Saturday, May 6, 2023: 1:15 PM - 5:00 PM
Los Angeles Convention Center
Posted Room Name: West Hall B
Track
Adult Cardiac
Congenital
Multi-Specialty
Perioperative Care
Thoracic
103rd Annual Meeting
Presentations
Total Time: 20 Minutes
Speaker
*Yolonda Colson, Massachusetts General Hospital
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Dover, MA
United States
Total Time: 20 Minutes
Objective: The purpose of this study was to quantitate the impact of heart donation after circulatory death on waitlist times and post-transplant outcomes, including post-transplant peri-operative survival, in the United States.
Methods: A retrospective review utilizing the United Network for Organ Sharing database from October 18, 2018 to June 30, 2022 was performed. Adult recipients that underwent isolated heart transplantation within the United States utilizing either donation after brain death (DBD) or donation after circulatory death (DCD) were analyzed. The primary outcome was median waitlist time. Other outcomes included 90-day post-transplant survival, and post-transplant complications.
Results: Since 10/18/2018, a total of 10,368 isolated adult heart transplants were performed, including 9,954 (96.0%) utilizing DBD donors and 414 (4.0%) utilizing DCD. On average, DCD donors were younger (28 vs 32 years; P<0.001) and had a higher left ventricular ejection fraction (62% [IQR 60-66%] vs 60% [IQR 56-65]; P=0.002). Median donor-recipient hospital distances were farther with DCD donation [351 miles vs 224 miles; P<0.001) with a longer median total graft ischemic time (4.8 hours vs 3.4 hours; P<0.001). Overall, median waitlist time was shorter in recipients from DBD donors (47 days vs 33 days; P=0.001). However, the greatest proportion of DBD donors were allocated to Status 2 recipients across all blood types (Figure A) whereas the greatest proportion of DCD donors were allocated to Status 4 recipients across all blood types (Figure B). Of all recipients transplanted as a Status 1 or 2, there was a nonsignificant reduction in median waitlist times with DCD donation (15 days [IQR 5-48] vs 17 days [IQR 6-69]. Among Status 3 or 4 recipients, median waitlist time was significantly reduced with DCD donation (73 days [IQR 19-246] vs 91 days [IQR 24-314], P=0.040). 90-day survival was similar for recipients of DBD and DCD hearts (Figure C). Perioperative stroke was comparable between cohorts, as were rates of renal failure, and acute rejection within the first year.
Conclusions: DCD heart donation represents one means of alleviating the current shortage of donor hearts for transplantation. These data demonstrate that utilization of DCD hearts is particularly beneficial to select candidate populations, such as those with lower priority status. Further, use of DCD donors results in similar post-transplant outcomes compared to DBD donors.
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Invited Discussant
*Ashish Shah, Vanderbilt University
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Nashville, TN
United States
Abstract Presenter
Nicholas Hess, University of Pittsburgh
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Pittsburgh, PA
United States
Total Time: 20 Minutes
Objective: Reducing need for blood transfusion among patients undergoing cardiac surgery has potential to reduce post-operative complications and mortality. Our study aimed to assess effects of pre-operative intravenous ferric carboxymaltose (FCM) on post-surgical red blood cell (RBC) transfusion requirements in non-anemic patients undergoing cardiac surgery.
Methods: A double-blind, randomized, single center, placebo-control trial conducted between Oct 2016-Nov 2019, with follow-up period of up to 6 weeks post-operation. Participants were non-anemic patients undergoing non-emergent on-pump cardiac surgery, received intravenous iron in form of FCM or placebo, administered once 24-72 hours before surgery.
Primary outcome- number of RBC units transfused during first 4 post-operative days. Secondary outcomes- Blood hemoglobin levels at 4-days and 6-weeks post-operation.
Results: We randomized 200 patients, where 194 were included, 99 patients in FCM group vs 95 in placebo group; mean age (62.9±9.1 and 62.9±9.1 respectively) and gender (87% males) equally distributed between the groups. By day 4 post-surgery, a significantly lower mean number of RBC units were transfused in FCM than placebo group (0·3±0·9 vs 1·6±4·5, respectively; p=0·006). Number of patients receiving RBCs in FCM and placebo groups was 19 (19%) and 34 (36%), respectively [OR 0·42(95%CI 0·22-0·88); p=0·01]. Mean hemoglobin levels on day 4 post-surgery were 9·7±1 g/dl vs. 9·3±1 g/dl, respectively (p=0·03). Corresponding values at 6-weeks post-surgery were 12·6±1·4 g/dl vs. 11·8±1·5 g/dl, respectively (p=0·012).
Conclusion: In non-anemic patients undergoing on-pump cardiac surgery, pre-treatment with single FCM dose of 1000 mg within 1-3 days pre-surgery significantly reduced the need for postoperative RBC transfusions and improved both serum iron level, transferrin saturation and hemoglobin levels.
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Invited Discussant
Victor Ferraris, Lexington VAMC
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Lexington, KY
United States
Abstract Presenter
Tom Friedman, Rambam Health Care Campus
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Haifa, Israel
Israel
Total Time: 15 Minutes
Total Time: 20 Minutes
Objective:
Over the past several years, there has been growing concern that surgeons are at increased risk for work-related orthopedic injuries due to poor ergonomics. We sought to conduct a survey of cardiothoracic surgeons in the U.S. and Canada to evaluate the incidence of occupational injury among cardiothoracic surgeons, as well as cardiothoracic surgeons' perceptions of and use of ergonomic techniques in the operating room (OR) and office.
Methods:
Cardiothoracic surgeons identified through the Cardiothoracic Surgery Network were asked to complete a 33-question survey assessing their musculoskeletal health, as well as their perceptions and use of ergonomic techniques in the OR and office. Results were analyzed using Wilcoxon rank sum and Pearson's chi square tests. Multivariable logistic regression was used to identify characteristics of surgeons associated with an increased odds of experiencing a work-related injury.
Results:
Of the 602 surgeon respondents, the majority were male (92%) and between 56-65 years of age. With regards to specialization, 40% practiced thoracic surgery, 48% cardiac surgery, and 12% reported having mixed practices. The overall incidence of work-related musculoskeletal injuries was 64%, with 30% of injured surgeons requiring time off from work and 20% requiring surgery or the use of narcotics. Cervical spine injury (n=216) was the most common orthopedic injury attributed to operating, followed by lumbar spine injury (n=180) and neck tension (n=171). In multivariable-adjusted analysis, surgeons who predominately practiced cardiac surgery were significantly more likely to experience work-related orthopedic injury than thoracic surgeons (aOR: 3.4, p<0.01). Notably, 90% of surgeons reported that they felt that their institution did not provide sufficient ergonomics education and support for cardiothoracic surgeons and only 35% felt that the cardiothoracic surgical community is supportive of implementing ergonomics techniques in the OR and office.
Conclusions:
In this survey, North American cardiothoracic surgeons reported experiencing work-related orthopedic injuries at an alarmingly high rate, leading to significant time away from work and for many to retire from over a decade early from surgical practice. These findings illustrate a critical need for institutions to prioritize ergonomics education and implement ergonomics-directed techniques in the OR and office.
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Invited Discussant
*Michael Maddaus, University of Minnesota
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Minneapolis, MN
United States
Abstract Presenter
Camille Mathey-Andrews, Massachusetts General Hospital
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Boston, MA
United States
Total Time: 20 Minutes
Objective: Vitamin K antagonists are the only approved oral anticoagulants to prevent valve thrombosis and thromboembolism in patients with mechanical heart valves. The PROACT Xa trial assessed whether patients with bileaflet aortic valves can be safely anticoagulated with apixaban, a direct factor Xa inhibitor, as an alternative to warfarin.
Methods: PROACT Xa was a randomized, multicenter, open-label trial comparing apixaban with warfarin in patients with bileaflet carbon aortic valves. Patients at least 3 months out from AVR were randomized 1:1 to receive apixaban 5 mg twice daily or warfarin with a target INR of 2–3. Primary efficacy outcome is composite of valve thrombosis and valve-related thromboembolism; primary safety outcome is major bleeding. All events are independently adjudicated by a clinical events committee blinded to study drug assignment. A planned sample size of 1000 patients allowed >90% power to assess noninferiority of apixaban to warfarin, assuming the primary efficacy outcome occurs in warfarin-treated patients at a rate of 1.75%/pt-yr with an absolute noninferiority margin of 1.75%/pt-yr. A co-primary efficacy analysis was to compare hazard rate for the apixaban arm to twice the objective performance criterion (3.4%/pt-year).
Results: A total of 863 patients from 60 sites were randomized from May 2020–Sep 2022. Enrolled patients had a median age of 56 years; 24% were female. Among participants, 46% had AVR in the 12 months prior to randomization, 17% had AVR along with an aortic root graft, and 16% were reoperations on the aortic valve. Most (93%) patients received aspirin 81 mg daily with the assigned anticoagulant. Median time in therapeutic range for warfarin-treated patients was 71.4% [55.1, 82.9]. On Sep 21, 2022, the DSMB recommended discontinuation of enrollment based on observed higher rate of thromboembolic events in patients randomized to apixaban than warfarin. All patients were transitioned off study drug and will be followed for at least 30 days after study drug discontinuation for all pre-specified outcomes.
Conclusions: Complete data on primary efficacy and safety outcomes will be available for presentation at the AATS Meeting in May 2023. While final data collection is ongoing, the PROACT Xa trial is likely to conclude that apixaban does not provide a safe alternative to warfarin for the prophylaxis of valve thrombosis or valve-related thromboembolism in patients with bileaflet mechanical aortic valves.
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Invited Discussant
*Leonard Girardi, Weill Cornell Medical Center
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New York, NY
United States
Abstract Presenter
*Lars Svensson, Cleveland Clinic
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Cleveland, OH
United States
Total Time: 40 Minutes
Did you know that if a female surgeon has a patient death, that referrals to all women in the group can decreased by over 50%? Did you know that top universities turn out black and Hispanic computer science and computer engineering graduates at twice the rate that leading technology companies hire them, casting doubt on the "pipeline" being the issue? Dr. Gilda Barabino, a national leader in the efforts to engage engineers in the development of solutions to health disparities, will open the session with data that speaks to the disparity around us in science and healthcare and ways to move forward.
Drs. Yolonda Colson and Lars Svensson, AATS President and President-Elect, will moderate a subsequent discussion with Gilda Barabino and Judy Woodruff, an award-winning journalist and former major network news anchor, comparing and contrasting the challenges in journalism, STEMM, education and cardiothoracic surgery that make effective sustainable change difficult to achieve.
The panel aims to identify unappreciated obstacles in recruitment & retention, finances, culture, and safety, that undermine the success of programmatic initiatives to increase diversity, thereby challenging our efforts to attract and support excellent surgical partners & trainees. Whether a department chair, division chief, or fellow cardiothoracic surgeon, each of us has a vital stake in the success of all of us. By including a broad range of experiences and perspectives in this conversation it is hoped that valuable insights and practical strategies may be identified that will improve not only the health and wellbeing of our surgeons, staff and patients but also the cultural and financial health of our surgical practices.
Panelist(s)
*Yolonda Colson, Massachusetts General Hospital
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Dover, MA
United States
*Lars Svensson, Cleveland Clinic
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Cleveland, OH
United States
Gilda Barabino, President, Olin College of Engineering
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Needham, MA
United States
Judy Woodruff, Senior Correspondent for the PBS NewsHour
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