Importance:Characterizing the quality of cardiac surgery care provided by Department of Veterans Affairs (VA) hospitals is necessary to inform patient referral and resource allocation after clinical advances and programmatic changes, such as implementation of the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act. Objective:To explore cardiac surgery volume, trends, and outcomes within VA hospitals. Design, Setting, and Participants:This retrospective cohort study was conducted among all patients who underwent cardiac surgery at VA medical centers (VAMCs) across the US from January 1, 2005, through September 30, 2024. Patients were identified using the VA Surgical Quality Improvement Program (VASQIP) cardiac surgery database. Data analysis was conducted from November 1, 2024, through November 7, 2025. Exposure:Cardiac surgery performed at VAMCs. Main Outcomes and Measures:Cardiac surgery case volume and trends for all cases performed at VAMCs nationwide. Operative mortality was determined for 12 procedures indexed by the Society of Thoracic Surgeons: coronary artery bypass graft (CABG), CABG with aortic valve replacement (AVR), CABG with mitral valve (MV) replacement (MVR), CABG with MV repair, CABG with AVR and MVR or MV repair, AVR, AVR with MVR or MV repair, MVR, MV repair, tricuspid valve (TV) replacement (TVR), TV repair, and aortic aneurysm surgery. All outcomes were explored over 5-year intervals between 2005 and 2024. Adjusted mortalities were determined using the Age-Adjusted Charlson Comorbidity Index (ACCI). Results:A total of 94 694 patients (mean [SD] age at procedure, 67.0 [9.1] years; 1410 [1.5%] female) at 43 VAMCs were identified, with 30 053 patients in the 2005-2009 cohort, 26 641 patients in the 2010-2014 cohort, 23 438 patients in the 2015-2019 cohort, and 14 562 patients in the 2020-2024 cohort. Age, diversity in self-reported race and ethnicity, and ACCI increased significantly over the 20-year period. Cardiac surgery volumes were highest in 2006, with a dip in volume after 2019 and subsequent stabilization. Adjusted 30-day mortalities in 2020 to 2024 were as follows: CABG, 0.8% (95% CI, 0%-99.9%); CABG with AVR, 4.3% (95% CI, 2.4%-7.5%); CABG with MVR, 3.0% (95% CI, 0.8%-10.2%); CABG with MV repair, 0% (95% CI, 0%-1.0%); CABG with AVR and MVR or MV repair, 11.8% (95% CI, 1.4%-56.4%); AVR, 1.6% (95% CI, 0.8%-3.0%); AVR with MVR or MV repair, 6.9% (95% CI, 1.7%-24.7%); MVR, 3.0% (95% CI, 1.1%-7.9%); MV repair, 0% (95% CI, 0%-100%); TVR, 0% (95% CI, 0%-100%); TV repair, 0% (95% CI, not applicable owing to no mortality across the years); and aortic aneurysm surgery, 0% (95% CI, 0%-100%). Conclusions and Relevance:Cardiac surgery outcomes at VA hospitals remained consistent over time, demonstrating high-quality care, despite increasing ACCI and shifting procedural volumes.

BACKGROUND:Quadricuspid aortic valve (QAV) is a rare congenital anomaly characterized by the presence of four cusps instead of the usual three. It is estimated to occur in less than 0.05% of the population, with Type A (four equal-sized leaflets) accounting for roughly 30% of QAV subtypes. Based on limited clinical series, the usual presentation is progressive aortic valve regurgitation (AR) with symptoms occurring in the fourth to sixth decade of life. Severe aortic valve stenosis (AS) and acute AR are very uncommon.CASE PRESENTATION:We describe two cases of Type A QAV in patients who remained asymptomatic until their seventies with very uncommon presentations: one with severe AS and one with acute, severe AR and flail leaflet. In Case A, a 72-year-old patient with history of moderate AS presents to clinic with progressive exertional dyspnea. During work-up for transcatheter vs. surgical replacement pre-operative computed tomography angiogram (CTA) reveals a quadricuspid aortic valve with severe AS, and the patient undergoes surgical aortic valve replacement. Pre-discharge transthoracic echocardiography (TTE) shows good prosthetic valve function with no gradient or regurgitation. In Case B, a 76-year-old patient is intubated upon arrival to the hospital for acute desaturation, found to have wide open AR on catheterization, and transferred for emergent intervention. Intraoperative TEE reveals QAV with flail leaflet and severe AR. Repair is considered but deferred ultimately due to emergent nature. Post-operative TTE demonstrates good prosthetic valve function with no regurgitation and normal biventricular function.CONCLUSIONS:QAV can present as progressive severe AS and acute AR, with symptoms first occurring in the seventh decade of life. The optimal treatment for QAV remains uncertain. Although aortic valve repair or transcatheter option may be feasible in some patients, aortic valve replacement remains a tenable option.

Background: Women and racial/ethnic minority groups have been shown to experience poor outcomes after endovascular aortic aneurysm repair (EVAR). One potential reason is the rare inclusion of these populations in initial phases of device development. The objective of this systematic review is to understand enrollment and outcome reporting by sex and race/ethnicity in industry-funded EVAR device development trials. Methods: MEDLINE, PubMed, and Embase were searched from inception to January 2022 without language restrictions using the following terminology: "stent'', ``graft'', "endograft'', "device'', and "abdominal aortic aneurysm'' (AAA). Clinicaltrials.gov was also searched from inception to January 2022 for "AAA.'' Two independent reviewers screened and extracted data. All phase I-III and postmarket evaluation trials that included patients >= 18 years of age, who underwent EVAR were assessed. Participation-to-prevalence ratios (PPRs) were calculated to estimate representation of participants by sex and race/ethnicity in trials compared with their share of disease burden. Results: Among the 4,780 retrieved articles, 55 industry-funded trials met inclusion criteria for this review. A total of 51 trials (93%) reported enrollment by sex/gender, and only 7 trials (13%) reported enrollment by race/ethnicity of the participants. A median of 19 (interquartile range [IQR]: 4.5, 51) women participants were recruited compared to 171 (IQR: 57, 311.5) men, and 17 (IQR: 7.5, 21.5) racial/minority patients were recruited compared to 241 (IQR: 123, 463.5) White participants. Women represent 16.6% of the disease population, and the median PPR is 0.62 (IQR: 0.42, 0.88), which has remained constant over time (Figure 1). None of the device trials reported outcomes based on sex/gender or race/ethnicity. Conclusions: This systematic review highlights the disparities in recruitment and outcome reporting based on sex and race/ethnicity in EVAR device development trials. While most trials may be underpowered to study these differences, recent registry studies show differential outcomes based on sex and race/ethnicity of vascular patients. Therefore, it is imperative to include and report outcomes in these participants, starting from the initial device development phases to improve generalizability of device-use and understand sources of variation in device performance.

Background: Micro-computed tomography (microCT) is excellent for detecting macrocalcification but ineffective at revealing other pathologically relevant structural details in the valves affected by aortic stenosis (AS). Here, we aimed to develop a dual contrast-enhanced microCT technique to simultaneously assess macrocalcification and layer-specific remodeling in diseased human aortic valves. Methods: Diseased (n=15) and normal (n=9) aortic valve leaflets were obtained from human subjects undergoing aortic valve replacement for AS and heart transplantation/autopsy, respectively. Leaflets were fixed (4% paraformaldehyde and 2% glutaraldehyde), stained with dual contrast (1% osmium tetroxide and 1% uranyl acetate), and embedded in epoxy resin. Additional unstained leaflets (n=3 diseased, n=3 normal), similarly processed otherwise, served as staining controls. MicroCT of embedded leaflets was performed using a ZEISS Xradia 520 Versa scanner, with low energy beam (80 kVp, 5 W, LE4 filter) and high-resolution acquisitions (15 μm x 15 μm, 5 sec exposure x 1601 projections). Reconstructed images were analyzed for leaflet/layer thicknesses at midline and macrocalcification volume using Dragonfly. Results: The tri-layered tissue structure was only visualized in stained but not unstained leaflets ( p =0.002). With staining, each layer was found to be thicker in the diseased than the normal leaflets (0.28±0.13 mm vs 0.18±0.07 mm, p =0.0002 for fibrosa; 0.64±0.68 mm vs 0.29±0.19 mm, p =0.012 for spongiosa; 0.32±0.16 mm vs 0.16±0.07 mm, p <0.0001 for ventricularis). The macrocalcification volume in the diseased leaflets was greater than that in the normal leaflets (84.7±84.4 mm 3 vs 0 mm 3 , p <0.0001) and correlated only with the thickness of spongiosa ( r =0.79, p <0.001) but not other layers ( p =0.67, p =0.26). Macrocalcification was as frequently observed in spongiosa as in fibrosa (66.7% vs 66.7% of diseased leaflets, p =0.3) but never in ventricularis. Conclusions: Dual contrast-enhanced microCT enables high-quality imaging of both macrocalcification and layer-specific remodeling in diseased human aortic valves. The results here suggest an intimate relationship between macrocalcification and spongiosa that warrants further investigation.

Introduction: Ventilator-induced diaphragm dysfunction (VIDD) is an important phenomenon that has been repeatedly demonstrated in experimental and clinical models of mechanical ventilation. Even a few hours of MV initiates signaling cascades that result in, first, reduced specific force, and later, atrophy of diaphragm muscle fibers. This severe, progressive weakness of the critical ventilatory muscle results in increased duration of MV and thus increased MV-associated complications/deaths. A drug that could prevent VIDD would likely have a major positive impact on intensive care unit outcomes. We identified the JAK/STAT pathway as important in VIDD and then demonstrated that JAK inhibition prevents VIDD in rats. We subsequently developed a clinical model of VIDD demonstrating reduced contractile force of isolated diaphragm fibers harvested after similar to 7 vs similar to 1 h of MV during a thoracic surgical procedure. Materials and methods: The NIH-funded clinical trial that has been initiated is a prospective, placebo controlled trial: subjects undergoing esophagectomy are randomized to receive 6 preoperative doses of the FDA-approved JAK inhibitor Tofacitinib (commonly used for rheumatoid arthritis) vs. placebo. The primary outcome variable will be the difference in the reduction that occurs in force generation of diaphragm single muscle fibers (normalized to their cross-sectional area), in the Tofacitinib vs. placebo subjects, over 6 h of MV. Discussion: This trial represents a first-in-human, mechanistic clinical trial of a drug to prevent VIDD. It will provide proof-of-concept in human subjects whether JAK inhibition prevents clinical VIDD, and if successful, will support an ICU-based clinical trial that would determine whether JAK inhibition impacts clinical outcome variables such as duration of MV and mortality.

Burdon, Thomas MD; Bhandari, Prasha MPH; Marshall, Nell PhD; Harris, Alex Sox PhD; Fann, James I. MD, FACS; Burdon, Thomas A. MD, FACS; Backhus, Leah M. MD, MPH, FACS Author Information

Several modern learning frameworks (eg, cognitive apprenticeship, anchored instruction, and situated cognition) posit the utility of nontraditional methods for effective experiential learning. Thus, development of novel educational tools emphasizing the cognitive framework of operative sequences may be of benefit to surgical trainees. We propose the development and global deployment of an effective, mobile cognitive cardiac surgical simulator. In methods, 16 preclinical medical students were assessed. Overall, 4 separate surgical modules (sternotomy, cannulation, decannulation, and sternal closure) were created utilizing the Touch Surgery (London, UK) platform. Modules were made available to download free of charge for use on mobile devices. Usage data were collected over a 6-month period. Educational efficacy of the modules was evaluated by randomizing a cohort of medical students to either module usage or traditional, reading-based self-study, followed by a multiple-choice learning assessment tool. In results, downloads of the simulator achieved global penetrance, with highest usage in the USA, Brazil, Italy, UK, and India. Overall, 5368 unique users conducted a total of 1971 hours of simulation. Evaluation of the medical student cohort revealed significantly higher assessment scores in those randomized to module use versus traditional reading (75% ± 9% vs 61% ± 7%, respectively; P < 0.05). In conclusion, this study represents the first effort to create a mobile, interactive cognitive simulator for cardiac surgery. Simulators of this type may be effective for the training and assessment of surgical students. We investigated whether an interactive, mobile-computing-based cognitive task simulator for cardiac surgery could be developed, deployed, and validated. Our findings suggest that such simulators may be a useful learning tool.

BACKGROUND:It is speculated that, in operative environments, real-time visualization of the trainee's viewpoint by the instructor may improve performance and teaching efficacy. We hypothesized that introduction of a wearable surgical visualization system allowing the instructor to visualize otherwise "blind" areas in the operative field could improve trainee performance in a simulated operative setting. METHODS:A total of 11 surgery residents (4 in general surgery training and 7 in an integrated 6-year cardiothoracic surgery program) participated in the study. Google (Mountain View, CA) Glass hardware running proprietary software from CrowdOptic (San Francisco, CA) was utilized for creation of the wearable surgical visualization system. Both the learner and trainer wore the system, and video was streamed from the learner's system in real time to the trainer, who directed the learner to place needles in a simulated operative field. Subjects placed a total of 5 needles in each of 4 quadrants. A composite error score was calculated based on the accuracy of needle placement in relation to the intended needle trajectories as described by the trainer. Time to task completion (TTC) was also measured and participants completed an exit questionnaire. RESULTS:All residents completed the protocol tasks and the survey. Introduction of the wearable surgical visualization system did not affect mean time to task completion (278 ± 50 vs. 282 ± 69 seconds, p = NS). However, mean composite error score fell significantly once the wearable system was deployed (18 ± 5 vs. 15 ± 4, p < 0.05), demonstrating improved accuracy of needle placement. Most of the participants deemed the device unobtrusive, easy to operate, and useful for communication and instruction. CONCLUSIONS:This study suggests that wearable surgical visualization systems allowing for adoption of the learner's perspective may be a useful educational adjunct in the training of surgeons. Further evaluations of the efficacy of wearable technology in the operating room environment are warranted.

Introduction: Coronary artery bypass grafting (CABG) remains a mainstay of treatment in patients with coronary artery disease. Outcomes of CABG from a large modern U.S. cohort (the Medicare database) were analyzed, with a focus on outcomes. Methods: Medicare patients undergoing CABG from 1999-2010 were assessed. ICD-9 and CPT codes were used to describe operative details. Survival distributions were estimated with the Kaplan-Meier method, and compared with an age-/sex-/race-matched general US population cohort. A Cox proportional hazards analysis determined variables associated with survival. Cubic-spline analyses were used to assess hospital and surgeon volume-outcome relationships. Results: Median survival following CABG for the entire cohort (n=1,902,315) was 9.43 years (95% confidence intervals [CI] 9.41-9.45) (Figure 1A), and was 10.02 years (95% CI: 10.00-10.04) in isolated CABG (n=1,523,529) recipients (Figure 1B). During the 12 year study period, Medicare patients underwent CABG at 1,391 U.S. hospitals and by 5,899 U.S. surgeons. Multivariable analysis identified multiple predictors of death including age, gender, race, patient comorbidities, prior cardiac surgery, year of operation, adjunct cardiac procedures (e.g. valve repair/replacement or aortic repair), the lack of internal mammary artery (IMA) use, the absence of billing for cardiopulmonary bypass, and both hospital and surgeon volume. A transition point was identified in the surgeon-volume and hospital-volume relationships suggesting a volume beyond which additional case numbers only improved outcomes minimally (Figures 1C/1D). Conclusions: Survival following CABG in Medicare patients is robust. Even in this elderly cohort, the use of a single IMA was associated with significantly improved outcomes, and bilateral IMA use was associated with an even lower hazard for death compared with single IMA. Both hospital and surgeon volume had strong associations with survival.

OBJECTIVES The purpose of this study was to characterize health status outcomes after transcatheter aortic valve replacement (TAVR) with a self-expanding bioprosthesis among patients at extreme surgical risk and to identify pre-procedural patient characteristics associated with a poor outcome.BACKGROUND For many patients considering TAVR, improvement in quality of life may be of even greater importance than prolonged survival.METHODS Patients with severe, symptomatic aortic stenosis who were considered to be at prohibitive risk for surgical aortic valve replacement were enrolled in the single-arm CoreValve U. S. Extreme Risk Study. Health status was assessed at baseline and at 1, 6, and 12 months after TAVR using the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Short Form-12, and the EuroQol-5D. The overall summary scale of the KCCQ (range 0 to 100; higher scores = better health) was the primary health status outcome. A poor outcome after TAVR was defined as death, a KCCQ overall summary score (OS) <45, or a decline in KCCQ-OS of 10 points at 6-month follow-up.RESULTS A total of 471 patients underwent TAVR via the transfemoral approach, of whom 436 (93%) completed the baseline health status survey. All health status measures demonstrated considerable impairment at baseline. After TAVR, there was substantial improvement in both disease-specific and generic health status measures, with an increase in the KCCQ-OS of 23.9 points (95% confidence interval [CI]: 20.3 to 27.5 points) at 1 month, 27.4 points (95% CI: 24.2 to 30.6 points) at 6 months, 27.4 points (95% CI: 24.1 to 30.8 points) at 12 months, along with substantial increases in Short Form-12 scores and EuroQol-5D utilities (all p < 0.003 compared with baseline). Nonetheless, 39% of patients had a poor outcome after TAVR. Baseline factors independently associated with poor outcome included wheelchair dependency, lower mean aortic valve gradient, prior coronary artery bypass grafting, oxygen dependency, very high predicted mortality with surgical aortic valve replacement, and low serum albumin.CONCLUSIONS Among patients with severe aortic stenosis, TAVR with a self-expanding bioprosthesis resulted in substantial improvements in both disease-specific and generic health-related quality of life, but there remained a large minority of patients who died or had very poor quality of life despite TAVR. Predictive models based on a combination of clinical factors as well as disability and frailty may provide insight into the optimal patient population for whom TAVR is beneficial. (C) 2015 by the American College of Cardiology Foundation.

Objectives\r\nThe purpose of this study was to characterize health status outcomes after transcatheter aortic valve replacement (TAVR) with a self-expanding bioprosthesis among patients at extreme surgical risk and to identify pre-procedural patient characteristics associated with a poor outcome.

BACKGROUND: The US Food and Drug Administration recently approved a transcatheter aortic valve for patients for whom open heart surgery is prohibitively risky.METHODS: A multidisciplinary heart valve team partnered with administration to launch a transcatheter aortic valve replacement (TAVR) program. Clinical registries were used to show robust valve caseloads and outcomes at our Veterans Affairs (VA) facility and to project future volumes. A TAVR business plan was approved by the VA leadership as part of a multiphase project to upgrade and expand our surgical facilities.RESULTS: The heart valve team completed a training program that included simulations and visits to established TAVR centers. Patients were evaluated and screened through a streamlined process, and the program was initiated successfully.CONCLUSIONS: Establishing a TAVR program at a VA facility requires a multidisciplinary team with experience in heart valve and endovascular therapies and a supportive administration willing to invest in a sophisticated infrastructure. Published by Elsevier Inc.

Brewer III Fund, featured Arnold Milstein from the Stanford Clinical Excellence Research Center, a collaboration of the Schools of Medicine, Engineering and Business to design and test new health care delivery models that both lower per capita

Objective: Limited exposure and visualization and technical complexity have affected resident training in mitral valve surgery. We propose simulation-based learning to improve skill acquisition in mitral valve surgery.Methods: After reviewing instructional video recordings of mitral annuloplasty in porcine and plastic models, 11 residents (6 integrated and 5 traditional) performed porcine model mitral annuloplasty. Video-recorded performance was reviewed by attending surgeon providing audio formative feedback superimposed on video recordings; recordings were returned to residents for review. After 3-week practice with plastic model, residents repeated porcine model mitral annuloplasty. Performance assessments initially (prefeedback) and at 3 weeks (postfeedback) were based on review of video recordings on 5-point rating scale (5, good; 3, average; 1, poor) of 11 components. Ratings were averaged for composite score.Results: Time to completion improved from mean 31 +/- 9 minutes to 25 +/- 6 minutes after 3-week practice (P = .03). At 3 weeks, improvement in technical components was achieved by all residents, with prefeedback scores varying from 2.4 +/- 0.6 for needle angles to 3.0 +/- 0.5 for depth of bites and postfeedback scores of 3.1 +/- 0.8 for tissue handling to 3.6 +/- 0.8 for suture management and tension (P <= .001). Interrater reliability was greater than 0.8. In this sample, composite scores of first-year integrated and traditional residents were lower than those of senior level residents; comparatively, third-year integrated residents demonstrated good technical proficiency.Conclusions: Simulation-based learning with formative feedback results in overall improved performance of simulated mitral annuloplasty. In complex surgical procedures, simulation may provide necessary early graduated training and practice. Importantly, a "passing" grade can be established for proficiency-based advancement. (J Thorac Cardiovasc Surg 2011;141:107-12)

Heparin-induced thrombocytopenia (HIT) is a prothrombotic complication of heparin therapy mediated by antibodies that recognize platelet factor 4/heparin complexes and cause platelet activation and thrombin generation. Early recognition of HIT and treatment with non-heparin anticoagulants are essential in reducing thrombotic events, but diagnosis of HIT in patients postcardiac surgery may be confounded by thrombocytopenia because of bleeding, infection, drugs, or intraaortic balloon pump counterpulsation. Furthermore, postoperative thrombocytosis after cardiac surgery may mask platelet consumption because of HIT.1Selleng S. Seleng K. Wollert H.G. Muellejans B. Lietz T. Warkentin T.E. et al.Heparin-induced thrombocytopenia in patients requiring prolonged intensive care unit treatment after cardiopulmonary bypass.J Thromb Haemost. 2008; 6: 428-435Crossref PubMed Scopus (60) Google Scholar HIT is typically suspected in patients with thrombosis or thrombocytopenia, usually defined as a platelet count less than 100,000/μL or relative decrease of 30% to 50%.2Greinacher A. Farner B. Kroll H. Kohlmann T. Warkentin T.E. Eichler P. Clinical features of heparin-induced thrombocytopenia including risk factors for thrombosis. A retrospective analysis of 408 patients.Thromb Haemost. 2005; 94: 132-135PubMed Google Scholar, 3Pouplard C. May M.A. Regina S. Marchand M. Fusciardi J. Gruel Y. Changes in platelet count after cardiac surgery can effectively predict the development of pathogenic heparin-dependent antibodies.Br J Haematol. 2005; 128: 837-841Crossref PubMed Scopus (140) Google Scholar, 4Warkentin T.E. Roberts R.S. Hirsh J. Kelton J.G. An improved definition of immune heparin-induced thrombocytopenia in postoperative orthopedic patients.Arch Intern Med. 2003; 163: 2518-2524Crossref PubMed Scopus (271) Google Scholar, 5Warkentin T.E. Greinacher A. Heparin-induced thrombocytopenia: recognition, treatment, and prevention: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.Chest. 2004; 126: 311S-337SCrossref PubMed Scopus (756) Google Scholar We present a patient in whom HIT developed without thrombocytopenia after off-pump coronary artery bypass grafting. A 55-year-old man with coronary artery disease, diabetes mellitus, hyperlipidemia, and hypertension presented with an acute coronary syndrome. Coronary angiogram demonstrated multivessel coronary artery disease. He was placed on a heparin drip. The following day, he underwent a 2-vessel off-pump coronary artery bypass, during which he received 15,000 units of unfractionated heparin intravenously. He was given no heparin postoperatively. On postoperative day 2, his platelet count decreased from 213 to 168 K/μL (Figure 1). A heparin-induced antibody test was sent, the result of which was negative. On postoperative day 12, computed tomography of the chest, which was obtained to evaluate a fever, decrease in oxygen saturation to 93%, and mild increase in heart rate, demonstrated a saddle pulmonary embolus (Figure 2). The patient was otherwise asymptomatic. Lower-extremity ultrasound showed a thrombus in the left popliteal vein. The patient was anticoagulated with intravenous argatroban after obtaining specimens for and pending results of heparin-induced antibody and heparin-induced platelet aggregation tests. The results of the heparin-induced antibody and heparin-induced platelet aggregation were positive. The transition to oral anticoagulation with warfarin was made, and the patient was discharged on postoperative day 28. Follow-up computed tomography before discharge demonstrated significant diminution of the pulmonary embolus. He remained well at the 3-month follow-up. HIT is a life-threatening complication in patients undergoing cardiac surgery. Early detection and anticoagulation may limit morbidity caused by HIT, but the diagnosis of HIT in patients undergoing cardiac surgery is confounded by other causes of thrombocytopenia. Also, the reactive thrombocytosis often seen in the normal postoperative course may mask immune-mediated platelet consumption. Furthermore, although the platelet count profile after on-pump cardiac surgery has been described,1Selleng S. Seleng K. Wollert H.G. Muellejans B. Lietz T. Warkentin T.E. et al.Heparin-induced thrombocytopenia in patients requiring prolonged intensive care unit treatment after cardiopulmonary bypass.J Thromb Haemost. 2008; 6: 428-435Crossref PubMed Scopus (60) Google Scholar, 3Pouplard C. May M.A. Regina S. Marchand M. Fusciardi J. Gruel Y. Changes in platelet count after cardiac surgery can effectively predict the development of pathogenic heparin-dependent antibodies.Br J Haematol. 2005; 128: 837-841Crossref PubMed Scopus (140) Google Scholar the changes in platelet count after off-pump cardiac surgery are less well understood. Pouplard and colleagues3Pouplard C. May M.A. Regina S. Marchand M. Fusciardi J. Gruel Y. Changes in platelet count after cardiac surgery can effectively predict the development of pathogenic heparin-dependent antibodies.Br J Haematol. 2005; 128: 837-841Crossref PubMed Scopus (140) Google Scholar described 2 patterns of thrombocytopenia used to predict the development of pathogenic heparin-dependent antibodies after cardiopulmonary bypass: decrease in platelet count after correction of thrombocytopenia occurring during cardiopulmonary bypass and persistent thrombocytopenia in the days after cardiopulmonary bypass. A large saddle pulmonary embolus developed in the patient in this report, with positive studies for heparin-induced antibody and heparin-induced platelet aggregation, but he was not thrombocytopenic. His platelet nadir was 168 K/μL, and he never had a significant relative decrease in platelet count. In fact, the test for heparin-induced antibody on postoperative day 2 (at the time of his nadir) was negative. Of note, this patient was never placed on cardiopulmonary bypass, perhaps explaining why he did not fit into the patterns previously described for on-pump cardiac surgery. Figure 1 shows the platelet count of this patient along with the mean platelet count of 21 other consecutive, contemporaneous patients who had off-pump coronary artery bypass at our institution (Palo Alto VA Hospital). Note that both curves have a similar shape with a nadir at approximately postoperative day 3, followed by an increase to well above preoperative levels. We suggest that thrombocytopenia may be an unreliable indicator of HIT after cardiac surgery (particularly off-pump), and that prospective studies are needed to refine diagnostic criteria for HIT in this difficult population. Until then, we recommend a high index of suspicion for HIT in patients undergoing cardiac surgery and consideration of an alternative anticoagulant to heparin to treat vascular thrombosis pending the results of heparin-induced antibody and heparin-induced platelet aggregation.

We have a unique opportunity to harness recent advances in computer hardware and software to integrate the various forms of gastrointestinal imaging modalities and implement an efficient and potentially more effective practice of gastroenterology. The integration of gastrointestinal imaging is timely to enhance and expand our diagnostic and therapeutic abilities. The application of these technologies permit instant processing of computed tomography (CT) scans into a 3-dimensional (3D) view, and axial, coronal, or oblique plane images—which can serve as virtual anatomic images, and be readily correlated with endoscopy, endoscopic ultrasonography (EUS) or endoscopic retrograde cholangiography (ERCP) (Figure 1).

OBJECTIVE:Cardiac surgery trainees might benefit from simulation training in coronary anastomosis and more advanced procedures. We evaluated distributed practice using a portable task station and experience on a beating-heart model in training coronary anastomosis.METHODS:Eight cardiothoracic surgery residents performed 2 end-to-side anastomoses with the task station, followed by 2 end-to-side anastomoses to the left anterior descending artery by using the beating-heart model at 70 beats/min. Residents took home the task station, recording practice times. At 1 week, residents performed 2 anastomoses on the task station and 2 anastomoses on the beating-heart model. Performances of the anastomosis were timed and reviewed.RESULTS:Times to completion for anastomosis on the task station decreased 20% after 1 week of practice (351 +/- 111 to 281 +/- 53 seconds, P = .07), with 2 residents showing no improvement. Times to completion for beating-heart anastomosis decreased 15% at 1 week (426 +/- 115 to 362 +/- 94 seconds, P = .03), with 2 residents demonstrating no improvement. Home practice time (90-540 minutes) did not correlate with the degree of improvement. Performance rating scores showed an improvement in all components. Eighty-eight percent of residents agreed that the task station is a good method of training, and 100% agreed that the beating-heart model is a good method of training.CONCLUSIONS:In general, distributed practice with the task station resulted in improvement in the ability to perform an anastomosis, as assessed by times to completion and performance ratings, not only with the task station but also with the beating-heart model. Not all residents improved, which is consistent with a "ceiling effect" with the simulator and a "plateau effect" with the trainee. Simulation can be useful in preparing residents for coronary anastomosis and can provide an opportunity to identify the need and methods for remediation.

Congenital coronary anomalies can be found in up to 1% of patients undergoing angiography. The most severe of these lesions become symptomatic in early childhood, while others can remain without consequence. However, while being silent in the early decades of life, these asymptomatic anomalies can contribute to the presentation of acquired heart disease and can themselves become clinically significant. We describe the clinical course of two patients with congenital coronary artery anomalies presenting beyond the fifth decade of life with concurrent acquired heart disease.