United States: 2000 census and 2010 census.https://www.census.gov/library/visualizations/interactive/race-and-ethnicity-in-the-united-state-2010-and-2020-census.htmlDate accessed: May 20, 2022Google Scholar The patient population served by tertiary-care centers does not necessarily reflect the overall population. In context, the average Ross patient, a 43-year-old White male, has a 3.3-year longer life expectancy than his Black counterpart.8Centers for Disease Control and PreventionNational Vital Statistics reports (n.d.).https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-02-508.pdfDate accessed: May 20, 2022Google Scholar Appropriate comparisons with age- and sex-matched norms must take into account race in addition to other social determinants of health, such as income, education, marital status, lifestyle factors, and area of residency. This requires more complex analysis than with age- and sex-matched comparisons, so tools from National Institutes of Health data have been constructed to account for such variables.9Foster D. How Long Will I Live? Life expectancy calculator.https://www.blueprintincome.com/tools/life-expectancy-calculator-how-long-will-i-live/Date accessed: May 20, 2022Google ScholarWhile the Ross procedure has demonstrated excellent outcomes with superior hemodynamics and freedom from lifelong anticoagulation, the survival benefit must not be overstated and outcomes from high-volume referral centers should not be overgeneralized. Evidence supporting the efficacy of the Ross procedure is promising but remains inconclusive, resulting in a Class IIB recommendation from the 2020 American College of Cardiology/American Heart Association valve guidelines.10Writing Committee Members Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.J Am Coll Cardiol. 2021; 77: e25-e197Crossref PubMed Scopus (331) Google Scholar We caution against describing the Ross procedure as restorative of survival to age- and sex-matched controls without accounting for confounding factors, such as demographics and social determinants of health. We previously reported poorer quality of life in Ross patients relative to matched aortic valve replacement controls, which may reflect greater patient expectations and a potential overstatement of anticipated quality of life in the informed consent process.11Chen L, Hammoud MS, Ghandour HZ, Artis A, Svensson LG, Johnston DR, et al. Does the Ross operation outperform prosthetic aortic valve replacement in young adults in the long term? Paper presented at: 102nd Annual Meeting of the American Association for Thoracic Surgery; May 14-17, 2022; Boston, Mass.Google Scholar Our center's experience in managing the failed autograft after the Ross operation using a variety of strategies, including the Ross reversal procedure, has also demonstrated successful outcomes in a heterogenous cohort of patients who underwent the initial Ross operation at other centers.12Hussain S.T. Majdalany D.S. Dunn A. Stewart R.D. Najm H.K. Svensson L.G. et al.Early and mid-term results of autograft rescue by Ross reversal: a one-valve disease need not become a two-valve disease.J Thorac Cardiovasc Surg. 2018; 155: 562-572Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 13Chen L. Salim Hammoud M. Mahboubi R. Karamlou T. Pulmonary conduit reoperation following the Ross procedure.Eur J Cardiothorac Surg. Published online May 6, 2022; https://doi.org/10.1093/ejcts/ezac267Crossref Scopus (2) Google Scholar, 14Chen L. Salim Hammoud M. Ghandour H. Frankel W. Karamlou T. Risk of endocarditis extension in Ross reintervention with transcatheter pulmonary valve replacement.J Am Coll Cardiol. 2022; 79: e457https://doi.org/10.1016/j.jacc.2022.01.055Crossref PubMed Scopus (2) Google Scholar In the context of evaluating all potential aortic valve interventions, we emphasize the importance of holistic review of the evidence in shared decision-making. The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The optimal treatment for aortic valve pathology in young patients is a subject of debate in the current literature. This subset of patients constitutes a clinical challenge due to their longer life expectancy and increased lifetime risk of prosthesis-related complications.1Chen L. Salim Hammoud M. Karamlou T. The tale of two valves: role of the Ross procedure for aortic stenosis in young adults.Can J Cardiol. Published online 2022; https://doi.org/10.1016/j.cjca.2022.04.012Abstract Full Text Full Text PDF Scopus (1) Google Scholar With numerous options for aortic valve replacement, the Ross procedure has been championed as the only intervention capable of restoring late survival to that of the age- and sex-matched general population.2David T.E. David C. Woo A. Manlhiot C. The Ross procedure: outcomes at 20 years.J Thorac Cardiovasc Surg. 2014; 147: 85-93Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar, 3El-Hamamsy I. Toyoda N. Itagaki S. Stelzer P. Varghese R. Williams E.E. et al.propensity-matched comparison of the Ross procedure and prosthetic aortic valve replacement in adults.J Am Coll Cardiol. 2022; 79: 805-815Crossref PubMed Scopus (17) Google Scholar Dedicated Ross programs have been established at several high-volume tertiary-care centers, with expert surgeons and ancillary staff experienced in the complex postoperative care required by these patients. Notable disparities in access, quality, and cost of tertiary-care centers have been well-established.4Riley W.J. Health disparities: gaps in access, quality and affordability of medical care.Trans Am Clin Climatol Assoc. 2012; 123 (discussion 172-4): 167-172PubMed Google Scholar The patient population at these centers is generally highly educated, wealthier, and has longer life expectancies than the general population.5Evans L.A. Go R. Warsame R. Nandakumar B. Buadi F.K. Dispenzieri A. et al.The impact of socioeconomic risk factors on the survival outcomes of patients with newly diagnosed multiple myeloma: a cross-analysis of a population-based registry and a tertiary care center.Clin Lymphoma Myeloma Leuk. 2021; 21: 451-460.e2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar A recent Society of Thoracic Surgeons Adult Cardiac Surgery Database study of 3054 patients who underwent the Ross procedure across registered centers in North America between 1994 and 2010 reported that 87% of patients were White, compared with 75.1% and 72.4% of the US population from the 2000 and 2010 census, respectively.6Reece T.B. Welke K.F. O'Brien S. Grau-Sepulveda M.V. Grover F.L. Gammie J.S. Rethinking the Ross procedure in adults.Ann Thorac Surg. 2014; 97: 175-181Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar,7US Census BureauRace and ethnicity in the United States: 2000 census and 2010 census.https://www.census.gov/library/visualizations/interactive/race-and-ethnicity-in-the-united-state-2010-and-2020-census.htmlDate accessed: May 20, 2022Google Scholar Our own registry of Ross patients between 1990 and 2021 showed similar disparities, with 94% of patients self-reporting as non-Hispanic White compared with 86.1% and 84.5% of the Ohio population from the 2000 and 2010 census, respectively.7US Census BureauRace and ethnicity in the United States: 2000 census and 2010 census.https://www.census.gov/library/visualizations/interactive/race-and-ethnicity-in-the-united-state-2010-and-2020-census.htmlDate accessed: May 20, 2022Google Scholar The patient population served by tertiary-care centers does not necessarily reflect the overall population. In context, the average Ross patient, a 43-year-old White male, has a 3.3-year longer life expectancy than his Black counterpart.8Centers for Disease Control and PreventionNational Vital Statistics reports (n.d.).https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-02-508.pdfDate accessed: May 20, 2022Google Scholar Appropriate comparisons with age- and sex-matched norms must take into account race in addition to other social determinants of health, such as income, education, marital status, lifestyle factors, and area of residency. This requires more complex analysis than with age- and sex-matched comparisons, so tools from National Institutes of Health data have been constructed to account for such variables.9Foster D. How Long Will I Live? Life expectancy calculator.https://www.blueprintincome.com/tools/life-expectancy-calculator-how-long-will-i-live/Date accessed: May 20, 2022Google Scholar While the Ross procedure has demonstrated excellent outcomes with superior hemodynamics and freedom from lifelong anticoagulation, the survival benefit must not be overstated and outcomes from high-volume referral centers should not be overgeneralized. Evidence supporting the efficacy of the Ross procedure is promising but remains inconclusive, resulting in a Class IIB recommendation from the 2020 American College of Cardiology/American Heart Association valve guidelines.10Writing Committee Members Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.J Am Coll Cardiol. 2021; 77: e25-e197Crossref PubMed Scopus (331) Google Scholar We caution against describing the Ross procedure as restorative of survival to age- and sex-matched controls without accounting for confounding factors, such as demographics and social determinants of health. We previously reported poorer quality of life in Ross patients relative to matched aortic valve replacement controls, which may reflect greater patient expectations and a potential overstatement of anticipated quality of life in the informed consent process.11Chen L, Hammoud MS, Ghandour HZ, Artis A, Svensson LG, Johnston DR, et al. Does the Ross operation outperform prosthetic aortic valve replacement in young adults in the long term? Paper presented at: 102nd Annual Meeting of the American Association for Thoracic Surgery; May 14-17, 2022; Boston, Mass.Google Scholar Our center's experience in managing the failed autograft after the Ross operation using a variety of strategies, including the Ross reversal procedure, has also demonstrated successful outcomes in a heterogenous cohort of patients who underwent the initial Ross operation at other centers.12Hussain S.T. Majdalany D.S. Dunn A. Stewart R.D. Najm H.K. Svensson L.G. et al.Early and mid-term results of autograft rescue by Ross reversal: a one-valve disease need not become a two-valve disease.J Thorac Cardiovasc Surg. 2018; 155: 562-572Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 13Chen L. Salim Hammoud M. Mahboubi R. Karamlou T. Pulmonary conduit reoperation following the Ross procedure.Eur J Cardiothorac Surg. Published online May 6, 2022; https://doi.org/10.1093/ejcts/ezac267Crossref Scopus (2) Google Scholar, 14Chen L. Salim Hammoud M. Ghandour H. Frankel W. Karamlou T. Risk of endocarditis extension in Ross reintervention with transcatheter pulmonary valve replacement.J Am Coll Cardiol. 2022; 79: e457https://doi.org/10.1016/j.jacc.2022.01.055Crossref PubMed Scopus (2) Google Scholar In the context of evaluating all potential aortic valve interventions, we emphasize the importance of holistic review of the evidence in shared decision-making.

You have accessJournal of UrologyCME1 May 2022PD20-12 VASECTOMY REVERSAL SEARCH TRENDS AND ADVERTISING IN THE UNITED STATES Vivian Hua, Lin Chen, Scott Lundy, and Sarah Vij Vivian HuaVivian Hua More articles by this author , Lin ChenLin Chen More articles by this author , Scott LundyScott Lundy More articles by this author , and Sarah VijSarah Vij More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002558.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Approximately 3-6% of the 300,000 vasectomy patients per year will eventually seek a reversal, which is a technically demanding cash-pay operation requiring microsurgical expertise to achieve optimal outcomes. In this study, we first sought tosummarize the current public search patterns for vasectomy reversal information. Next, we studied internet advertising information provided by vasectomy reversal clinic websites to better understand the training patterns, geographical distribution, technical details, reported success rates, and cost for providers in the United States. METHODS: Google trends was used to identify search trends over the preceding 10 years. Web search engines were queried using the term “+(vasectomy reversal OR vasovasostomy OR vasoepididymostomy) +[state]” and assessed by clinicians for inclusion and relevance. RESULTS: First, vasectomy reversal searches represented 6% of the searches for vasectomy during the same interval. There was no strong trend in search frequency or seasonal variation over the 10-year search period. Oklahoma and Wyoming showed the highest enrichment for vasectomy reversal searches relative to population.Next, A total of 251 unique clinics were identified. Providers were 98% male and graduated from residencies in urology (97%), obgyn (1%), general surgery, 1%), orthopedics (1%), and family medicine (1%). 44% of urologists had completed fellowship training in andrology. 10% of providers explicitly did not perform vasoepididymostomy even if indicated. 42% of websites reported success rates, which varied from 77% to 100%, and there was no relationship between success and cost. 17% of websites reported total cost ranging from $1990 to $14175 (median $6318). The highest density of reversal providers per million patients occurred in the Northeast (1.63) and the lowest density was in the west (1.04). There was no statistical difference in cost by region. CONCLUSIONS: Vasectomy reversals are performed using a variety of techniques by surgeons with a wide breadth and depth of training. Costs vary by an order of magnitude, and reported success rates vary significantly. Only a minority of clinic websites discuss complications, and not all providers offer vasoepididymostomy when indicated. This information underscores the difficulty that patients may face when choosing their surgeon and suggests efforts towards standardization and transparency may be of benefit to the public. Source of Funding: n/a © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e360 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Vivian Hua More articles by this author Lin Chen More articles by this author Scott Lundy More articles by this author Sarah Vij More articles by this author Expand All Advertisement PDF DownloadLoading ...