Faculty Bibliography

OBJECTIVE/UNASSIGNED:Prolonged intubation is associated with worse outcomes and longer intensive care unit (ICU) and hospital length of stay (LOS). Extubation in the operating room for patients undergoing isolated coronary artery bypass grafting is feasible, safe, and decreases ICU and hospital LOS. Aortic root and arch procedures are lengthy and often require circulatory arrest. Here, we present our experience with the safety and feasibility of operating room extubation following simple and complex aortic surgery. METHODS/UNASSIGNED:All consecutive patients who underwent aortic surgery from August 2023 to April 2025 were included in this descriptive study. We evaluated 30-day postoperative outcomes for patients who were extubated in the operating room and those in the ICU. Outcomes of interest were time to chair, ICU and hospital LOS, as well as reintubation and reoperation rates. RESULTS/UNASSIGNED:< .001). Thirty-day outcomes were excellent and comparable in both groups with no deaths or myocardial infarctions for operating room extubation compared with ICU extubation, respectively: atrial fibrillation (n = 49 [21.9%] vs n = 9 [60%]), stroke (n = 1 [0.4%]) vs n = 0), reoperation for bleeding (n = 1 vs n = 0), reintubation for respiratory failure (n = 0 vs n = 1), and 30-day readmission (n = 11 [4.9%] vs n = 2 [11.8%]). CONCLUSIONS/UNASSIGNED:Routine extubation in the operating room is safe and feasible for a wide variety of patients undergoing both simple and complex aortic surgery, even when most of them undergo circulatory arrest. Operating room extubation may accelerate recovery and early ICU and hospital discharge, without increasing readmission or morbidity.

The Society of Thoracic Surgeons (STS) 2026 Expert Consensus Pathway on Robotic Cardiac Training outlines principles for the safe initial introduction and subsequent expansion of robotic cardiac programs. The 25-year history of robotic cardiac surgery has established safety and efficacy while providing multiple innovations. There is currently a unique opportunity to coalesce best practices and evidence to inform a recent global surge in interest in incorporating robotic techniques into standard cardiac surgical practice. This consensus is a collaborative effort between the STS Workforce on Evidence Based Surgery, the STS Robotic Cardiac Surgery Taskforce, and multinational leaders in robotic cardiac surgery that aims to standardize initial core principles of preparatory elements, followed by 4 phases of robotic cardiac training to proceed from program commencement to mastery.

OBJECTIVES/UNASSIGNED:Some patients with degenerative mitral valve regurgitation have incidental coronary artery disease. When these patients are referred to our robotic cardiac surgery program, they are offered robotic mitral valve surgery combined with staged percutaneous coronary intervention performed during the same hospital admission. The objective of this study is to compare this new "hybrid" approach with the "conventional" operation consisting of sternotomy mitral valve surgery with coronary artery bypass grafting performed as a single procedure. METHODS/UNASSIGNED:Between 2011 and 2024, 181 consecutive patients with degenerative mitral valve regurgitation and coronary artery disease underwent hybrid robotic mitral valve surgery + percutaneous coronary intervention (n = 79) or conventional sternotomy mitral valve surgery + coronary artery bypass grafting (n = 102) at a single high-volume quaternary care center. Information was prospectively entered into Society of Thoracic Surgeons, regional, and institutional data collection instruments. Survival was obtained from a National Death Index. RESULTS/UNASSIGNED:01). In the hybrid group, 92.4% (73/79) of percutaneous coronary interventions were performed after robotic mitral valve surgery and 58.7% (44/75) involved a single coronary distribution only. In the conventional group, 53.9% (55/102) coronary artery bypass grafting surgeries consisted of 1 distal anastomosis. In the hybrid group, the median hospital length of stay was shorter by 2 days. The 30-day mortality and 5-year survival were excellent and identical in both groups. CONCLUSIONS/UNASSIGNED:For patients with degenerative mitral valve regurgitation and coronary artery disease, a hybrid approach (robotic mitral valve surgery + percutaneous coronary intervention) provided enhanced postoperative outcomes with short- and mid-term survival comparable to the conventional operation (sternotomy mitral valve surgery + coronary artery bypass grafting).

OBJECTIVE/UNASSIGNED:The arterial switch operation (ASO) is the standard repair for d-transposition of the greater arteries, although coronary reimplantation remains technically complex and carries the risk of both early and late complications. Coronary ostial plasty for late stenosis has been described using various patch materials, each with its own advantages and limitations. However, the optimal patch material remains unclear. METHODS/UNASSIGNED:We report 2 cases of symptomatic late left main coronary artery (LMCA) stenosis after ASO in young adults with complex coronary artery. Both patients underwent coronary ostial plasty in which a femoral artery homograft patch was used. The patients' preoperative presentation, imaging findings, operative details, and postoperative course are reviewed. RESULTS/UNASSIGNED:Case 1 was a 22-year-old man with a single coronary artery arising from the right anterior sinus and >75% LMCA ostial stenosis. Case 2 was a 25-year-old young man with interarterial LMCA atresia and collateralization from a dominant right coronary artery. In both cases, surgical repair involved extending the aortotomy into the LMCA and performing ostial plasty using a femoral artery homograft patch. Both patients had uneventful recoveries and remain asymptomatic with excellent functional status. CONCLUSIONS/UNASSIGNED:Late coronary artery stenosis is a recognized complication after ASO, particularly in patients with complex coronary anatomy. Although multiple patch materials have been used for ostial plasty, each has drawbacks. Femoral artery homograft may represent a promising alternative in these challenging anatomical settings.

OBJECTIVE/UNASSIGNED:During septal myectomy, once the heart is arrested and drained of blood on cardiopulmonary bypass, transesophageal echocardiography can no longer assess septal thickness. In the present study, we evaluated the effectiveness of on-pump intracardiac echocardiography (OPIE) for real-time intraoperative septal thickness assessment in patients with preoperative thickness ≤2.0 cm. Our hypothesis was that OPIE measurements would be conconcordant with the pre- and postcardiopulmonary bypass transesophageal echocardiography measurements that are at present the primary operative guides. METHODS/UNASSIGNED:We retrospectively reviewed patients with hypertrophic cardiomyopathy and septal thickness ≤2.0 cm on transthoracic echocardiography who underwent septal myectomy from July 2017 to July 2024. The OPIE probe was introduced into the left-ventricular chamber during cardioplegic arrest, with repeated measurements to assess the depth and adequacy of resection. Septal thickness was evaluated pre-myectomy using transthoracic echocardiography, cardiac magnetic resonance imaging, transesophageal echocardiography, and OPIE. Lin's concordance correlation coefficients and Bland-Altman analyses were used to evaluate agreement between modalities. RESULTS/UNASSIGNED:A total of 220 patients were included with preoperative thickness ≤2.0, 56 of whom underwent myectomy with OPIE guidance. Preresection transesophageal echocardiography and OPIE demonstrated the strongest agreement of all the imaging modalities (Lin's concordance correlation coefficient, 0.81; 95% CI, 0.72-0.88), with minimal bias (-0.73) and the narrowest limits of agreement (-3.76, +2.31]. OPIE-derived resection thickness estimates were tightly clustered. In the OPIE cohort, there was 1 ventricular septal defect (1.8%) and no 30-day mortality. CONCLUSIONS/UNASSIGNED:OPIE is a reliable tool for intraoperative assessment of septal thickness, particularly in patients with mild hypertrophy.

GOAL/OBJECTIVE:In 2024, the Centers for Medicare & Medicaid Services (CMS) introduced equity metrics for healthcare systems to document social determinants of health (SDOH). Payment determinations were also linked to readmission performance measures. Readmission prevention programs for vulnerable patients, defined by CMS as dually eligible (DE) for Medicare and Medicaid, racial/ethnic minorities, and those with disabling conditions, have the potential to reduce readmission disparities. Our goal was to develop a systematic and pragmatic approach to collect, analyze, and utilize SDOH and insurance status to assign patients to an intensified protocol for reducing readmission disparities after coronary artery bypass grafting (CABG). METHODS:Patients admitted to a major urban medical center for isolated CABG from October 2023 to October 2024 (N = 286) completed a standardized clinician-assisted SDOH questionnaire. SDOH risk was adapted from ICD-10 Z codes that targeted social risk factors within the scope of healthcare providers' practices (i.e., language barriers, health literacy, access to a heart-healthy diet, lack of transportation to postoperative appointments, financial difficulties impeding access to prescription medications or medical care, and lack of a caregiver/social support). Project managers reviewed electronic health records and documented racial/ethnic categories using current CMS recommendations. SDOH+ (positive) and Medicaid or DE patients were assigned to a vulnerable patient intensified protocol (VPIP) readmission prevention program focused on education, deployment of hospital and community-based resources, transportation assistance, and increased frequency of postoperative follow-up. Non-VPIP patients continued their surgeons' usual care protocols. PRINCIPAL FINDINGS/RESULTS:Of the 286 isolated CABG patients, 55% were ≥65 years old, 80% were male, 47% were White, 24% had Medicaid, and 14% were DE. The most prevalent SDOH+ responses were the need for an interpreter (31%), low health literacy or less than a high-school education (23%), and transportation issues (17%). White patients were significantly (p < .05) less likely to qualify for VPIP than non-White patients, as were patients with Medicare compared to those with self-pay, commercial, or military insurance. Overall, 27% of patients had ≥2 SDOH risk factors. The need for an interpreter was 6.6 times more likely to be associated with having Medicaid or being DE than not. Low health literacy or less than a high school education, transportation issues, and the lack of access to a heart-healthy diet were all significantly associated with Medicaid or DE patients. White patients, compared to non-White patients or unknown or declined responses, were significantly less likely to be SDOH+ (13% vs. 39%, p < .0001). Asian patients were at a higher risk for SDOH+ compared to White patients (49% vs.13%, p < .0001), and among Asian patients, 29% had neither Medicaid nor DE status. The strongest predictor of SDOH+ status in logistic regression models was Medicaid or DE status compared to all other insurance types (OR = 5.4, confidence interval [3.0-9.9]) when adjusted for age, race/ethnicity, and gender. PRACTICAL APPLICATIONS/CONCLUSIONS:Our findings demonstrate that a social-risk-informed care model is feasible in a hospital-based CABG readmission prevention program. Vulnerable patients can be identified through the standardized collection of SDOH, insurance status, and race/ethnicity data. Insurance status may be an excellent proxy to ascertain social risk and is readily accessible. Other healthcare organizations should consider regional demographics for possible SDOH risk. Our findings may support other initiatives to improve the collection of SDOH and demographic information. The VPIP CABG readmission prevention program could be adapted for other conditions and settings to achieve equitable care.