Faculty Bibliography

Purpose: In the U.S., heart transplantation from donation after circulatory death (DCD) is increasing. We present our institutional experience of DCD transplantation by using a thoracoabdominal-normothermic regional perfusion (TA-NRP) protocol and compare the results to a cohort concomitantly transplanted, from standard brain death (

This paper is the first of a four-part series that details the current barriers to diversity in the field of adult cardiothoracic anesthesiology and outlines actionable programs that can be implemented to create change. Part I and Part II address the training experience of women and underrepresented minorities (URMs) in adult cardiothoracic anesthesiology (ACTA), respectively, and explore concrete opportunities to promote positive change. Part III and Part IV examine the professional experience of URMs and women in ACTA, respectively, and discuss interventions that can facilitate a more equitable and inclusive environment for both groups. Although these problems are complex, the authors here offer a detailed analysis of the challenges faced by each group both in the training phase and the professional practice phase of their careers. The authors also present meaningful and concrete actions that can be implemented to create a more diverse, equitable, and inclusive professional environment in cardiovascular and thoracic anesthesiology.

OBJECTIVES/OBJECTIVE:To investigate if the lack of sex diversity in adult cardiothoracic anesthesiology fellowships is a result of few female applicants or low acceptance rate. DESIGN/METHODS:Retrospective review of adult cardiothoracic anesthesiology applicants and fellows by sex and geographic regions across the United States. SETTING/METHODS:Accreditation Council for Graduate Medical Education's adult cardiothoracic anesthesiology fellowship programs across the United States. PARTICIPANTS/METHODS:Applicants to adult cardiothoracic anesthesiology fellowship programs and fellows. INTERVENTIONS/METHODS:No intervention. MEASUREMENTS AND MAIN RESULTS/RESULTS:Numerical comparison of male and female applicants by percentage and acceptance rates into adult cardiothoracic anesthesiology fellowship programs in each geographic region. Women comprised between 27% and 35% of applicants from 2013 to 2018. Acceptance rates for men completing residency in the Midwest region ranged between 67% and 84%, and 67% and 87% for women from the Midwest (p = 0.1-0.9). Men from Northeast residencies had acceptance rate of 71% to 86% and women had rate of 69% to 83% (p = 0.2-0.8). Male and female residents from the Southeast had acceptance rates of 65% to 94% and 71% to 93%, respectively (p = 0.3-0.8). The male residents from the Southwest had acceptance rates of 73% to 85%, and female residents had rates between 44% and 100% (p = 0.02-0.8). The male residents from the West had rates of 59% to 88%, female residents had rates between 64% and 100% (p = 0.1-0.7). CONCLUSIONS:There is an absence of clear identification of the barriers preventing women from entering cardiac anesthesiology. The reasons leading to a male-dominated field of cardiac anesthesiologists stem from fewer female anesthesiology residents applying to cardiothoracic anesthesiology fellowships. No bias against acceptance of women into cardiothoracic anesthesiology fellowships was found.

Worldwide, the majority of heart transplant organs are from donation after brain death. However, the shortage of suitable donors places severe limitations on this route. One option to increase the donor pool is to use organs from donation after circulatory death (DCD). Transplant centers for solid organs have been using DCD organs for years. At this time, 40% of solid organ transplantation in the United Kingdom uses organs from DCD. Use of DCD for solid organ transplants in Canada is also rising. Recently, there has been interest in using DCD organs for heart transplantation. The authors will discuss their experience of 4 heart transplants with organs from DCD donors after normothermic regional perfusion (NRP). The authors' first heart transplant using a DCD organ was in January 2020, and the fourth was in March 2020, just before the coronavirus disease 2019 (COVID-19) pandemic. The authors' protocol using NRP allows adequate evaluation of the donor heart to confidently determine organ acceptance. The co-location of the donor and the recipient in neighboring operating rooms limits ischemic times. Avoidance of an expensive ex vivo organ perfusion machine is an additional benefit for programs that may not have the resources required to purchase and maintain the machine. Some hospitals may not have the resources and space to be able to co-locate both the donor and recipient. Use of cold storage may be an option to transport the procured organ, similar to donation after brain death organs. The authors hope that this technique of NRP in DCD donors can help further increase the donor pool for heart transplantation in the United States.

Postoperative atrial fibrillation (poAF) is the most common adverse event after cardiac surgery and is associated with increased morbidity, mortality, and hospital and intensive care unit length of stay. Despite progressive improvements in overall cardiac surgical operative mortality and postoperative morbidity, the incidence of poAF has remained unchanged at 30%-50%. A number of evidence-based recommendations regarding the perioperative management of atrial fibrillation (AF) have been released from leading cardiovascular societies in recent years; however, it is unknown how closely these guidelines are being followed by medical practitioners. In addition, many of these society recommendations are based on patient stratification into "normal" and "elevated" risk groups for AF, but criteria for that stratification have not been clearly defined. In an effort to improve the perioperative management of AF, the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee developed a multidisciplinary Atrial Fibrillation Working Group that created a summary of current best practice based on a distillation of recent guidelines from professional societies involved in the care of cardiac surgical patients. An evidence-based set of survey questions was then generated to describe the current practice of perioperative AF management. Through collaboration with the European Association of Cardiothoracic Anaesthetists (EACTA), that survey was distributed to the combined memberships of both the SCA and EACTA, yielding 641 responses and resulting in the most comprehensive understanding to date of perioperative AF management in North America, Europe, and beyond. The survey data demonstrated the broad range of therapies utilized for the prevention and treatment of poAF, as well as a spectrum of adherence to published guidelines. With the goal of improving adherence, a graphical advisory tool was created with an easily accessible format that could be utilized for bedside management. Finally, given that no evidence-based threshold currently exists to differentiate patients at normal risk to develop poAF from those at elevated risk, the SCA/EACTA AF working group created a list of poAF risk factors using expert opinion and based on published risk score models for poAF. This approach allows stratification of patients into risk groups and facilitates adherence to the evidence-based recommendations summarized in the graphical advisory tool. It is our hope that these new additions to the clinical toolkit for the management of perioperative AF will improve the evidence-based care and outcomes of cardiac surgical patients worldwide.

Postoperative atrial fibrillation (poAF) is the most common adverse event after cardiac surgery and is associated with increased morbidity, mortality, and increased hospital and intensive care unit length of stay. Despite progressive improvements in overall cardiac surgical operative mortality and postoperative morbidity, the incidence of poAF has remained unchanged at 30% to 50%. A number of evidence-based recommendations regarding the perioperative management of atrial fibrillation (AF) have been released from leading cardiovascular societies in recent years; however, it is unknown how closely these guidelines are being followed by medical practitioners. In addition, many of these society recommendations are based on patient stratification into "normal" and "elevated" risk groups for AF, but criteria for that stratification have not been defined clearly. In an effort to improve the perioperative management of AF, the Society of Cardiovascular Anesthesiologists (SCA) Clinical Practice Improvement Committee developed a multidisciplinary Atrial Fibrillation Working Group that created a summary of current best practices based on distillation of recent guidelines from professional societies involved in the care of cardiac surgical patients. An evidence-based set of survey questions then was generated to describe the current practice of perioperative AF management. Through a collaboration with the European Association of Cardiothoracic Anaesthetists (EACTA), that survey was distributed to the combined memberships of both the SCA and the EACTA, yielding 641 responses and resulting in the most comprehensive understanding to date of perioperative AF management in North America and Europe and beyond. The survey data demonstrated the broad range of therapies used for prevention and treatment of poAF, as well as a spectrum of adherence to published guidelines. With the goal of improving adherence, a graphical advisory tool was created with an easily accessible format that could be used for bedside management. Finally, given that no evidence-based threshold currently exists to differentiate patients at normal risk of developing poAF from those at elevated risk, the SCA/EACTA AF working group created a list of poAF risk factors using expert opinion, based on published risk score models for poAF. This allows stratification of patients into risk groups and facilitates adherence to the evidence-based recommendations summarized in the graphical advisory tool. It is the working group's hope that these new additions to the clinical toolkit for management of perioperative AF will improve the evidence-based care and outcomes of cardiac surgical patients worldwide.